Cancer and its treatments often contribute to burdensome symptoms that negatively impact patients’ quality of life and treatment outcomes, including fatigue, anxiety, and depression.1 Many patients experience multiple symptoms concurrently2 that can disrupt their treatments and lead to unplanned hospitalizations.3,4 Of note, fatigue is the cause for many emergency department visits and is correlated with poor treatment-related outcomes, such as overall survival, in patients with advanced cancer.5,6
Substantial evidence indicates that mind-body therapies such as meditation, yoga, and tai chi that are centered on mind-body-behavior interactions, as well as exercise, are effective in managing fatigue,7-9 anxiety and depression,10 along with nausea and vomiting7,8 in patients with cancer. Practice guidelines from ASCO, the National Comprehensive Cancer Network, and the Society for Integrative Oncology recommend mind-body therapies and exercise for symptom control in patients with cancer who are on active treatment.11,12
Jun J. Mao, MD, MSCE
Bobby Daly, MD, MBA
However, despite these guideline recommendations, patient-level barriers that include transportation and time, as well as institutional-level barriers such as staffing, space, and scarcity of providers trained in integrative oncology impede patient access to these therapies.13,14
The Integrative Medicine@Home (IM@Home) intervention—a virtual, live mind-body therapy and fitness program developed to address the symptom management needs of patients with cancer during the COVID-19 pandemic—was shown to be feasible and scalable, with high rates of patient use and acceptance.15 The randomized clinical IMPROVE trial then looked to evaluate the effect of a virtual integrative medicine program on patient-centered outcomes, such as symptom burden and acute care use.
IMPROVE Trial: Key Results
The IMPROVE study was conducted at Memorial Sloan Kettering Cancer Center to evaluate the effect of IM@Home on fatigue, comorbid symptoms, and acute health-care use. The 12-week trial included 200 participants undergoing active treatment and experiencing moderate or severe fatigue. Patients were randomly assigned to the IM@Home group (n = 99), where patients had access to 23 synchronous, virtual mind-body therapy and exercise classes via Zoom, or to an enhanced usual care (n = 101) arm that received standard care along with access to 17 prerecorded, on-demand audio or video recordings for meditation, relaxation, and guided imagery.
Of the 88 patients who registered for IM@Home classes, the majority engaged in three classes a week (31, 35.2%), followed by four classes/week (21, 23.9%), two classes/week (15, 17.0%), five classes per week (13, 14.8%), six classes/week (6, 6.8%), and one class/week (2, 2.3%). The most popular classes were yoga (69, 78.4%) and fitness (63, 71.6%), followed by meditation (52, 59.1%), tai chi/qigong (50, 56.8%), music therapy (20, 22.7%), and dance (15, 17.0%). Among the group given enhanced usual care, 81 patients (80.2%) accessed on-demand resources at least once, averaging three times a week (range: 1–10 times per week).
The mean age of the participants was 59.9 years (range: 29–90 years); 181 patients were women; 155 were White, 18 were Black, 15 were Asian, and 178 were non-Hispanic/Latino Hispanic. A total of 73 patients had breast cancer, 49 had thoracic cancer, 43 had gynecologic cancer, 25 had head and neck cancer, and 10 had melanoma.
The primary outcome was severity of fatigue, measured by the Brief Fatigue Inventory. Secondary outcomes were symptom distress, anxiety, depression, insomnia, quality of life, and acute health-care use.
Study findings showed that from baseline to week 12, the fatigue score of patients in the IM@Home arm decreased by a mean of 1.99 points (95% confidence interval [CI] = −2.29 to −1.70) compared with the enhanced usual care group, with a reduction in mean of 1.51 points (95% CI = −1.81 to −1.21; P = .04). The IM@Home group also had favorable reductions in anxiety (P = .03), symptom distress score (P = .003), and depression (P = .02).
The number of patients with emergency department visits was the same in both groups (9 [9.1%] IM@Home vs 12 [11.9%] enhanced usual care; P = .45). However, among participants who had an emergency department visit, the mean number of visits per patient was nearly half in the IM@Home arm vs the enhanced usual care group (rate ratio = 0.49%; 5% CI = 0.23 to – 0.95; P = .04). Furthermore, the number of participants who were hospitalized during the study period in the IM@Home arm was substantially fewer than in the enhanced usual care group (4 [4.0%] vs 13 [12.9%]; P = .03), and those patients also spent fewer days in the hospital (4.3 vs 10.0 days per patient; rate ratio = 0.42; 95% CI = 0.25–0.68; P < .001).
There were no adverse events reported in either study arm.16
Concluding Thoughts
The IMPROVE trial, the first of its kind, showed that a digital synchronous intervention, comprising mind-body therapies and exercise classes, affected significant reductions in fatigue along with physical symptoms as well as anxiety and depression in patients with cancer receiving active treatment. Of particular note, the program also led to substantially fewer emergency department visits and hospitalizations.
These findings highlight the potential of digital health offerings for overcoming patient-level barriers to supportive care and improving the patient experience. Such digital health offerings not only lower the symptom burden, but also may reduce acute care use, which can lead to considerable cost savings for patients and health systems and improve treatment-related outcomes. Future trials are needed to evaluate the long-term effectiveness of digitally delivered therapies in enhancing patient-centered outcomes in this subset of patients with cancer.
Dr. Mao, Guest Editor of The ASCO Post’s Integrative Oncology series, is the Laurance S. Rockefeller Chair in Integrative Medicine and Chief of the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center, New York. Dr. Daly is a thoracic medical oncologist in the Department of Medicine at Memorial Sloan Kettering Cancer Center.
DISCLOSURE: Dr. Mao has received institutional research funding from Tibet Cheezheng Tibetan Medicine Co. Ltd. Dr. Daly is a member of the JCO Oncology Practice Editorial Board; has stock and other ownership interests in CVS Health, Lilly, and Roche/Genentech; and has served as a consultant or advisor to Varian Medical Systems.
REFERENCES
1. Chen F, Leng Y, Zhang L, et al: The correlation of symptom clusters and functional performance in adult acute leukemia patients under chemotherapy. Cancer Nurs 44:E287-E295, 2021.
2. Daly B, Nicholas K, Gorenshteyn D, et al: Misery loves company: Presenting symptom clusters to urgent care by patients receiving antineoplastic therapy. J Oncol Pract 14:e484-e495, 2018.
3. Adam R, Nair R, Duncan LF, et al: Treatment burden in individuals living with and beyond cancer: A systematic review of qualitative literature. PLoS One 18:e0286308, 2023.
4. Henry DH, Viswanathan HN, Elkin EP, et al: Symptoms and treatment burden associated with cancer treatment: Results from a cross-sectional national survey in the U.S. Support Care Cancer 16:791-801, 2008.
5. Alishahi Tabriz A, Turner K, Hong YR, et al: Trends and characteristics of potentially preventable emergency department visits among patients with cancer in the US. JAMA Netw Open 6:e2250423, 2023.
6. Mo J, Darke AK, Guthrie KA, et al: Association of fatigue and outcomes in advanced cancer: An analysis of four SWOG treatment trials. JCO Oncol Pract 17:e1246-e1257, 2021.
7. Duan L, Xu Y, Li M: Effects of mind-body exercise in cancer survivors: A systematic review and meta-analysis. Evid Based Complement Altern Med 2020:7607161, 2020.
8. Wayne PM, Lee MS, Novakowski J, et al: Tai chi and qigong for cancer-related symptoms and quality of life: A systematic review and meta-analysis. J Cancer Surviv 12:256-267, 2018.
9. Bower JE, Bak K, Berger A, et al: Screening, assessment, and management of fatigue in adult survivors of cancer: An American Society of Clinical oncology clinical practice guideline adaptation. J Clin Oncol 32:1840-1850, 2014.
10. Carlson LE, Zelinksi E, Toivonen K, et al: Mind-body therapies in cancer: What is the latest evidence? Curr Oncol Rep 19:67, 2017.
11. Mao JJ, Ismaila N, Bao T, et al: Integrative medicine for pain management in oncology: Society for Integrative Oncology–ASCO guideline. J Clin Oncol 40:3998-4024, 2022.
12. Carlson LE, Ismaila N, Addington EL, et al: Integrative oncology care of symptoms of anxiety and depression in adults with cancer: Society for Integrative Oncology–ASCO guideline. J Clin Oncol 41:4562-4591, 2023.
13. Bauml JM, Chokshi S, Schapira MM, et al: Do attitudes and beliefs regarding complementary and alternative medicine impact its use among patients with cancer? A cross-sectional survey. Cancer 121:2431-2438, 2015.
14. Desai K, Liou K, Liang K, et al: Availability of integrative medicine therapies at National Cancer Institute–designated comprehensive cancer centers and community hospitals. J Altern Complement Med 27:1011-1013, 2021.
15. Emard N, Lynch KA, Liou KT, et al: Virtual mind-body programming for patients with cancer during the COVID-19 pandemic: Qualitative study. JMIR Cancer 7:e27384, 2021.
16. Mao JJ, Bryl K, Gillespie EF, et al: Randomized clinical trial of a digital integrative medicine intervention among patients undergoing active cancer treatment. NPJ Digit Med 8:29, 2025.
