Online Program Helps Breast Cancer Survivors Cope With Depression and Fatigue

Researchers at Duke University developed an online, self-care, coping skills curriculum to help survivors manage post-treatment symptoms such as pain, depression and fatigue.

The program, “Reimagine,” which has evolved over several years, was found to reduce symptoms of both depression and fatigue, but not pain, in breast cancer survivors when compared with those assigned to usual care. The findings of this randomized controlled trial were presented by Sophia Kustas Smith, M.S.W., Ph.D., at the 2017 Cancer Survivorship Symposium held January 27-28 in San Diego.

In her presentation, Smith noted that pain, including that which is treatment induced, is especially prevalent among breast cancer survivors, with an estimated 30 percent reporting above-average pain even 10 years after treatment.

“Pain rarely occurs alone,” she emphasized. “For example, one in four survivors from the American Cancer Society study fell into the ‘high symptom’ category for pain, depression, and fatigue.”

Recruiting from the Susan Love Research Foundation Army of Women® volunteer registry, the researchers enrolled 121 breast cancer survivors who had self-reported chronic pain; 89 percent of the participants were either cured of their cancer or in remission. The mean age of the patients was 56 years, and the mean time since diagnosis was eight years. The women were evenly randomized to the Reimagine treatment arm or usual care.

Patients in the treatment arm accessed all of the content online, including videos and group meetings, and completed cognitive reframing exercises. “The curriculum teaches two major skillsets,” Smith explained: “Solution-focused thinking about stressors, first identifying patient needs and what’s in their control to get their needs met, and cognitive reframing, identifying the reasons for their choices using better-feeling thoughts.” Reimagine also teaches mind—body exercises, such as guided imagery and meditation.

Outcomes measured at baseline and at 18 weeks post-intervention were pain severity, pain interference, fatigue, and depression. Pain severity and interference were measured with the Brief Pain Inventory. Depression was measured through the Personal Health Questionnaire Depression Scale (PHQ-8), and fatigue through the Functional Assessment of Chronic Illness Therapy — Fatigue (FACIT-Fatigue). Additionally, participants were asked to report on program satisfaction.

A total of 34 treatment-arm participants and 52 usual care controls were included in the analysis. Although the researchers found no significant difference between the two arms when measuring either pain severity or pain interference, there was a difference in depression and fatigue. “We found a greater reduction in depression and improvement in fatigue symptoms in the treatment versus usual care arm,” explained Smith, an associate professor at the Duke University School of Nursing.

“All participants in the treatment arm endorsed the effectiveness of the videos in teaching the skills,” Smith reported. Additionally, patients who used Reimagine were satisfied with the program, with 94 percent saying that they would recommend Reimagine to others, and 85 percent reporting that they felt more resilient at study completion.

Smith cautioned that although partnering with a patient group like the Army of Women helped to drive recruitment, this approach also presented limitations, as the women were mainly college-educated and white.

Compared with the usual care controls, more women dropped out in the treatment arm; many women cited either being too busy or too sick to continue with the trial as the reason, and this is another study limitation cited by Smith. Based on these early findings, the investigators recommend further research on the intervention using larger and more diverse samples.