Stepped-care models for cancer symptom management: a systematic review of efficacy and cost-effectiveness

The delivery of clinical care services using personalized health approaches is an integral component of cancer care. This review synthesized evidence on the efficacy and cost-effectiveness of stepped-care interventions delivered to manage therapy-related symptoms in cancer populations compared with care as usual (CAU).

Systematic searches were conducted in MEDLINE, PsycINFO, Embase, Web of Science, Cochrane Library, National Health Service Economic Evaluation Database, and EconLit to identify studies published from January 2010 to November 2024. Peer-reviewed studies that reported outcomes of stepped interventions and CAU were included, and quality appraisal was performed using the Cochrane Risk of Bias 2 and the Risk of Bias in Non-Randomised Studies-of Interventions tools.

The review summarizes a total of 22 studies, involving 4588 unique adult cancer survivors. Fourteen studies identified statistically significant improvements in symptom severity and clinical outcomes comparable to those of CAU. The stepped-care group showed reduced mean severity scores for distress, insomnia, and fatigue, as well as improved stress reactions and emotional reactivity, and fewer palliative care visits. The low uptake of the intervention and inadequate assessment of comorbid symptoms have hindered the ability to draw conclusive recommendations across several studies. Four studies evaulated the cost-effectiveness of stepped-care interventions compared to CAU. Two of these studies reported significant cost savings of approximately €19 991 for each point improvement on the distress scale and lower incremental costs of approximately €3950 associated with stepped-care interventions.

This review highlights the potential clinical and economic benefits of implementing stepped-care interventions to reduce the severity of cancer-related symptoms. Further research is warranted to assess the long-term effectiveness, cost-effectiveness, and implementation feasibility of stepped-care interventions in real-world clinical care settings serving cancer populations with diverse needs.