Online Symptom-Management Curriculum May Improve Depression and Fatigue in Breast Cancer Survivors

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With thousands of devices to track and manage health and wellness, eHealth tools are beginning to transform modern health care and research, demonstrating quantifiable improvements in patient outcomes. According to the results of a randomized controlled trial (Reimagine), breast cancer survivors participating in an online symptom self-management curriculum experienced a greater reduction in depression and fatigue compared with the control arm.1

Nevertheless, there are still limits to the reach of these interventions. Researchers in the Reimagine trial found no significant differences in pain outcome measures. Moreover, participants were predominantly white and college-educated, suggesting possible socioeconomic barriers to uptake.

Overall, the treatment participants found the program helpful and beneficial, and 93% would recommend Reimagine to others.
— Sophia K. Smith, PhD, MSW

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“These results suggest that Reimagine affected depression and fatigue symptoms for breast cancer survivors,” said Sophia K. Smith, PhD, MSW, of Duke School of Nursing, Duke Cancer Institute, “and the study was well received by participants. However, additional research is needed with larger and more diverse samples.”

As Dr. Smith reported at the 2017 Cancer Survivorship Symposium, chronic pain is prevalent in breast cancer survivors, with an estimated 30% of patients reporting above-average pain even 10 years after treatment.2

To address this burden, Dr. Smith and colleagues at Duke developed the Reimagine curriculum to teach two major skill sets: solution-focused thinking and mind-body skills. “Solution-focused thinking is a way of restructuring people’s thinking about stressors,” Dr. Smith explained. “It starts with patients identifying what they need to feel better, recognizing what’s in their control, and choosing better thoughts and feelings. The program also teaches mind-body exercises such as guided imagery and meditation.”

Study Details

To be eligible for the study, patients required a breast cancer diagnosis and had to self-report pain of at least 3 on a scale of 0 to 10. Dr. Smith and colleagues randomized 121 participants to receive either Reimagine intervention or usual care. Web-based surveys were administered via REDCap at baseline and following the intervention (at 18 weeks). (REDCap is a free Web-based application designed to support data capture for research studies.)

“Everything was online,” said Dr. Smith. “Treatment participants viewed videos online, attended group meetings online, and completed homework online as well. These assignments involved cognitive reframing and mind/body exercises.”

Dr. Smith and colleagues ultimately analyzed data from 34 patients in the Reimagine arm and 52 patients from the usual care arm. The dropout rate was higher in the Reimagine arm, Dr. Smith noted, with “too busy” or “too sick” being the most commonly cited reasons for nonparticipation.

The majority of participants were college graduates, married, white, and employed. The mean age was 57 years.

Key Findings

Although the researchers found no significant difference in pain outcome measures between the two arms, results showed that Personal Health Questionnaire Depression Scale score improved in the Reimagine arm when compared with the control arm (P = .035). In addition, Functional Assessment of Chronic Illness Therapy-Fatigue scores reflected improvement in quality of life in the experimental arm vs the control arm (P = .038).

Finally, nearly all participants endorsed the effectiveness of the videos.

“Overall, the treatment participants found the program helpful and beneficial,” said Dr. Smith, “and 93% would recommend Reimagine to others.”

Multiple Sources of Information

Tara O. Henderson, MD, MPH

Tara O. Henderson, MD, MPH

In a discussion of the abstract, Tara O. Henderson, MD, MPH, Associate Professor of Pediatrics and Director of the Childhood, Adolescent and Young Adult Cancer Survivor Center at the University of Chicago, emphasized the need for cost-effective, widely disseminated interventions to improve symptoms and quality of life for cancer ­survivors.3

“Dr. Smith and her colleagues were very successful in attracting patients to this study with an e-mail blast of volunteers in a research foundation,” said Dr. Henderson, “and the online, multiapproach behavior intervention demonstrated significant improvements in depression and fatigue. However, we should note that only 61% of the intervention arm completed their measures.”

According to Dr. Henderson, this relatively high dropout rate highlights the importance of providing multiple sources of complementary information and education in combination with eHealth tools to improve outcomes and health behaviors of cancer survivors. In a study by Fleisher et al examining the efficacy of eHealth interventions, 90% of cancer patients reported using print materials, whereas only 60% of the experimental arm used the online intervention.4

“Despite widespread availability of the Web, barriers to using these eHealth interventions still exist,” said Dr. ­Henderson. “It’s important to identify the optimal combination of eHealth, in-person, and paper strategies to optimize survivor and provider outcomes.” ■

Disclosure: This study was funded by Pfizer. Dr. Smith has received research funding from Pfizer. Dr. Henderson reported no potential conflicts of interest.


1. Smith SK, et al: 2017 Cancer Survivorship Symposium. Abstract 182. Presented January 27, 2017.

2. Glare PA, et al: J Clin Oncol 32:1739-1747, 2014.

3. Henderson TO: 2017 Cancer Survivorship Symposium. Oral Abstract Session A—Discussion II. Presented January 27, 2017.

4. Fleisher L, et al: Internet Interv 2:392-398, 2015.