The effectiveness of telehealth programs on the mental health of women with breast cancer: A systematic review

Abstract

Objective: The purpose of this systematic review is to determine the evidence-based information and results about the effectiveness of telehealth programs on the mental health of women with breast cancer. Methods: The research process was carried out using PRISMA guidelines. Randomized controlled trials with available abstract and full text, which were published in English with the keywords “telehealth,” “telemedicine,” “web-based therapy,” “telepsychiatry,” "online therapy" and "breast cancer" in Pub Med, PsycINFO, Medline, Science Direct, Scopus, Web of Sciences and Cochrane databases between 2015–2019 were searced. As a result of the evaluations, the research was completed with 16 studies meeting the research criteria. Results: There was strong evidence for reduce the fear of relapse of cancer, depressive symptoms and severity of depression, distress, intrusive thoughts, anxiety, sleep disorder, insomnia, improve quality of life and for improve cognitive functions, improve psychological strength and sleep quality of telehealth programs in women with breast cancer. Furthermore, evidence was found for increase psychological health, functionality, optimism and control over the future, positive mood and life appreciation, and drug compliance of these programs. Conclusion: This review found evidence for the effectiveness of telehealth programs on the mental problems of women with breast cancer. In this sense, it is recommended to expand the use of telehealth programs, which can save time and cost, are accessible and easily applicable by nurses, to improve the mental health of women with breast cancer, and further studies are recommended.

Keywords

Breast cancer mental health telehealth programs telepsychiatry nursing

Introduction

According to Global Cancer Observatory 2020 data, breast cancer is the most frequently diagnosed cancer among women in the world and has the highest mortality rate.¹ In high-income countries, however, 5-year net survival probabilities are generally above 80%.² More than 2.9 million women in the United States,³ more than 570,000 women in the United Kingdom/England,⁴ and many women worldwide are currently diagnosed with breast cancer, and these numbers are expected to increase further.^2–4 In parallel with the world data, it is the most common breast cancer in women as one of every 4 women's cancers in Turkey. The incidence of breast cancer was 45.8 per 100.000, and approximately 17.000 women were diagnosed with breast cancer in one year.⁵ More women are diagnosed with breast cancer than ever before,⁶ and these women face many challenges as they try to come back to life after cancer diagnosis and treatment. These difficulties lead to many mental problems.⁶ In addition, treatment methods such as mastectomy, breast-conserving surgery, nodule biopsy, axillary lymphatic dissection, chemotherapy, hormone therapy, and medication are frequently used in the treatment of breast cancer today. However, although these developments in medical technology reduce the mortality rate, physical and psychological problems associated with the side effects of treatment occur.⁷⁸

Being diagnosed with breast cancer is generally disturbing.⁹ Having breast cancer or receiving treatment is seen as a traumatic experience due to its effects on women's self-image and sexual relations, and it causes shock, denial, anger, depression, anxiety, hopelessness, helplessness, uncertainty about the future, reflection, psychological stress, pathological addiction, Anxiety and intense fear about the recurrence and progression of cancer can lead to psychological reactions such as loss of femininity and fear of death, suicidal thoughts.^9–13 Therefore, the problems experienced by survivors of breast cancer diagnosis include physical symptoms, psychological reactions and existential concerns that could potentially impair their well-being.¹⁴ Initial reactions to the diagnosis of breast cancer are usually associated with pain and death, and later reactions are associated with breast loss, which may occur secondary to surgical treatments.⁹ When breast-conserving surgeries and mastectomy surgeries are compared, there is no significant difference in survival after surgical intervention, but patients encounter many physical and psychosocial symptoms after mastectomy surgeries.^15–17 In a meta-analysis study, which included 40 studies, it was found that 30–47% of the mental disorders were seen without a significant difference between breast-conserving surgery and Modified Radical Mastectomy, which are among the surgical procedures applied in the treatment of breast cancer. It has been determined that 20–45% of these disorders continue 1 year after the operation, and 10% turn into serious mental disorders after 6 years. It has been observed that these mental disorders are mostly major and minor depression, anxiety and phobic disorders.¹⁸ In addition to the stigmatization effect caused by breast cancer, the loss of the breast is mostly interpreted as the loss of fertility, attractiveness, sexuality and femininity as a combination of all these.⁹ Therefore, although mastectomy causes a feeling of loss, it affects the person's self-confidence, perception of his own body, functions, relationships, and psychological state.¹⁹ A woman who has undergone a mastectomy may see herself as disabled, sexually inadequate, incomplete, and lonely. The loss of the body part, which is so important for women, causes serious mental problems.¹⁵ In addition, various anxieties and fears occur in women, such as separation anxiety from relatives and the environment, fear of losing love, interest, support and approval caused by esthetic concerns, anxiety of losing control over the body and basic functions.¹⁹ Various reasons such as, diagnosis and treatment of breast cancer, physical symptoms, the fear of recurrence and death, uncertainty about the future, the fear of pain, difficulties in the activities of daily living, also cause some mental disorders.^9,20–22

Mental disorders such as depression and anxiety disorders are common in most breast cancer patients.^{2,9,10,23–27} Mentioned anxiety disorders include generalized anxiety disorder, post-traumatic stress syndrome, anxious mood and adjustment disorder.²⁶ In addition, sleep problems, body dysmorphic disorder,⁹ substance abuse similar to opioid analgesic use, suicide, and neurocognitive and sexual dysfunctions are common in women with breast cancer.² A recent systematic review found that breast cancer survivors are more likely to have anxiety and depression, and have an increased risk of suicide and other mood disorders, including neurocognitive and sexual dysfunctions, than women without a history of cancer.²⁵ In another study, approximately one-third of the breast cancer patients reported the symptoms of depression.²⁸ In another study, both depression and anxiety had negative effects on relapse and all-cause mortality in the patients with breast cancer, and depression were found to predict cancer-specific mortality.²⁹

Considering all these study results and the overall burden of mental disorders,² early and regular detection and timely treatment of mental disorders of the breast cancer patients, especially in the early period after cancer diagnosis, is extremely important. It is extremely important to address these mental problems experienced by breast cancer patients during the treatment process. On the other hand, within the scope of preventive mental health, mental problems that may develop can be prevented by protecting and improving mental health for these patients. In this study, the mental states of women with breast cancer, the mental problems experienced by the patients and their mental health are examined. In this context, in the study; depression, quality of life, psychological distress/distress anxiety and cognitive functions, cancer recurrence/fear of recurrence and psychological empowerment, sleep, intrusive/avoidant/invading thoughts, functional/functional capacity, optimism and control over the future, positive mood state and life appreciation, drug compliance, and psychological adjustment were addressed. There are many types of psychological interventions in dealing with these mental states. In recent years, the widespread use of portable computers and the development of reliable communication systems have made telehealth applications popular in psychological support therapies.³⁰

According to the World Health Organization, telehealth is defined as improving the health levels of individuals and communities, preventing diseases and accidents, continuing education of healthcare professionals, and providing health services by using information and communication technologies remotely and with valid information communication methods.³¹ Telehealth was originally developed as a technology to increase access to the healthcare services for individuals living in rural and low-population areas.³² However, factors such as the increase in the cost of healthcare services with the population, the need to reduce the frequency of patient visits to the hospital, more effective use of specialist doctors, accessing long-term statistical information about the disease, and determining more effective treatment methods have led to the widespread use of telehealth practices.³³

The literature has shown that telehealth practices are important for women with breast cancer due to their positive effects on cancer and treatment-related psychological conditions.^34–36 The studies have shown that internet-based cognitive behavioral therapy applied within the scope of telehealth/telepsychiatry services reduced fatigue,³⁷ increased sleep quality,³⁸ reduced stress,³⁹ increased the quality of life, reduced anxiety and depression.³⁷ Although there are many randomized controlled studies in the literature on the subject, no systematic review has been encountered. Considering that systematic reviews and Meta-analyzes are the most reliable sources of evidence, it can be understood how valuable the studies in this direction are. Based on this idea, it has been seen that accessing studies at the level of evidence on the effectiveness of telehealth practices, which is a new and popular field, on the mental states of women with breast cancer can provide beneficial contributions in providing more effective care to their patients. In the light of this information, this research was conducted to combine and summarize the information and results obtained from the studies on the effects of telehealth programs (They consist psychological interventions. These interventions are; psychotherapy, psychoeducation, game practice, etc.) on the mental state (mental health characteristics and mental problems) of women with breast cancer.

Review methods

In the research process, all details such as defining the articles and selecting them according to the criteria were carried out by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines (PRISMA).³⁸

In the present research, the studies which were published in English between the dates of 01.01.2015 and 12.31.2019 (including the last five years) in Pub Med, PsycINFO, Medline, Science Direct, Scopus, Web of Sciences and Cochrane databases and in the type of randomized controlled studies with the keywords of "telemedicine," "telehealth," "web-based therapy," "telepsychiatry," "online therapy" and "breast cancer" were examined. Since telehealth programs are an interventional study, descriptive and qualitative studies were not included in the study. It is also not included because there are not enough cohort studies on this subject. Since RCTs are both interventional and high-evidence studies, it included only these studies. Keywords were selected according to MeSH search results. For example, when the word “telemedicine” is entered into the MeSH search engine, this word is also listed for similar and more detailed words and has been selected from this list The related databases were preferred due to their substantial evidence-based literature in the field of health, nursing and psychiatry. The selection process was completed in two stages. The title and summary parts of the studies were systematically examined first in July 2019 and secondly in December 2019 in order to keep the errors caused by two independent researchers at a minimum level. When there was not enough information in the title and summary of the studies, the necessary data were obtained from the full texts, and the studies were evaluated. At this stage, the full texts of the studies deemed appropriate were downloaded and read by two independent researchers to verify the existence of each inclusion criteria. The rejected studies were separately recorded and the reasons for exclusion were shown. Of the 1730 studies that were rejected, it was seen that 1435 studies were excluded because the abstracts of them were excluding telehealth, telemedicine, web-based therapy, telepsychiatry, online therapy, breast cancer, and mental health, and the full texts of other 295 studies did not include a psychological intervention, and the collected results did not include the mental status (mental health characteristics and mental problems).

Selection Criteria

Included studies:

The studies dealing with telehealth, telemedicine, web-based therapy, telepsychiatry, online therapy, breast cancer and mental state (mental health and mental problems) between the years of 2015 and 2019

The articles published in English in a scientific journal

Randomized controlled studies on the subject

Exclusion Criteria:

The studies published before 2015

The studies other than telehealth, telemedicine, web-based therapy, telepsychiatry, online therapy, breast cancer and mental state

The studies published in a nonscientific journal

Non-English language articles in a scientific journal

The studies other than randomized controlled trials

Search result

120 articles in Pubmed search, 360 articles in PsycINFO search, 44 articles in Medline search, 108 articles in Scopus search, 817 articles in Web of Science search, 115 articles in Science-Direct search and 202 articles in Cochrane search were found online (Figure 1). The results from different databases were combined and duplicate studies were removed. A total of 1730 articles, including irrelevant abstracts (n = 1435), irrelevant full text (n = 295), and duplicate articles (n = 20), were excluded from the evaluation. As a result of the evaluations, the research was completed with 16 studies meeting the research criteria. The literature search procedure is shown in Figure 1. Summary tables were created to determine the methodology of the selected articles. Then, the theming process of the data was started by carefully examining the relevant data collection and analysis process. The objectives and results (Table 2) and methodological characteristics (Table 1) of the studies included in the present research were presented in the summary tables.

Figure 1.

Flowchart of literature review and selection criteria (PRISMA).³⁸

Table 1.

Some data on the methods of the included studies.

Author and year	Sample	Scanned indexes
Van Helmondt et al., 2019	262 female breast cancer survivors. Online self-help training (n = 130) or care as usual (CAU; n = 132)¹³	Cochrane.
Lally et al., 2019	One-hundred with breast cancer. Intervention group (n = 57), control group (n = 43).⁴⁰	Cochrane.
Jun Kim et al., 2018	A total of 76 patients with metastatic breast cancer. A mobile game play group (game group, n = 36) or a conventional education group (control group, n = 40).⁴¹	Scopus.
Meneses et al., 2018	In total, 40 Latina breast cancer survivors. Support and Early Education Intervention (n = 21) Orthe Support and Delayed Education Intervention (n = 19) group.⁴²	PubMed, Web of Sciences and Scopus.
Smith et al., 2018	89 adult breast cancer survivors. Intervention group (n = 37), Control group (n = 52).⁴³	Web of Sciences and Cochrane.
Visser et al., 2018	A total of 122 patients with breast cancer. Intervention group (n = 63), control group (n = 59).⁴⁴	Pubmed and Scopus.
Zachariae et al., 2018	A total of 255 women with breast cancer were randomly allocated to iCBT-I (n¼133) or waitlist control (n ¼ 122).³⁵	PubMed, Web of Sciences.
Admiraal et al., 2017	138 patients with breast cancer were included. Intervention group (n = 69), control group (n = 67).⁴⁵	Scopus and Cochrane.
Galiano-Castillo et al., 2017	76 patients with breast cancer were included. Telerehabilitation group n = 39, Control group n = 37.⁷	Pubmed, MEDLINE, Web of Sciences and Scopus.
Zhu, Ebert, Liu & Wai-Chi Chan, 2017	108 patients with breast cancer (n = ). Intervention group (n = 54), control group (n = 54).⁴⁷	MEDLINE and Scopus.
Ashing & Miller, 2016	39 patients with breast cancer were included. 20 in the intervention group and 19 in the control group.⁴⁸	Scopus and Cochrane.
Damholdt et al., 2016	A total of 157 female breast cancer survivors. Web-based cognitive training (eCogT)⁴⁹ with telephone support (n = 94) or a waitlist control (WLC) condition(n = 63).⁴⁹	Pubmed.
Lozano-Lozano et al., 2016	80 patients with breast cancer were included. Integral group (n = 40), Technological support using e-health mobile applications (m-health) group (n = 40).⁵⁰	Scopus.
Cleary & Stanton, 2015	88 patients diagnosed with breast cancer were included. Project Connect Online participants (n = 46), Control group participants (n = 42).⁵¹	PsycINFO and Cochrane.
Freeman et al., 2015	Women (n = 70) diagnosed with breast cancer. Telemedicine delivery (TD), n = 23, waitlist control (WL) group (n = 47).⁵²	MEDLINE and Scopus.
Van den Berg et al., 2015	150 women diagnosed with breast cancer were included. Randomly allocated to CAU = Care As Usual + BREATH = Web-Based Self-Management for Psychological Adjustment After Primary Breast Cancer (n = 70), Randomly allocated to CAU alone (n = 80).³⁶	PubMed, Web of Sciences and Cochrane.

Table 2.

Features of randomized controlled trials examined.

Author and year	Research type	Working area	Purpose of the study	Conclusions of the study
van Helmondt et al., 2019	Randomized controlled trial.	Online therapy and breast cancer.	The objective of this study was to evaluate the effectiveness of this online self-help training in reducing fear of cancer recurrence compared to a care as usual (CAU) control group in women with curatively treated breast cancer (breast cancer survivors).¹³	There was no effect of the Cognitive Behavioral Therapy (CBT)-based online self-help training¹³ to reduce fear of cancer recurrence.¹³
Lally et al., 2019	Randomized controlled trial.	Online therapy and breast cancer.	The objective of this study was to evaluate the preliminary efficacy of a new web-based, psychoeducationaldistress self-management program,⁴⁰ CaringGuidance⁴⁰ After Breast Cancer Diagnosis, on newly diagnosed women's reporteddistress.⁴⁰	This study, CaringGuidance⁴⁰ a self-managed web-based psychoeducation program designed for women diagnosed with new breast cancer, has been shown to be more effective on depressive symptoms, distress and intrusive/avoidant thoughts than normal care. Significant differences were found between the intervention group in which CaringGuidance was performed and the control group in which classical care was performed. In the intervention group, in the 2nd and 3rd months, depressive symptoms, distress, intrusive/avoidant thoughts decreased over time, while these symptoms increased in the control group.⁴⁰
Jun Kim et al., 2018	Randomized controlled trial.	Online therapy and breast cancer.	The objective of this study was to evaluate if patient education using a mobile game may increase drug compliance, decrease physical side effects of chemotherapy, and improve psychological status in breast cancer patients.⁴¹	This study suggests the feasibility and potentiality of the use of smartphone mobile games⁴¹ for patients with breast cancer receiving chemotherapy. Education using a mobile game led to better patient education, improved drug compliance, decreased side effects (nausea, fatigue, numbness of hand or foot, and hair loss) and better quality of life (QoL) compared with conventional education. However, there were no significant differences in terms of depression and anxiety scales. The use of the game had no impact on psychological side effects including mood and anxiety. Mobile games⁴¹ can be used as easy, fun, and effective measures for patient education and have the potential to improve treatment outcomes.⁴¹
Meneses et al., 2018	Randomized controlled trial.	Telehealth and breast cancer.	The objective of this study was to evaluate the effect of Telephone-Based Latina Breast Cancer Survival Intervention (LBCSI)⁴² on physical and emotional well-being, fatigue, pain and depressive symptoms.⁴²	This was a pilot study of the LBCSI,⁴² a survivorship self-management intervention delivered via telephone. Overall, physical and emotional well-being remained similar over time with well-being scores poorer compared with the general population. Pain levels improved over 6 months and showed a high effect size. Fatigue scores improved at 3 months and showed a moderate effect size. Depressive symptoms remained elevated but were not clinically significant.⁴²
Smith et al., 2018	Randomized controlled trial.	Online therapy and breast cancer.	The objective of this study was to examined the effect of Reimagine,⁴³ an online symptom self-management curriculum that teaches coping skills, on pain, depression and fatigue.⁴³	This study's results suggest that Reimagine⁴³ has an effect on depression and fatigue symptoms for breast cancer survivors. Online programs can be a feasible and effective alternative to in-person support.⁴³
Visser et al., 2018	Randomized controlled trial.	Online therapy and breast cancer.	Group medical consultations provide individual medical visits in the presence of <7 peer patients. My-GMC is the new combined care, an online support session and a GMC, combined with tablet online app, with additional information. The objective of this study is to evaluate the effect of My-GMC⁴⁴ on psychological distress and empowerment in breast cancer patients. The secondary objective is to determine the effect of My-GMC⁴⁴ on cancer recurrence fear and quality of life in women with breast cancer.⁴⁴	The effect of My-GMC⁴⁴ on distress and empowerment did not significantly differ from the effect of individual visits. The secondary outcomes cancer worry and quality of life were not significantly different between both groups at all time points.⁴⁴
Zachariae et al., 2018	Randomized controlled trial.	Web-based therapy and breast cancer.	The objective of study was to tested the efficacy of internet-delivered Cognitive Behavioral Therapy for Insomnia (iCBT-I)³⁵ in breast cancer survivors with clinically significant sleep disturbance.³⁵	In the study, it was seen that iCBT-I³⁵ decreases the severity of insomnia and fatigue and increases the quality of sleep, in breast cancer survivors.³⁵
Admiraal et al., 2017	Randomized controlled trial.	Web-based therapy and breast cancer.	The objective of this multicenterrandomized controlled trial was to examine the effectiveness of a web-based tailored psychoeducational program (ENCOURAGE)⁴⁵ for breast cancer patients which aims to empower patients to take control over prevailing problems. In the study, it was aimed to test the effect of ENCOURAGE⁴⁵ primarily on optimism and control over the future, and secondaryly on distress and quality of life.⁴⁵	In the study, almost all patients visited ENCOURAGE⁴⁵ as requested. No differences between the control and the intervention group were observed for primary (optimism and control over the future) and secondary (distress and quality of life) outcomes. An unplanned subgroup analysis showed that in clinically distressed patients, use of the ENCOURAGE⁴⁵ program increased optimism and control over the future at 12 weeks more than in patients in the control group. Although results showed no harmful effects of the ENCOURAGE⁴⁵ program, no additional beneficial effects of the program compared to the information leaflets that are part of standard care, were observed. The valuable information of the current study can be used as a starting point for further improvement and use of the program^.⁴⁵
Galiano-Castillo et al., 2017	Randomized controlled trial.	Telehealth and breast cancer.	The objective of this study was to determine the effect of an Internet-based special exercise program compared to the usual care control aimed at improving functional capacity and cognition among breast cancer survivors.⁷	In this study, it was found that physical exercise based telehealth system (e-CUIDATE)⁷ in breast cancer survivors (BCS) improved functional capacity and cognitive functionality. In addition, there was a significant difference between the telerehabilitation group and the control group in terms of functional capacity and cognitive functionality. Compared to the control group, there was more improvement in the telerehabilitation group in terms of functional capacity and cognitive functionality.⁷
Zhu, Ebert, Liu & Wai-Chi Chan, 2017	Randomized controlled trial.	Online therapy and breast cancer.	The objective of this RCT is to evaluate the effectiveness of the BCS (The breast cancer e-support program)⁴⁷ program for Chinese women with breastcancer undergoing chemotherapy in terms of enhancing the women's self-efficacy, social support and QoL, andreducing their symptom distress, anxiety and depression.⁴⁷	The results of this study provide a better understanding of the role of self-efficacy and social support in reducing symptom distress, anxiety and depression and the credibility of using a theoretical framework to develop a BCS (The breast cancer e-support program)⁴⁷ intervention. Internet-based interactive methods to promote women's symptom self-management, thus improving women's QoL and psychological well-being.⁴⁷
Ashing & Miller, 2016	Randomized controlled trial.	Telepsychiatry and breast cancer	The objective of this study was to evaluate the usefulness of a telephone-induced psychoeducational intervention to improve health-related quality of life in African American breast cancer survivors.⁴⁸	In the study, as a result of telephonically delivered psychoeducational intervention, there was a significant improvement in the physical, emotional and health-related quality of life (HRQOL) among the participants. In the follow-up, a statistically significant difference was found between the intervention group and the control group in terms of physical and emotional well-being and overall HRQOL. While the general HRQOL, physical and emotional well-being did not change from the beginning to follow-up for the control group participants, there was an increase in the intervention group.⁴⁸
Damholdt et al., 2016	Randomized controlled trial.	Web-based therapy and breast cancer.	The objective of this study is to evaluate the effectiveness of the web-based cognitive training (eCogT)⁴⁹ with telephone support or a waitlist control (WLC) working memory and a measure of perceived cognitive functioning (primary outcome). Secondary outcomes were neuropsychological tests of memory, executive function, working memory and questionnaire-based assessment of anxiety, depression and somatization.⁴⁹	There were no statistically significant baseline differences between eCogT⁴⁹ and WLC on any of the neuropsychological tests or cognitive functioning, depression or anxiety. There was no statistically significant change in the primary or secondary outcome at follow-up in both groups. Statistically significant improvements (p 0.040-0.043) were found in the eCogT group for verbal learning and on a working memory test⁴⁹
Lozano-Lozano et al., 2016	Randomized controlled trial.	Online therapy and breast cancer.	The objective of this study is to compare the clinical efficacy of ae-health mobile applicationsm-health (e-health mobile applications)⁵⁰ lifestyle intervention system alone versus an integral strategy to improve Quality of Life (QoL), cognitive function, anxiety and depression in breast cancer survivors.⁵⁰	M-health system⁵⁰ cause significant differences in QoL, cognitive function, anxiety and depression compared with the integral strategy group. The results of this study provide a better understanding of the role of M-health system⁵⁰ in reducing symptom anxiety and depression and improve QoL, cognitive function.⁵⁰
Cleary & Stanton, 2015	Randomized controlled trial.	Web-based therapy and breast cancer.	The primary purpose was to evaluate Project Connect Online (PCO),⁵¹ an internet-based psychosocial intervention, on depressive symptoms, positive mood, and appreciation of life. The secondary purpose of this article is to be able to mediate the depressive development of Project Connect Online,⁵¹ to evaluate trust in coping, loneliness, social support from friends, positive mood.⁵¹	A personal website led to an increase in coping self-confidence, and a decrease in loneliness. Changes in these mediating variables were associated with reduced depressive symptoms and increased positive mood and life appreciation.⁵¹
Freeman et al., 2015	Randomized controlled trial.	Telemedicine and breast cancer	The primary aim of the current study was to compare the effects of an intervention entitled ‘Envision the Rhythms of Life’ (ERL)⁵² delivered live delivery (LD) or via telemedicine delivery (TD) compared with a waitlist control (WL) on quality of life (QOL) for breast cancer survivors. Secondary aim is to evaluate the effect of ERL⁵² on fatigue, cognitive dysfunction, sleep disturbance and health and breast cancer-related quality of life in breast cancer survivors.⁵²	The ERL program⁵² represents a mind-body program that comprehensively addresses many facets of QOL relevant to breast cancer survivors, including general health-related and cancer-related QOL, spiritual well-being, cognitive function, fatigue, sleep disturbance, and distress. Changesin fatigue, cognitive dysfunction, sleep disturbance, and health-related and breast cancer-relatedQOL were clinically significant. There were no differences between LD and TD. Further, our results suggest that telemedicine is an effective and viable method to deliver a group intervention aimed at improving QOL in breast cancer survivors.⁵²
Van den Berg et al., 2015	Randomized controlled trial.	Web-based therapy and breast cancer.	The Breast Cancer E-Health (BREATH)³⁶ trial is a Web-based self-management intervention to support the psychological adjustment of women after primary treatment, by reducing distress and improving empowerment. The main purpose of the study is to evaluate whether CAU (Care as Usual) + BREATH (The Breast Cancer E-Health-Web-based self-management intervention to support the psychological adjustment of women after primary treatment) is more effective than CAU alone in decreasing distress and increasing empowerment.The secondary purpose of the study is to evaluate whether CAU + BREATH is more effective than CAU alone on negative adjustment (general and cancer-specific distress, fatigue, helplessness, and fear of cancer recurrence) and positive adjustment (self-efficacy, remoralization, personal control, quality of life, fulfillment, reevaluation, new ways of living, and valuing life).³⁶	Access to BREATH³⁶ reduced distress and improve empowerment among breast cancer survivors, but this effect was not sustained during follow-up. CAU + BREATH is superior to CAU alone in reducing distress and improving empowerment.Secondary outcome analyses revealed that CAU + BREATH led to significant improvements in five of seven negative adjustment variables (general and cancer-specific distress, fatigue, and two fear of cancer recurrence outcomes) with small-to-medium effect sizes and in 3 of 10 positive adjustment variables (self-efficacy, remoralization, new ways of living) with small-to-medium effect sizes.CAU + BREATH participants also showed a greater decrease than CAU alone participants in fear of cancer recurrence, fatigue, and general and cancer-related distress. The effect of BREATH on fear of cancer recurrence was sustained during follow-up. The secondary outcomes revealed that CAU + BREATH decreased general and cancer-specific distress, fatigue, and fear of cancer recurrence, which may reflect the multicomponent nature of distress in cancer patients.³⁶

Results

The results of the analysis were evaluated in two separate sections: The methods of the studies, the thematic areas and the content-related features.

The Features Related to the Studies’ Methods: When the distribution of 16 studies meeting the research criteria by years is examined, it was determined that 2 of them were published in 2019, 5 of them were published in 2018, and 3 of them were published in 2017, 2016 and 2015. All of the investigated studies are randomized controlled experimental studies in which randomization was provided in the assignment of the sample to the intervention and control group, and most of them used the blind technique. It was found that all of the studies were published in Science Citation Index Expanded and Social Sciences Citation Index journals. The sample size of these studies was determined to be at most 262 (intervention group:130, control group:132) and at least 39 (intervention group:20, control group:19) women.

The features of telehealth applications applied in studies

Telehealth programs included in the studies, which were selected for the research, were as follows: Cognitive Behavioral Therapy (CBT) based online self-help training,¹³ CaringGuidance,⁴⁰ a web-based psychoeducational distress self-management program,⁴⁰ a self-directed intervention training with using mobile games,⁴¹ Telephone-Based Latina Breast Cancer Survival Intervention (LBCSI),⁴² Reimagine,⁴³ an online symptom self-management curriculum that teaches coping skills,⁴³ online support session and combined care group medical consultation (GMC) with additional information with online application My-GMC,⁴⁴ Internet-based Cognitive Behavioral Therapy (iCBT-I) for insomnia,³⁵ a web-based special psychoeducation program (ENCOURAGE),⁴⁵ an internet-based special exercise program,⁴⁶ breast cancer e-support program (BCS),⁴⁷ a psychoeducational intervention on the phone,⁴⁸ web-based cognitive training (eCogT),⁴⁹ an e-health mobile application (m-health) with a lifestyle intervention system,⁵⁰ Project Connect Online (PCO),⁵¹ an internet-based psychosocial intervention,⁵¹ The intervention titled "Envision the Rhythms of Life" (ERL),⁵² which represents a soul-body program that comprehensively addresses many aspects of quality of life,⁵² Breast Cancer E-Health (BREATH) trial,³⁶ a Web-based self-management intervention to support psychological adjustment,³⁶ e-CUIDATE,⁷ a telehealth system based on physical exercise.⁷

When the results of the studies were examined, the effects of telehealth practices on the mental health of women with breast cancer were divided into the following main areas: The most investigated mental problems were respectively, depression (8 of the 16 studies), quality of life (7 of the 16 studies), psychological disturbance/distress (6 of the 16 studies), anxiety and cognitive functions (4 of the 16 studies), the fear of relapse/recurrence of cancer and psychological empowerment (3 of the 16 studies), sleep and psychological state/psychological health (2 of the 16 studies). The least studied mental problems were determined as intrusive/avoidant/evoker thoughts, functional/operational capacity, optimism and control over the future, positive mood and life appreciation, drug compliance, psychological adjustment (1 of the 16 studies). Let us consider the findings of these mental states one by one.

The fear of relapse/recurrence of cancer: 3 of the 16 studies examined the effect of telehealth practices on the risk of cancer recurrence/recurrence of women with breast cancer. Of these studies, 2 of them found that telehealth practices had no effect on the cancer recurrence/recurrence, and the other 1 study found that the telehealth practices reduced the cancer recurrence/recurrence fear. When examined in terms of intervention, it was found that the CBT-based online self-help training and My-GMC⁴⁴ had no effect on reducing the fear of cancer recurrence, while the BREATH³⁶ trial reduced the fear of cancer recurrence.

Psychological disturbance/distress: 6 of the 16 studies examined the effect of telehealth practices on psychological distress/distress of women with breast cancer. It was found that telehealth applications were effective in reducing distress/distress in 4 studies, but not in the other 2 studies. In terms of intervention, it was determined that CaringGuidance,⁴⁰ BCS,⁴⁷ BREATH³⁶ and ERL⁵² reduced the disturbance/distress, and My-GMC⁴⁴ and ENCOURAGE⁴⁵ were not effective in reducing the distress.

Depressive symptoms/Depression: 8 of the 16 studies examined the effect of telehealth practices on depressive symptoms/depression of women with breast cancer. In 5 studies, it was found that telehealth applications were effective in reducing depressive symptoms and depression compared to normal care/face-to-face intervention, and there was no difference/effectiveness between them in the other 3 studies. When the studies were examined in terms of the interventions, it was observed that CaringGuidance,⁴⁰ Reimagine,⁴³ BCS,⁴⁷ m-health⁵⁰ and PCO⁵¹ reduced the depressive symptoms and depression severity of women with breast cancer, the training using mobile games,⁴¹ LBCSI⁴² and eCogT⁴⁹ did not affect the depressive symptoms and depression severity.

Intrusive/avoidant/evoker thoughts: 1 of the 16 studies examined the effect of telehealth practices on intrusive/avoidant/introversive thoughts. In this study, it was found that CaringGuidance⁴⁰ reduced intrusive/avoidant/evoker thoughts over time and was more effective than the normal care.

Quality of life: 7 of the 16 studies addressed the impact of telehealth practices on the quality of life of women with breast cancer. In 5 studies, it was determined that telehealth applications increased the quality of life in women with breast cancer, and in the other 2 studies, it did not affect the quality of life. When the studies were examined in terms of intervention, it was determined that patient education with mobile games,⁴¹ BCS,⁴⁷ m-health,⁵⁰ psychoeducational intervention given on the phone,⁴⁸ ERL⁵² increased the quality of life, while ENCOURAGE⁴⁵ and BREATH³⁶ did not affect the quality of life.

Anxiety: 4 of the 16 studies addressed the impact of telehealth practices on the anxiety of women with breast cancer. While 2 of them found that telehealth applications reduced anxiety, the other 2 studies found no effect on anxiety. When the studies were examined in terms of intervention, it was determined that BCS⁴⁷ and m-health⁵⁰ reduced the anxiety of women with breast cancer, and patient eduction with using mobile games⁴¹ and eCogT⁴⁹ did not affect the anxiety.

Psychological State-Psychological Health: 2 of the 16 studies examined the effect of telehealth practices on the psychological state/psychological health of women with breast cancer. In 2 studies, it was found that BCS⁴⁷ improved psychological health, and in the other 2 studies, patient education with using mobile games⁴¹ did not affect psychological health/psychological state.

Psychological Empowerment: 3 of the 16 studies examined the effects of telehealth practices on the psychological empowerment of women with breast cancer. It was found that telehealth practices improved/increased psychological empowerment in 2 studies, and it did not affect psychological empowerment in 1 study. It was determined that telehealth BREATH³⁶ and PCO⁵¹ improved the psychological empowerment of women with breast cancer, whereas My-GMC⁴⁴ did not affect psychological empowerment of them.

Cognitive Functions (Cognitive function, neuropsychological memory, executive function, working memory): 4 of the 16 studies addressed the impact of telehealth practices on the cognitive functions of women with breast cancer. In 3 studies, it was determined that telehealth applications improved the cognitive functions, and in 1 research it had no effect on the cognitive functions. When the studies were examined in terms of intervention, it was found that m-health,⁵⁰ e-CUIDATE⁷ and ERL⁵² improved cognitive functions, and eCogT⁴⁹ had no effect on neuropsychological memory, executive function, working memory, cognitive functions compared to live education.

Functional/Operational Capacity: 1 of 16 studies examined the effect of telehealth practices on the functional capacity of women with breast cancer. E-CUIDATE⁷ was found to increase the functionality of women with breast cancer.

Sleep, sleep disturbance, insomnia, sleep quality: 2 of the 16 studies examined the impact of health practices on the sleep of women with breast cancer, such as sleep disturbance, insomnia, and sleep quality. In all of the studies, it was determined that telehealth applications reduce the severity of insomnia and sleep disturbance and increase sleep quality. It was determined that iCBT-I³⁵ and ERL,⁵² among telehealth applications, improved sleep quality and reduced the severity of insomnia.

Optimism and control over the future: 1 of the 16 studies examined the effects of telehealth practices on the optimism and future control of women with breast cancer. In this study, it was stated that the use of ENCOURAGE⁴⁵ did not differ between the control and intervention groups in terms of optimism and control results over the future; however, an unplanned subgroup analysis found that the use of the ENCOURAGE⁴⁵ program in clinically distressed patients increased the optimism and control over the future after 12 weeks compared to patients in the control group.

Positive mood and life appreciation: 1 of the 16 studies examined the effect of telehealth practices on the positive mood and life appreciation of women with breast cancer. In this study, it was found that PCO⁵¹ increased the positive mood and life appreciation of women with breast cancer.

Drug compliance: One of 16 studies examined the effect of telehealth practices on the drug compliance of women with breast cancer. In this study, it was determined that patient education with using mobile games⁴¹ increased the drug compliance of women with breast cancer.

Psychological adjustment: 1 of the 16 studies examined the effect of telehealth practices on the psychological adjustment of women with breast cancer. In this study, it was found that the application of BREATH³⁶ increased the psychological adjustment of women by causing improvements in negative adjustment variables such as general and cancer-specific distress, fatigue and fear of cancer recurrence, and positive adjustment variables such as efficacy, regret, and new life styles.

Discussion

The aim of this paper is to systematically describe current telehealth intervention options available to mental health professionals across breats cancer diagnostic populations, and reviewing the results for use of different telehealth intervention. In this regard, the present study was conducted to analyze the studies conducted on evidence-based research results on the effects of telehealth practices on the psychological conditions of women with breast cancer. Although there are many randomized controlled studies on the effects of telehealth practices on the psychological conditions of women with breast cancer, there is no systematic review study. This study is the first systematic review study conducted in terms of evidence-based practices in this field. In this study, a total of 16 studies meeting the inclusion criteria examined the effects of telehealth services on the psychological conditions of women with breast cancer. Among the effects of telehealth practices on the psychological conditions of women with breast cancer, eight studies addressing depression, seven studies on quality of life, six studies on distress, four studies in the category of anxiety and cognitive functions, three studies on the fear of relapse of cancer, two studies on sleep and psychological health, and other psychological effects (Intrusive/avoidant/evoker thoughts, functional/operational capacity, optimism and control over the future, positive mood and life appreciation, drug compliance, psychological adjustment) were found.

Today's technology and internet usage have increased the accessibility of telehealth services. Web-based psychoeducations using computers, tablets and smart phones have enabled interventional studies.³⁹ Examples of these applications include computer games, web-based care guides, mobile applications via smart phones, online cognitive behavioral therapy and group therapies, and phone calls.⁵³ It can be stated that technology-based interventions are effective on the depressive symptoms experienced by women with breast cancer. Depression is quite common in women with breast cancer, and its prevalence doubles in low-income countries.⁵⁴ Study results indicated that psychoeducational distress self-management program,⁴⁰ online symptom self-management program,⁴³ breast cancer e-support program³ and internet-based Psychosocial intervention⁵¹ reduced the depressive symptoms and severity of depression in women with breast cancer, on the other hand, the training with using mobile games,⁴¹ phone-based⁴² and web-based cognitive training⁴⁹ did not affect depressive symptoms and depression severity of women with breast cancer. Several factors can be mentioned in the effectiveness of self-management studies. Individuals’ supervision of these practices can help them develop learning strategies and positively affect their attitudes towards treatment by increasing their perceived self-efficacy. These results showed that more studies are needed in order to investigate the effects of telehealth applications performed with different methods on the depressive symptoms of women with breast cancer.

Research findings proved that telehealth practices have an impact on the quality of life of women with breast cancer.^41,48,50 When the studies were examined in terms of intervention; patient education with mobile games,⁴¹ breast cancer e-support program,⁴⁸ m-health,⁵⁰ psychoeducational intervention delivered on the phone,⁴⁸ Designing life rhythms⁵² improved the quality of life, and it was determined that the web-based special psychoeducation program⁴⁵ and the breast cancer e-health trial,³⁶ which is a web-based self-management intervention, did not affect the quality of life. There are mind-body programs and psychoeducation practices that comprehensively address many aspects of the quality of life of breast cancer patients such as general health and cancer-related mental well-being, cognitive functions, fatigue, nausea and vomiting.^48,52 In these programs, the effect of mental imagery and emotional experience on physiological processes was determined and the quality of life was tried to be increased.⁵² In addition to these studies, meta-analysis results also have proved that mind-body and online psychoeducation-based practices are effective on the quality of life.⁵⁵ It has been determined that group medical consultation including combined care and web-based special psychoeducation program are not effective in reducing distress. The ineffectiveness of these programs on the quality of life suggests that the sociodemographic characteristics of the patients used in the combined care and psychoeducation program were different, they showed different symptoms related to their diseases, and they were at different stages of cancer.^44,45

Web-based psychoeducational distress self-management program, breast cancer e-support program, breast cancer e-health trial with web-based self-management intervention, and designing life rhythms appeared to have an impact on the distress.^7,36,40,52 The main purpose of self-made programs that increase psychoeducational distress self-management and psychological adjustment was to increase psychological resilience. In the intervention studies conducted with women with breast cancer, it was seen that mindfulness-based practices were effective in reducing psychological compulsion and distress.⁵⁶

In addition, telehealth practices have been found to be effective in reducing the anxiety levels of women with breast cancer and on their cognitive functions. It has been determined that breast cancer e-support program and m-health reduced the anxiety of women with breast cancer, while patient education with mobile games and web-based cognitive training did not affect the anxiety.^41,47,49,50 It can be said that breast cancer e-support program and m-health applications increased the motivation of the patients and reduced anxiety because they are practices that encourage the self-symptom method and interfere with lifestyle such as diet and exercise.^47,50 However, the fact that patient education with mobile games and web-based cognitive education had no effect on anxiety has indicated that more studies should be carried out on these practices. However, it has been found that m-health, the telehealth system based on physical exercise, and designing life rhythms improved cognitive functions, and web-based cognitive training had no effect on neuropsychological memory, executive functions, working memory, and cognitive functions compared to live education.^7,49,50,52 The studies have showed that lifestyle intervention system, physical practices and mind-body practices improved cognitive functions. However, according to online trainings, it is thought that the therapist's professional guidance, supportive attitude and immediate patient feedback played a role in the development of cognitive functions in face-to-face cognitive trainings.

On the other hand, the findings have showed that CBT-based online self-help training¹³ and group medical consultation with combined care⁴⁴ had no effect on reducing the fear of cancer recurrence. The breast cancer e-health trial,³⁶ a management intervention, have proved that the intervention reduced the fear of cancer recurrence. CBT-based online self-help training consisted of 2 basic modules with psychoeducation and 4 sub-modules, which included how to stop rumination, plans to do when fear of cancer recurrence emerges, relaxation practices and assurance times. The ineffectiveness of this method on the fear of recurrence of cancer may be due to the inclusion of patients with cancer recurrence or metastasis in the study, and the fact that the assessment was done by the individual, not by the nurses or primary caregivers. The fact that the group medical consultation practice that included combined care was technically difficult to use, and nurses needed to have more complex communication skills compared to providing face-to-face care in this practice may have caused no effect on the fear of cancer recurrence.

Internet-based cognitive behavioral therapy³⁵ and ERL⁵² among telehealth applications have been found to improve sleep quality and reduce insomnia severity. In non-drug interventions for insomnia, behavioral interventions such as psychoeducation, relaxation, stimulus control and cognitive interventions such as intervention to dysfunctional thoughts have been proven to be effective, and the treatments containing these interventions are defined as Cognitive Behavioral Therapies for Insomnia (iCBT-I). iCBT-I has been offered as the first therapy option for insomnia.^35,52 These applications have been used due to the limited availability of therapists trained in sleep and the relatively high costs of CBT-I applied face-to-face, and from this point of view, it can be said that the treatment packages and the underlying theory of change in the CBT have been effective in insomnia.

In addition to all these effects of telehealth practices, it has been seen that they are also effective on other psychological conditions such as intrusive/avoidant/evoker thoughts, functional/operational capacity, optimism and control over the future, positive mood and life appreciation, drug compliance, and psychological adjustment. However, it is noteworthy that there are a limited number of studies in this area. More research is needed.

Limitations of the study

The presented study contains certain limitations. The heterogeneity of the studies limits the generalizability of this systematic review study. The inclusion of different intervention and comparison groups in the studies prevented making a definite judgment about the effectiveness of the studies. In addition, the samples consisted of women with breast cancer who were at different cancer stages and at different stages (for example, those receiving primary treatment or cancer follow-up) or who were receiving different cancer treatments. These differences are likely to have various psychological consequences.

Conclusion and recommendations

The evidence generated through a systematic review can provide the mental health professionals with greater confidence in decision making at the moment of practice and optimize the benefits to patients with breast cancer, serving as a tool to assist managers in making decisions regarding the implementation of new strategies in favor of the mental health. As a result of the studies examining telehealth practices in women with breast cancer, these practices were determined to reduce the fear of cancer recurrence (1 of the 3 studies), depressive symptoms and severity of depression (5 of the 8 studies), psychological disturbance/distress (4 of the 6 studies), intrusive thoughts (1 study), anxiety (2 of the 4 studies), sleep disturbance and insomnia (2 studies) and improve quality of life (5 of the 7 studies), cognitive functions (3 of the 4 studies) and increase psychological strength (2 of the 3 studies) and sleep quality (2 studies). In addition, telehealth practices have been found to increase psychological health, functionality, optimism and control over the future, positive mood and life appreciation, and drug adherence. In line with all these findings, it can be said that telehealth practices are positive effective on the mental states of women with breast cancer. In the majority of telehealth applications, it has been observed that it improves mental health while reducing mental problems in women with breast cancer. Further, our results suggest that telehealth intervention is an effective and viable method to deliver an intervention aimed at improving the mental health in breast cancer survivors. The valuable information of the current study can be used as a starting point for further improvement and the use of the telehealth program. In this sense, it is recommended to expand the use of telehealth applications, which are less time consuming, low cost, accessible and easily applicable by nurses, to improve the mental status of women with breast cancer, and further studies on this subject are recommended. In this systematic review, women's many mental health states (fear of cancer recurrence, depressive symptoms and depression severity, psychological distress/distress, intrusive thoughts, anxiety, sleep disturbance, insomnia, sleep and quality of life, cognitive functions, psychological strength, psychological health, functionality optimism and control over the future, positive mood and life appreciation, and medication adherence) are reviewed. It has been seen that more studies and results are needed for specific telehealth programs that address each of these separately. Although there are relatively many studies to compare its effectiveness on depression, more studies investigating mental health problems other than depression are needed. In this review, different telehealth programs that are effective and ineffective on the investigated mental health parameters are presented. In these studies, it has been seen that telehealth programs are not standard and different techniques are used in each program. Conducting more studies on telehealth programs, especially effective on mental problems, and systematic review will guide the practices.

Footnotes

Acknowledgements

We greatly appreciate the support of Gaziantep University Faculty of Health Sciences, Department of Nursing for the research.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Ece Kaplan

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