Telehealth for Anxiety and Depression in Patients With Breast Cancer: An Umbrella Review and Meta-Meta-Analysis (Preprint)

BACKGROUND Anxiety and depression are highly prevalent yet often undertreated psychological burdens among patients with breast cancer. While psychosocial care is essential, barriers to traditional in-person support highlight the need for innovative approaches. Telehealth interventions have emerged as promising strategies to address these challenges and additionally contribute to environmental sustainability by reducing greenhouse gas emissions associated with in-person visits and patient transportation. Despite these advantages, evidence regarding the effects of telehealth interventions on psychological outcomes remains inconsistent, raising concerns about the reproducibility and generalizability of existing findings. OBJECTIVE This study aimed to synthesize evidence from published meta-analyses of randomized controlled trials (RCTs) that evaluated the effects of telehealth interventions, including eHealth and mHealth, on anxiety and depression in patients with breast cancer, using a meta-meta-analysis approach. METHODS Published meta-analyses of RCTs assessing telehealth interventions for anxiety, depression, or both in breast cancer populations were included. Methodological quality was evaluated using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Effect sizes reported in the included meta-analyses were quantitatively pooled using a random-effects model. The results are presented as standardized mean differences (SMDs) and 95% CIs. Leave-one-out sensitivity analyses were performed to assess heterogeneity. Moreover, subgroup analyses by intervention type were performed. Certainty of evidence was graded through umbrella review as follows: convincing (Class I), highly suggestive (Class II), suggestive (Class III), weak (Class IV), or nonsignificant. RESULTS Seven meta-analyses (including 88 RCTs with 13 998 participants) were included. Telehealth interventions led to a small but significant reduction in anxiety (SMD = −0.10, 95% CI −0.18 to −0.03; I2 = 1.2%). For depression, the pooled effect was nonsignificant (SMD = −0.05, 95% CI −0.23 to 0.12; I2 = 54.7%). No subgroup differences by modality were detected for anxiety or depression. For anxiety, mixed-modality approaches revealed a small, consistent benefit, but eHealth or mHealth alone did not. Moderate interstudy heterogeneity was noted for mHealth. Intervention type exerted no significant effects on depression. In leave-one-out sensitivity analyses, heterogeneity decreased (I2 ≈ 0%) after the exclusion of 4 studies that varied in terms of intervention duration (<6 wk to >1 y) and outcome measures. Across meta-analyses, all calculable 95% prediction intervals included the null, and heterogeneity was often moderate to high. certainty ratings were predominantly Class IV or non-significant, with one depression meta-analysis rated Class III and showing small-study effects. CONCLUSIONS Telehealth interventions, particularly eHealth incorporating synchronous professional communication, may moderately reduce anxiety in patients with breast cancer. Interstudy variability in intervention duration and outcome measures limited the certainty of our pooled estimates. Telehealth may indirectly support sustainable development goals (SDG 3: Good Health and Well-being; SDG 13: Climate Action) by improving access to psychosocial care while reducing travel-related emissions. CLINICALTRIAL The study protocol was registered with the International Prospective Register of Systematic Reviews database (registration number: CRD420251103916).