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Web-based stress management program improves quality of life for patients with cancer
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CHICAGO — An 8-week, web-based stress management program improved quality of life and relieved the distress of patients with cancer, according to a prospective study presented at the ASCO Annual Meeting.
“Diagnosis of cancer elicits high levels of distress which negatively affect physical and mental health,” Viviane Hess, MD, medical oncologist at University Hospital of Basel in Switzerland, said during a press conference. “Distress can lead to diminished treatment and tolerance [to treatment]. From randomized controlled trials, we know cognitive behavior therapies are effective in patients in distress. However, the majority of patients with cancer lack psychological support due to barriers on the patients’ side and a lack of resources on the providers’ side. With this online intervention, we aim to close this gap.”
According to a 2012 study by Mehnert and colleagues, one in every two patients with cancer experiences clinically relevant psychosocial distress that can erode quality of life and negatively affect the course of disease and a patient’s ability to tolerate treatment.
Remote therapy — known as therapist-guided online intervention — is becoming a standard approach for psychological disorders and appears to be as effective as traditional face-to-face therapy. Hess noted that 70% of patients with cancer use the internet, primarily to seek information. Remote therapy requires less time for therapists and is more convenient for patients facing many other medical appointments following diagnosis, according to the researchers.
“New technologies open new opportunities,” Hess said in a press release. “With this intervention we can deliver much needed psychological support in the comfort of the patients’ living rooms or other favorite Wi-Fi spots. It seems that patients and psychologists can still form a therapeutic bond through this online contact.”
The analysis included 129 patients (84% women; median age, 52 years) from Germany, Switzerland and Austria diagnosed with cancer within the past 12 weeks. Most received chemotherapy (58%) in a curative setting (91%), and the majority had early-stage breast cancer (71%). Other cancers included lung, ovarian, gastrointestinal, lymphoma and melanoma.
Researchers assigned patients to either an 8-week STREAM intervention developed by Swiss oncologists and psychologists, or a wait-list control group.
Each week, patients in the intervention group received written and audio information on topics such as bodily reaction to stress, cognitive stress reduction, feelings and social interactions, as well as exercises and questionnaires to complete. Psychologists reviewed patients’ progress weekly and provided personalized, written guidance and support through a secure online portal. Intervention patients also had the opportunity to write to the psychologists directly through the online program.
Patients in the wait-list control group received psychological support 2 months after enrollment.
Researchers used validated scales to measure quality of life, distress and anxiety/depression at study entry and 2 months after intervention.
At baseline, 75% of patients self-reported distress above 4 on a 10-point scale.
At 2 months, distress scores in the intervention group dropped from a median score of 6 at the start of study to 4 (P = .032) after 2 months of counseling, whereas they remained at 6 for the control group.
Also, patients who participated in the stress management program scored 8.59 points higher (P = .044) than those without intervention in quality-of-life assessments. Median quality-of-life scores were 101 at baseline and 119 at 2 months for the intervention group compared with 108.3 at baseline and 109.5 in the control group.
Researchers observed no significant differences in anxiety and depression between the two groups.
“Our online stress management program is feasible for patients during and after treatment,” Hess said during the press conference. “Three in four patients were highly distressed and we reached a target population in need of support. The therapist-guided online program significantly improved quality of life and lowered distress.”
STREAM intervention is available only in Germany; researchers plan on making it accessible to more psychologists and patients in North America.
“Online psychological support will be much more important in the years to come, as the digital generation reaches the age when they are at higher risk for cancer,” Hess said. “For them, it will be natural to use such online tools and communicate without face-to-face interactions, so now is the time to standardize and validate the tools.”
A new diagnosis of cancer can bring on a wave of emotions, including fear and uncertainty, and cancer care must be paired with high-quality psychological support, Don S. Dizon, MD, FACP, clinical co-director of gynecologic oncology at Massachusetts General Hospital, who was not involved in the study, said during the press conference.
“Most oncologists, when meeting patients for the first time and striving for curative intent therapy, assume there is a level of distress people have,” Dizon said. “But we assume that level of distress will fall naturally as we start them on therapy. This study shows three out of four patients not only have distress, but significant distress. Trying to get these patients support can be an issue because they are at our cancer centers quite frequently for medical therapy, and trying to squeeze psychological expertise into treatment plans can become difficult. Utilizing an online system has not only shown to be sensible, but the promise of being effective as well.”
The recent news that singer and actress Olivia Newtown-John had a recurrence of breast cancer after 25 years in remission sheds light on the distress cancer survivors live with on a daily basis, ASCO chief medical officer Richard L. Schilsky, MD, FASCO, said.
“To a great extent, for a cancer patient, every day is another unknown, and those unknowns create a lot of anxiety,” Schilsky said. “Concerns about what lies ahead in the cancer journey and how that impacts patients in their quality of life and how they cope with those concerns effectively is really a lifelong issue for those patients.” – by Chuck Gormley
References:
Hess V, et al. Abstract LBA10002. Presented at: ASCO Annual Meeting; June 2-6, 2017; Chicago.
Mehnert A, et al. BMC Psychiatry. 2012;doi:10.1186/1471-244X-12-70.
Disclosures: Hess reports travel expenses from CSL Behring. Please see the abstract for all other researchers’ relevant financial disclosures.
Perspective
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Holly Prigerson, PhD
There are numerous advantages to online psychotherapy, including potentially widespread access, convenience of time and place, less stigma or embarrassment in interacting about emotional concerns face-to-face with a therapist, and less cost — both out-of-pocket costs to patients and clinical and insurance costs for delivery. However, there is a need to establish efficacy of purely online psychotherapy. Often it is the case that the most effective ingredient in therapy is the human element, and the more automated something is, the less human it is. Another question relates to potential risks (eg, harm to self or others) missed by an automated, online intervention without human monitoring or staff support for crisis intervention. First, it needs to be demonstrated that online therapy is effective, with and without the online program being “therapist-assisted.” Then there are concerns about identifying and dealing with crisis situations that need to be allayed. For certain patient populations, web-based interventions will be preferred or an appreciated “adjuvant” to face-to-face therapy sessions (eg, those embarrassed to talk about their feelings in person; those unable to travel). For other patient populations, such as caregivers or bereaved family members, there is a need or desire for human contact. In the context of grievers, they are very lonely and feel socially isolated and yearn for human contact and help. I have conducted studies of how clinicians diagnose and treat bereaved caregivers. We have seen that there is something about face-to-face interaction with a mental health professional that picks up on nonverbal cues to enhance diagnostic precision and therapeutic impact. That might sound like psychobabble, but the point is that human interaction with a real live therapist is likely to result in the best outcomes. Perhaps analogous to Pinocchio becoming a real boy, online therapy may be a beneficial “puppet” therapy, but a software program is only as good as what it is programmed to do. It cannot pick up on subtle or nonverbal or unexpressed thoughts and feelings, improvise or have new insights. Certainly, this doesn’t mean that it is not valuable; quite the contrary. I think the web opens the door to therapy that might have been closed to thousands if not millions of people who might benefit from such web-based interventions.
Perspective
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Peter Gabriel, MD, MSE
Although web-based technology has fundamentally transformed the way we consume goods and services across so many industries, medicine has been slower to adopt technology in a way that alters the existing paradigm of face-to-face office visits with a provider. Certain areas like counseling, education and symptom monitoring, however, are ripe for innovative approaches such as the one evaluated in this study, and I think we will see continued advances in this direction.
Benefits include improved patient convenience and timeliness of information, communication and feedback. Timeliness can be especially important to patients with cancer who face considerable anxiety over a new diagnosis or the results of diagnostic tests that check for cancer recurrence or progression. One potential drawback to electronic interaction is that it is less personal, and many of the concerns that patients face are deeply personal and emotional. For this reason, it is unlikely we will ever see web-based counseling completely replace face-to-face sessions, but it can certainly become a useful tool as part of a multifaceted plan of care.
One major barrier to further progress in this area is that the current reimbursement system is almost entirely based on face-to-face contacts — providers are not paid for time spent on telephone calls or written communication, for example. As payment reform continues, however, we should see new opportunities for alignment of incentives that would enable providers to have the resources to engage in more of these types of activities.
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