Internet-Based Cognitive Behavioral Therapy Interventions for Caregivers of Patients With Cancer: Scoping Review

Introduction

The incidence and mortality rates of cancer are rapidly increasing globally. According to the International Agency for Research on Cancer, there were 19.29 million new cancer cases and 9.96 million cancer deaths worldwide in 2020, and the rise in cancer incidence and mortality rates has resulted in a significant disease burden on people [1]. The diagnosis and long-term treatment of cancer not only cause adversity for patients but also impose psychological stress and burdens on caregivers [2]. Caregivers of patients with cancer refer to informal caregivers, including family members, partners, or friends. They provide unpaid social, emotional, and economic support to a family member with cancer requiring care and are involved throughout the patient’s symptom management and nursing [3,4]. Caregivers attend to the daily needs of patients and fulfill family responsibilities; they also serve as the patient’s primary emotional support. Due to complex treatment environments, a lack of disease-related knowledge, and significant economic burdens, caregivers often experience negative emotions such as anxiety and depression [5]. Zhou et al [6] found that 60.7% of caregivers of patients with cancer experience sleep disturbances. Yang et al [7] conducted a survey involving 116 caregivers of terminally ill patients with cancer receiving home care, revealing that 83.62% of the caregivers reported experiencing moderate to severe fatigue, primarily characterized by physical fatigue. Geng et al [8] reported that the prevalence of anxiety and depression among caregivers of patients with cancer was 46.55% and 42.30%, respectively, with 62% of caregivers bearing a heavy burden that negatively affected their daily lives. Therefore, attention should be given to the physical and mental health of caregivers, along with the provision of appropriate supportive care.

Current interventions for caregivers of patients with cancer include psychosocial support, education, and informational support [9]. Cognitive behavioral therapy (CBT) has received considerable attention owing to its robust theoretical foundation, brief treatment duration, and well-defined structural approach. However, traditional CBT is often influenced by economics, time, and spatial factors, preventing some caregivers from accessing effective help and support [10]. In recent years, with the rise of the “Internet+Healthcare” service model, internet-based cognitive behavioral therapy (ICBT) has emerged. ICBT is an internet-based treatment approach that uses tools such as computers and mobile devices to deliver the core content and skills of CBT through text, video, images, and audio [11].

ICBT addresses the limitations of CBT in its application. Some caregivers concentrate on caregiving behaviors, frequently suppressing their own emotions, which may lead to distress stemming from a deficiency in caregiving skills. ICBT provides caregivers with a discreet online platform that allows them to access relevant information at any time through simple and user-friendly self-service methods, facilitating timely communication with health care professionals and enhancing their cognitive abilities. In addition, techniques such as emotional guidance and relaxation training are used to alleviate caregiver stress and improve their quality of life (QoL) [12,13]. Existing studies have shown that ICBT can mitigate the anticipatory grief experienced by caregivers of patients with cancer, decrease caregiving burden, and improve their self-efficacy [14].

Currently, research on the application of ICBT for caregivers of patients with cancer is steadily growing. However, there is significant heterogeneity in the forms of online interventions, intervention content, and outcome indicators. To gain a comprehensive understanding of the current research status of ICBT, this study uses a scoping review to systematically analyze pertinent studies from both domestic and international contexts. Our goal is to provide references to promote the use and dissemination of ICBT among caregivers of patients with cancer in China.

Methods

Study Design and Framework

This scoping review adhered to the methodological framework developed by the Joanna Briggs Institute (JBI; 2019) [15]. The reporting follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines (Checklist 1).

Research Questions

The review addressed three key questions: (1) what are the intervention components of ICBT for caregivers of patients with cancer?; (2) what are the intervention forms, duration, and evaluation time points for ICBT?; and (3) what are the outcome indicators and effects of ICBT interventions?

Search Strategy

A systematic search was conducted across 9 databases, including CNKI, Wanfang Database, China Biomedical Literature Database, VIP, PubMed, Web of Science, Embase, CINAHL, and Cochrane Library. The search timeframe extended from the establishment of the databases to June 6, 2024. A combination of subject headings and free-text terms was used. The search strategy was formulated with the guidance of a librarian. The English search terms were “neoplas*, carcinoma*, tumor, oncology, cancer*;” “Cognitive Behavio*, Behavio* Therap*, Cognitive Therap*, ICBT, cognitive behavioural therapy, CCBT;” “online, network, Internet, smartphone, telephone, computer;” and “caregiver*, spouse, family, informal caregiver, couple*.” The search strategy for each database was documented in the Multimedia Appendix 1.

Study Selection

The eligibility criteria is presented in Textbox 1.

Data Extraction and Quality Assessment

The literature search results were imported into EndNote X9 for duplicate removal. Two independent reviewers (CTS) and (XML) screened titles, abstracts, and full texts against the predefined inclusion and exclusion criteria. Discrepancies were resolved through discussion with a third researcher to reach consensus. One reviewer (CTS) extracted study data using a standardized Microsoft Excel form, capturing authors, publication year, country, design, population characteristics, sample size, interventions, and outcomes, with a second reviewer (XML) independently verifying the accuracy and completeness of all extracted data. For included randomized controlled trials, we conducted quality assessments using the Cochrane Risk of Bias Tool (version 5.1.0) [16], categorizing studies as grade A (low risk), B (moderate risk), or C (high risk), with any discrepancies resolved through consultation with a third researcher to reach consensus.

Results

Study Selection and Characteristics

The systematic search identified 1005 records, with 12 studies meeting inclusion criteria after screening (Figure 1) [14,16-26]. The studies (2013‐2023) represented diverse geographic regions, such as the United States (4/12, 33%), Australia (3/12, 25%), China (3/12, 25%), Lithuania (1/12, 8%), and Germany (1/12, 8%). Study designs included randomized controlled trials (9/12, 75%), quasi-experimental (1/12, 8%), mixed-methods (1/12, 8%), and feasibility studies (1/12, 8%). Quality assessment of randomized controlled trials (RCTs) indicated moderate methodological rigor (B-level). Table 1 details the basic characteristics of the included studies.

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Intervention Content

The included studies incorporated the following key components in their ICBT interventions for caregivers (Textbox 2).

The included studies typically incorporated 3‐5 core intervention modules. Following each intervention session, participants were required to complete structured homework assignments, which included documenting caregiving-related emotional experiences, evaluating automatic thoughts using thought records, emotional expression through writing exercises [21], completion of structured writing tasks [25], and home practice of acquired skills [19,20].

The reviewed literature revealed 2 distinct ICBT delivery models for caregivers. Seven studies [14,17,21-23,25,27] implemented caregiver-specific interventions focusing on cognitive restructuring, emotional regulation training, and evidence-based relaxation techniques to enhance multidimensional wellbeing. Alternatively, 5 studies [18-20,24,26] used dyadic approaches that simultaneously engaged both patients and caregivers through adapted protocols delivered in either parallel or joint therapeutic sessions. Both models demonstrated effectiveness in addressing the psychological needs of caregivers while accounting for different caregiving contexts.

Intervention Elements

The ICBT interventions examined in this study comprised several key components, such as delivery modality, provider qualifications, intervention duration, and evaluation timelines. The primary delivery modalities included web-based platforms (4/7, 57%) studies with real-time psychologist support or email feedback [14,17,20-22,25,26], telephone sessions (45‐60 min) [18,19,24,27], and video conferencing [23]. Interventions were predominantly delivered by psychotherapists, with 1 study [22] using a multidisciplinary team (psychologists, physicians, and nurses). Intervention duration varied (most commonly 6‐8 weeks [17,20-22,26]) depending on content and format. Telephone sessions typically lasted 45‐60 minutes [19,24], though some flexible protocols permitted completion within 1 week [14,17,21,26]. Effectiveness was evaluated at 3 time points: (1) baseline (preintervention, confirming group comparability [P>.05]), (2) postintervention, and (3) follow-up (1‐12 months) in 4 studies [18,22,23,25]. Qualitative components (semistructured interviews) were included in 2 studies [17,27] to assess participant experiences.

Outcome Indicators and Effectiveness Evaluation of Interventions

The ICBT interventions evaluated 7 primary outcome measures: feasibility (n=4 studies [17,23,24,27]), acceptability (n=4 studies [17,23,24,27]), QoL (n=8 studies [17,20-26]), caregiver burden (n=4 studies [14,19,21,27]), psychological distress (n=11 studies [14,17-25,27]), posttraumatic growth (n=3 studies [18,20,25]), and self-efficacy (n=3 studies [14,19,23]).

Feasibility

Feasibility was assessed based on recruitment, retention, and completion rates. In total, 2 studies [17,27] reported recruitment rates below 50%, primarily attributed to participants’ aversion to online support, lack of interest, demanding work schedules, and substantial caregiving commitments. Although most participants completed all intervention modules, attrition occurred due to heightened psychological distress, time constraints, or deterioration of the care recipient’s health [20]. Attrition rates generally ranged from 3% to 16%, with one exception reaching 31% [17]. Qualitative analysis suggests this discontinuation pattern may result from both the lack of personalized engagement in digital interventions and deliberate withdrawal after achieving therapeutic objectives.

Acceptability

Acceptability was assessed through participant-reported satisfaction with both intervention content and engagement modalities. Many caregivers expressed positive feedback regarding the intervention, stating that “the online intervention is convenient, time-saving, and practical,” “they were satisfied with the information and quality provided,” “the skills learned were relevant to cancer treatment,” and “the intervention courses helped alleviate stress.” However, 1 study [17] indicated that 33% of participants felt the intervention did not adequately address the needs of caregivers, while another study revealed disagreement about whether patients and caregivers should be treated together. Specifically, 45% of caregivers preferred individual interventions, 36.4% favored some combined treatment, and 18.2% preferred fully integrated interventions.

Psychological Outcomes of Caregiver Intervention

Cognitive-behavioral interventions demonstrated measurable benefits for caregiver mental health. The stress management program by Carr et al [27] significantly improved caregivers’ stress coping abilities (effect size r=0.39), while 2 other trials [14,21] reported statistically significant reductions in caregiver burden (P<.05). Caregivers often experience negative emotions such as anxiety, depression, or sadness due to prolonged caregiving and stress [28]. ICBT interventions showed moderate efficacy in alleviating anxiety and depression [17,21], with the structured writing intervention (“Online-Trauertherapie”) by Kaiser et al [25] producing effect sizes ranging from 0.29 to 0.84 across multiple psychological domains. Notably, Trevino et al [24] found patient-caregiver anxiety changes were positively correlated, though other psychological outcomes showed nonsignificant associations. Some studies [23,29] reported limited effects on anxiety or depression, potentially due to low baseline distress levels or requiring specific intervention components (eg, guided imagery) to achieve psychological benefits.

QoL

The included studies reported mixed effects on caregiver’s QoL. A total of 4 trials [17,20,21,25] demonstrated statistically significant QoL improvements following intervention. Notably, one spouse-focused intervention [26] showed significant patient QoL benefits, suggesting potential secondary effects. However, 3 studies [22-24] found no significant QoL changes for caregivers, potentially due to shorter intervention durations or differing outcome measures.

Discussion

Principal Findings and Comparison With Previous Work

This study examines the existing research on ICBT interventions for caregivers of patients with cancer. A systematic review of 12 eligible studies revealed that ICBT is a feasible and acceptable approach for this population. The findings suggest that ICBT may alleviate anxiety and depressive symptoms among caregivers, with some studies additionally reporting reduced caregiver burden and enhanced self-efficacy.

These findings are consistent with previous studies, demonstrating the acceptability and feasibility of ICBT when applied to caregivers. For instance, Meichsner et al [30] observed high satisfaction and enhanced well-being among dementia caregivers following ICBT. Similarly, Tur et al [31] documented strong participant satisfaction in an ICBT program for prolonged grief disorder, with 75% of participants achieving clinically significant reductions in depressive symptoms and 50% demonstrating meaningful improvements in grief-related cognitions. Further corroborating these results, Titov et al [32] reported that 63% of individuals with generalized anxiety disorder experienced significant anxiety reduction after ICBT, with concurrent improvements in comorbid depression.

However, the effects of ICBT on caregivers’ QoL were inconsistent across studies. While some improvement in QoL was observed, the overall effect was not statistically significant, possibly due to the relatively short intervention duration. Although follow-up assessments were conducted in some studies, no significant differences in QoL were detected. Li et al [33] suggested that improvements in QoL generally require a longer time to manifest compared with behavioral or mental health changes. In addition, multiple factors, such as caregivers’ socioeconomic status, age, caregiving duration, coping strategies, the patient’s clinical condition, and available social support may influence intervention outcomes [34]. Therefore, future studies should implement multidimensional assessments of caregiver well-being (addressing physical, psychological, emotional, and social domains) to inform personalized interventions, while extending intervention durations to better evaluate long-term QoL outcomes.

This scoping review synthesizes existing literature on ICBT interventions for caregivers of patients with cancer, offering key insights into the current evidence base. Our findings highlight the feasibility and acceptability of most programs; however, recruitment challenges were evident, with a substantial proportion of eligible caregivers declining participation. Furthermore, enrolled participants exhibited high attrition rates. To enhance intervention engagement and retention, future studies should focus on precise population targeting, refined inclusion criteria, and proactive baseline assessments to identify and support at-risk caregivers.

Population Specificity and Methodological Variability

Among the included studies, 3 investigations [21,24,25] specifically targeted subgroups with distinct characteristics, such as caregivers exhibiting elevated anxiety levels or heightened caregiving burdens. Another 3 studies [19,26,27] enhanced research specificity by focusing on particular cancer types. Several studies treated patient-caregiver dyads as intervention units [24,26], demonstrating that caregiver support could reduce patients’ psychological distress and improve their QoL. This reciprocal relationship reflects how caregivers’ comprehensive support impacts patients’ recovery and emotional state, while patients’ conditions similarly affect caregivers’ wellbeing. Li et al [35] found dyadic collaboration improved both QoL and coping outcomes, though some caregivers preferred individual interventions. Future research should systematically compare the efficacy of caregiver-only interventions versus dyadic intervention approaches.

In total, 2 studies [17,27] included qualitative postintervention evaluations. Carr et al [27] reported that caregivers benefited from recognizing automatic thought patterns, which improved their awareness of irrational thinking and overall wellbeing. However, participants suggested improvements, including initial in-person contact with facilitators, more personalized resources, and better scheduling to accommodate caregiving duties. While ICBT applications for caregivers remain exploratory, mixed-methods approaches combining quantitative outcome measures with qualitative insights can strengthen the evidence base for optimizing interventions [36].

Exploring Intervention Content and Delivery Formats

Effective intervention design must prioritize both engagement and usability through personalized support programs that address caregivers’ specific needs. A critical yet frequently overlooked component is the implementation of preparatory phases, as evidenced by our review finding that only 5 studies incorporated preintervention assessments. These preliminary modules should systematically collect caregiver characteristics to inform tailored recommendations, which could significantly improve both participation rates and intervention adherence. Establishing such foundational elements represents an important direction for future research development.

The caregiving role often generates substantial psychological burdens, stemming from challenging role transitions, difficulties adapting to medical environments, and the inherent stress of managing a loved one’s illness. Compounding these issues, caregivers frequently suppress their emotions and neglect self-care, resulting in diminished QoL [37,38]. Research by Zhang et al [39] demonstrates that targeted interventions incorporating relaxation training can yield multiple benefits, such as regulating neuropsychological functions, alleviating chronic physical tension, improving physiological responses, and reducing illness-related stress, ultimately decreasing caregiver burden while promoting positive behavioral changes. Therefore, intervention content should integrate 3 key components: (1) cognitive restructuring to modify maladaptive thought patterns; (2) emotional support systems; and (3) practical strategies including context-appropriate health education and relaxation techniques. This comprehensive approach will better equip caregivers to manage their multifaceted challenges.

This study found that few interventions target caregivers’ self-symptom management. While 2 studies assessed interventions for caregiver symptoms (eg, pain, fatigue, and sleep) [20,25], no significant improvements were observed, possibly due to differing intervention focuses. However, Shaffer et al [40] reported substantial reductions in insomnia among cancer caregivers through an internet-based program, even though it was not caregiver-specific. Similarly, Ye et al [41] demonstrated that ICBT improved sleep, anxiety, and depression in patients with insomnia . Future research should develop symptom-specific interventions tailored to caregivers to validate their efficacy.

Our study found that online caregiver interventions typically involve real-time psychologist support or email feedback. To optimize website- or WeChat-based interventions, integrating interactive features (eg, chat functions and message boards) is recommended. Caregivers should receive prompt module-specific feedback via email, with professionals addressing inquiries swiftly to build trust. Evidence confirms that therapist-guided ICBT outperforms unguided interventions [42], as therapist engagement sustains participant adherence. For caregivers with limited digital literacy, technical assistance and age-friendly design features (eg, larger subtitles and enhanced visibility) are essential [43]. While video or telephone interventions enable direct communication and emotional support, they risk inefficiency in handling repetitive queries and may compromise continuity. WeChat public platforms or online websites could serve as supplementary tools. Telemedicine and mobile health solutions should be leveraged to comprehensively address caregivers’ diverse needs.

Limitations

This review acknowledges several limitations. First, the included studies exhibited significant variability in intervention measures, participant characteristics, sample sizes, and outcome indicators, potentially limiting the generalizability of ICBT efficacy findings. Second, the lack of long-term follow-up assessments in most studies necessitates future research with extended evaluation periods to better understand sustained intervention effects. Third, while we only assessed risk of bias in RCTs, more comprehensive bias evaluations using standardized tools would strengthen future findings. Finally, the included studies originated from various countries, highlighting certain cultural differences. Nonetheless, this diversity underscores the feasibility and acceptability of ICBT among caregivers of patients with cancer.

Implications for Future Research

To optimize resource use and enhance support for caregivers seeking online assistance, it is imperative to establish a dedicated support team composed of oncologists, nurses, and psychotherapists. Oncologists can build trust with patients and caregivers, promoting engagement and addressing maladaptive cognitions, which has been shown to improve outcomes and reduce attrition [44]. Nurses can serve as interdisciplinary coordinators and health educators, identifying caregiver needs, delivering symptom management guidance, and providing holistic biopsychosocial support. By fostering collaboration among multidisciplinary professionals, caregivers can receive more comprehensive support, capitalizing on the diverse strengths of various specialists and enhancing overall caregiver satisfaction.

Conclusions

This study presents a scoping review of the application of ICBT among caregivers of patients with cancer. ICBT combines the advantages of CBT with the accessibility of smart devices. Preliminary evidence suggests that ICBT is effective in alleviating caregivers’ negative emotions, reducing stress, and enhancing positive experiences. Nevertheless, significant shortcomings remain in the research concerning intervention content, sample size, adherence, evaluation criteria, software development, and intervention teams. Currently, internet-based cognitive-behavioral interventions for caregivers of patients with cancer in our country are still in the nascent stages. It is crucial to draw upon relevant international studies while considering the unique characteristics of domestic caregivers to develop tailored ICBT intervention programs. By leveraging artificial intelligence to create safe and effective online platforms and fostering multidisciplinary collaboration, we can provide comprehensive physical and mental health interventions for caregivers, thereby genuinely alleviating their caregiving burden, reducing negative emotions, and enhancing their QoL.