Information and Communications Technology-Based Telehealth Approach for Occupational Therapy Interventions for Cancer Survivors: A Systematic Review

(1) Background: Occupational therapy (OT) practice has a unique perspective that addresses the complex needs of cancer survivors. Despite the expanded research and application of OT services using telehealth (TH) to promote clients’ health and well-being, studies on OT services using TH for cancer survivors are rare. This study aimed to review the TH approaches in the scope of OT and the outcome of factors affecting occupational engagement in adult cancer survivors. (2) Materials and Methods: This systematic review performed a literature search of five databases (Medline Complete, PubMed, CINAHL, PsycINFO, Web of Science) using a combination of keywords and cross-referencing. Studies were included if they described a TH intervention within the scope of OT practice to improve occupational engagement. (3) Results: Fifteen studies (12 randomized controlled trials, three quasiexperimental studies) were reviewed. Physical activity had a positive effect on physical and cognitive function. Symptom self-management showed positive effects on the relief of symptom burden. Psychosocial interventions, which included cognitive behavioral therapy, problem-solving, cognitive behavioral therapy for insomnia, mind–body training, reduced sleep disturbance, and improved physical activity. Lifestyle behavior change interventions improved participation in moderate-intensity physical activity and diet quality. In addition, these interventions reduced cancer-related symptoms such as pain, depression, fatigue, distress, and improved quality of life. There were no direct outcomes of occupational engagement, excluding sleep, that could be confirmed through this review. (4) Conclusion: This review explored and confirmed the usefulness of TH approaches in the scope of OT practice in adult cancer survivors. It also supports the notion that OT-specific research using TH interventions for cancer survivors will be needed in the future.


Introduction
According to the Centers for Disease Control and Prevention [1], a cancer survivor is defined as "a person who has been diagnosed with cancer from the time of diagnosis throughout his or her life". The transition from the primary treatment of cancer to aftercare is a difficult process that changes the survivors' daily lives and requires continuous medical care [2]. As a result of the treatment progress, the survival rate increases, but the survivors have physical and psychosocial sequelae, which limit meaningful activity and participation during survivorship [3]. Common sequelae experienced examined for inclusion and exclusion criteria postretrieval. A consensus among all the authors was sought for a study's final inclusion in the systematic review.

Eligibility Criteria
We included English peer-reviewed journals within the scope of OT practice published between 2011 and 2020 which met the following inclusion criteria: (1) adult cancer survivors aged 18 years or older; (2) survivors had completed primary cancer treatment (surgery plus adjuvant chemotherapy and/or radiation therapy); (3) studies using TH interventions including telephone calls and/or web-or mobile-app-based interventions; (4) studies with outcomes focused on physical, cognitive, and psychosocial factors affecting occupational engagement, symptom burden, QOL, and emotional factors affecting confidence, resilience, and self-control; and (5) studies with outcome focused on activity and participation in BADL, IADL, work, leisure, social participation, and rest and sleep.
The following studies were excluded: (1) studies involving childhood cancer survivors, (2) studies focusing on caregivers or family, (3) studies on the effectiveness of palliative care, (4) studies involving patients on active cancer treatment, and (5) dissertations, theses, and protocol studies.

Eligibility Criteria
We included English peer-reviewed journals within the scope of OT practice published between 2011 and 2020 which met the following inclusion criteria: (1) adult cancer survivors aged 18 years or older; (2) survivors had completed primary cancer treatment (surgery plus adjuvant chemotherapy and/or radiation therapy); (3) studies using TH interventions including telephone calls and/or web-or mobile-app-based interventions; (4) studies with outcomes focused on physical, cognitive, and psychosocial factors affecting occupational engagement, symptom burden, QOL, and emotional factors affecting confidence, resilience, and self-control; and (5) studies with outcome focused on activity and participation in BADL, IADL, work, leisure, social participation, and rest and sleep.
The following studies were excluded: (1) studies involving childhood cancer survivors, (2) studies focusing on caregivers or family, (3) studies on the effectiveness of palliative care, (4) studies involving patients on active cancer treatment, and (5) dissertations, theses, and protocol studies.   Nine hundred and twenty-four studies were identified from five databases: Medline Complete (n = 341), PubMed (n = 123), CINAHL (n = 177), PsycINFOI (n = 227), Web of Science (n = 48), and cross-referencing (n = 8). Only 15 studies fulfilled all the selection criteria. Two reviewers screened the full texts independently.

Quality Assessment
The randomized controlled trials (RCTs) were rated using the Physiotherapy Evidence Database (PEDro) Scale [19]. Ten out of 12 RCTs were rated as "High" quality but showed low scores in the following scale elements: concealed allocation, blind subjects, blind therapists, and blind assessors. Two studies were rated as "fair" quality but showed low scores in concealed allocation, blind subjects, blind therapists, blind assessors, adequate follow-up, and intention-to-treat analysis (Table 1).

Intervention Regime
The frequency, duration, and length of interventions varied among the 15 studies. In terms of frequency, participation was daily (n = 4), three times a week (n = 2), twice a week (n = 1), weekly (n = 2), or monthly (n = 1). Five studies did not specify the frequency [23,25,27,28,30] The duration of each session ranged from 25 to 60 min. The length of interventions ranged from one to six months ( Table 2).

Outcome Measures
The duration of the intervention from the baseline to the end was within 1-12 months, with 8 of 15 studies using ≥6 months as the final assessment ( Table 3).
The outcome measures of the TH interventions included assessments of pain, fatigue, depression, anxiety, distress, mobility, anthropometry, physiological measures, muscle strength, physical activity level, exercise intensity, cognitive function, symptom burden, QOL, well-being, sleep quality, diet quality, self-efficacy or confidence, and motivational readiness ( Table 3).
Other measures used included the rate of adherence to TH interventions, duration, satisfaction with delivery method or quality, usefulness, appropriateness of contents, barriers and facilitators to intervention contents, intervention effect according to participants' age group and completion rate of the session (module) or assignment (Table 3).

Symptom Self-Management
Symptom self-management intervention programs consisted of the medical management of conditions or issues related to chronic conditions and programs for meaningful behavior change and maintenance [21,24]. Along with the education session, support materials (call or written format) were provided for the continuous support of changed behavior. After the intervention, there was significant relief of the symptom burden and improvement of QOL [21], reduction of pain, fatigue, and depression [24] (Tables 2 and 3).

Lifestyle Behavior Change
Four studies used lifestyle behavior change interventions based on exercise and diet behaviors using the web-or mobile-based applications. They consisted mainly of education or counseling, monitoring of physical activity (duration and intensity) and healthy eating (food and drink intake), and provided feedback [22,[33][34][35]. Lifestyle change and support intervention had significant effects in improvements in moderate physical activity, self-efficacy for physical activity, QOL [22,33,35], and reduction in anthropometrics (body mass index, weight), positive changes in overall diet quality and consumption, and reduced severity of fatigue [35] (Tables 2 and 3). • Significantly higher in all EPIC domain areas in the intervention group from baseline at 5 and 12 months (p < 0.001) but no significant differences between groups maintained at 12 months • Improvement in symptom focus area domains in the intervention group from baseline at 5 and 12 months • No differences in confidence in symptom self-management, cancer control and outlook, or PEPPI at 5 months • higher coping appraisal in the intervention group at 5 months (p = 0.02) • Satisfaction rate with the program and intention to recommend: 80% or more
Cognitive Behavioral Therapy, Problem-Solving Therapy Three studies used specific CBT modules, Kanker Nazorg Wijzer (KNW), or internet-based survivorship program with information and resources (INSPIRE) developed based on psychoeducation with a cognitive behavioral approach [26,29,31]. KNW consists mainly of educational modules and covers topics related to return to work, fatigue, anxiety and depression, social relationship and intimacy issues, physical activity, diet, and smoking cessation [35]. INSPIRE is a program for hematopoietic stem cell transplantation survivors with the aim of boosting health (cardiovascular, bone, and second cancer risks and recommendations), restoring energy (fatigue, muscle weakness, and inactivity), and renewing outlook (depression, distress, and social isolation) [36]. Problem-solving therapy (PST) is based on problem-solving, a component of psychological education, and it focuses on problem identification, solution finding, trying out solutions, and evaluating the result. The study that used CBT-alone [29] showed an increase in moderate physical activity, but did not show a significant intervention effect on vegetable consumption. A combination of CBT and PST showed a significant improvement in the emotional and social function of QOL, reduction of depression and fatigue [26], and distress [31] ( Tables 2 and 3).

Cognitive Behavioral Therapy for Insomnia (CBTI)
CBTI is an intervention aimed at improving sleep quality without the use of pills. Two studies used this intervention. It involved education on topics such as sleep restriction and stimulus control, cognitive restructuring, sleep hygiene and relapse prevention, and completion of the sleep diary by participants [20,28]. There was a significant improvement in sleep-related outcomes (e.g., sleep efficiency, sleep onset latency) and decreased insomnia severity. McCarthy et al. also reported a significant improvement in QOL, beliefs, and attitudes towards sleep and reduction of fatigue [20] ( Tables 2 and 3).

Mind-Body Training (MBT)
One study used mind-body training [27]. It focuses on the mind-body connection that helped in the identification of passive imagery (fear and loss of control), creation of active imagery (empowering, meaning-making themes), and practice of targeted imagery (imagining healthy physiological conditions). There was a significant improvement in fatigue, cognitive dysfunction, sleep disturbance, and QOL in the web-based intervention group compared with the waitlist. However, there were no differences between the web-based intervention group and in-person intervention group (Tables 2 and 3).

Discussion
This systematic review comprehensively evaluated the effects of TH interventions within the scope of OT on outcomes of occupational engagement.
This review provides evidence that PA interventions using TH technology for cancer survivors had a positive effect on physical function, cognitive function, cancer-related pain, fatigue, and QOL. The types of physical activity included resistance and/or aerobic exercise and walking ( Figure 2). One study reported satisfaction with and adherence to PA interventions using the TH approach [23]. These interventions consisted of a battery of specific exercises, e.g., warm-up, resistance and aerobic exercise training, and cool-down. The effectiveness of PA interventions for cancer patients is known. They increase physical function, reduce cancer-related fatigue, and improve sleep quality and QOL regardless of the type or stage of cancer [37]. Spence et al. reported that PA is an effective approach for cancer patients or survivors regardless of the timing of cancer treatment [38]. OT practitioners can provide PA interventions using TH to incorporate PA into the survivors' daily life for enhancing health, wellness, and QOL.
Many cancer survivors experience symptoms such as fatigue, depression, hot flashes, breathing problems, pain, and sleep. There are specific symptoms that require management depending on the type of cancer [39]. In symptom self-management interventions included in the review, one study focused on the urinary tract, sexual organs, bowel, and general health for prostate cancer survivors. Another study addressed common concerns of breast cancer, health self-management techniques, and understanding of side effects. Both studies provided education and support via telephone. Symptom self-management interventions using a telephone had positive effects on relief of the symptom burden, improved the QOL, and reduced pain, fatigue, and depression [21,24]. OT practitioners can help clients engage in their occupational activities through symptom education and management by facilitating and supporting problem-solving skills using TH technology via a telephone. weeks [26]. In CBT-alone, moderate physical activity was improved in participants under the age of 57 [29]. CBTI improved sleep-related outcomes and QOL [20,28], and reduced fatigue [20]. Unlike face-to-face contacts, internet-based psychosocial interventions for cancer survivors overcome the limitations of accessibility. In this regard, the results of this review show the positive potential for psychosocial approaches using TH to improve survivors' daily lives and occupational performance. Occupation-based theories can be complemented with health behavior change theories such as the health belief model, the transtheoretical or stages of change theory, and social cognitive theory. These will aid in evaluating the factors that lead to healthy behaviors and to develop behavior-based interventions that promote change [44]. Lifestyle behavior change interventions in the review addressed exercise and diet behavior using the web-or mobile-based applications. Two out of four studies were compared to control groups that provided usual care. The possibility of lifestyle behavior change interventions using TH as an effective delivery service was confirmed in this review. There were significant improvements in moderate physical activity, QOL [22,32,35], overall diet quality, and reduction of fatigue [35]. Kim et al. reported an adherence rate of >91% (exercise, diet) and helpfulness rate of >95% for TH interventions, showing the possibility of using TH as a lifestyle behavior change intervention [22].
There is a wide range of interventions that OT practitioners can provide for cancer survivors. The review confirmed that the PA TH interventions, symptom self-management, lifestyle behavior change, and Psychosocial interventions in the review were CBT, CBT-PST, CBTI, and MBT. Cancer survivors need to take an active role in managing their health and well-being. However, many survivors have low self-efficacy in managing fatigue and distress [40]. PST and CBT have been reported to improve survivors' health and well-being management skills [41]. CBT is a problem-specific, goal-oriented approach that focuses on dealing with current problems such as inaccurate or negative thinking. PST focuses primarily on problem-solving skills including identifying problems, finding solutions, trying out solutions, and evaluating the results [31]. It has been reported that CBTI can lead to an improvement in sleep outcomes and a decrease in associated daytime symptoms in patients after cancer treatment [42]. MBT in the review was an image-based behavioral approach. It uses guided images to create a specific sensory experience for achieving clinical goals such as promoting the treatment of specific symptoms or overall well-being [43]. Hunter et al. reported that psychosocial components such as PST, CBT, and MBT are beneficial for survivors regardless of age or type or stage of cancer and can improve depression, anxiety, and QOL [37]. As a result of a combination of CBT and PST, there were significant improvements in depression and fatigue and distress reduction. In addition, Willems et al. showed a high adherence to TH interventions of 83.9% for 18 weeks [26]. In CBT-alone, moderate physical activity was improved in participants under the age of 57 [29]. CBTI improved sleep-related outcomes and QOL [20,28], and reduced fatigue [20]. Unlike face-to-face contacts, internet-based psychosocial interventions for cancer survivors overcome the limitations of accessibility. In this regard, the results of this review show the positive potential for psychosocial approaches using TH to improve survivors' daily lives and occupational performance.
Occupation-based theories can be complemented with health behavior change theories such as the health belief model, the transtheoretical or stages of change theory, and social cognitive theory. These will aid in evaluating the factors that lead to healthy behaviors and to develop behavior-based interventions that promote change [44]. Lifestyle behavior change interventions in the review addressed exercise and diet behavior using the web-or mobile-based applications. Two out of four studies were compared to control groups that provided usual care. The possibility of lifestyle behavior change interventions using TH as an effective delivery service was confirmed in this review. There were significant improvements in moderate physical activity, QOL [22,32,35], overall diet quality, and reduction of fatigue [35]. Kim et al. reported an adherence rate of >91% (exercise, diet) and helpfulness rate of >95% for TH interventions, showing the possibility of using TH as a lifestyle behavior change intervention [22].
There is a wide range of interventions that OT practitioners can provide for cancer survivors. The review confirmed that the PA TH interventions, symptom self-management, lifestyle behavior change, and psychosocial interventions improved the cognitive function, participation in PA, lifestyle change including dietary habits and QOL. They also reduced cancer-related pain, fatigue, depression, and anxiety of the survivors. Although the direct outcomes of occupational engagement excluding sleep could not be confirmed through this review, outcomes of factors affecting occupational engagement were confirmed. The limitations of this review arise from the study design and methods of the included studies such as small sample sizes, a control group setting that is difficult to compare with TH and in-person interventions. In the control group setting, most of the control groups were wait list groups, and interventions provided to them are related information and recommendations through written format. There were no comparative studies on the effects of in-person and TH intervention, adherence rate, and client's satisfaction. In addition, in the case of chronic conditions, such as cancer survivors, it is important to verify the long-term effect of the intervention, but some studies in this review did not verify the sustained positive effect for a prolonged period of time after the completion of the intervention. The studies included in this review focused on the outcomes of cancer-related symptoms and QOL. No study reflected the perspective of OT such as occupational performance and social participation. However, this study identified the evidence that OT practitioners can apply TH within a unique professional perspective for cancer survivors and plan TH intervention programs addressing OT concerns. OT-specific research focusing on occupation-based interventions using TH for cancer survivors, interventions that cooperate with daily life, and outcomes of activities and participation will be needed in the future.

Conclusions
This review shows that a TH approach in the scope of OT for cancer survivors has positive therapeutic effects and offers the possibility of an alternative service delivery model of OT services to survivors. Although the direct outcomes of occupational engagement such as ADL, work, leisure, social participation, and sleep could not be confirmed through this review, outcomes of factors affecting occupational engagement were confirmed. Occupational therapy-specific research using TH interventions for cancer survivors will be needed in the future. These studies should focus on occupation-based interventions using TH, and outcomes of activities and participation.