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

BACKGROUND The delivery of clinical care services using personalised health approaches is an integral component of cancer care. This review synthesised evidence on the efficacy and cost-effectiveness of stepped-care interventions delivered to manage therapy-related symptoms in cancer populations compared to care-as-usual (CAU). METHODS 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 Jan 2010 to Nov 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. RESULTS The review summarises a total of 22 studies, involving 4,588 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 reported cost-effectiveness evidence, which showed cost savings of approximately €19,991 for each point improvement on the distress scale and lower incremental costs of approximately €3,950 associated with stepped-care interventions. CONCLUSIONS 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 determine the long-term effectiveness and sustainability of stepped-care interventions in representative cancer populations and routine clinical care settings.