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Keywords:

  • cancer;
  • stress management;
  • exercise;
  • depression;
  • anxiety;
  • quality of life

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
  9. Supporting Information

Background

Research has shown that self-directed stress management training improves mental well-being in patients undergoing chemotherapy. The present study extends this work by evaluating separate and combined effects of stress management training and home-based exercise.

Method

Following assessment of mental and physical well-being, depression, anxiety, exercise, and stress reduction activity before chemotherapy started, patients were randomized to stress management training (SM), exercise (EX), combined stress management and exercise (SMEX), or usual care only (UCO). Outcomes were reassessed 6 and 12 weeks after chemotherapy started. Significance testing of group-by-time interactions in 286 patients who completed all assessments was used to evaluate intervention efficacy.

Results

Interaction effects for mental and physical well-being scores were not significant. Depression scores yielded a linear interaction comparing UCO and SMEX (p = 0.019), with decreases in SMEX but not UCO. Anxiety scores yielded a quadratic interaction comparing UCO and SMEX (p = 0.049), with trends for changes in SMEX but not UCO. Additional analyses yielded quadratic interactions for exercise activity comparing UCO and SMEX (p = 0.022), with positive changes in SMEX but not UCO, and for stress management activity comparing UCO and SM (p < 0.001) and UCO and SMEX (p = 0.013), with positive changes in SM and SMEX but not UCO.

Conclusion

Only the combined intervention yielded effects on quality of life outcomes, and these were limited to anxiety and depression. These findings are consistent with evidence that only the combined intervention yielded increases in both exercise and stress management activity. Future research should investigate ways to augment this intervention to enhance its benefits. Copyright © 2012 John Wiley & Sons, Ltd.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
  9. Supporting Information

The adverse effects of chemotherapy on quality of life are well documented. In addition to nausea [1] and fatigue [2], many patients experience heightened emotional distress and interference with usual functioning [3]. Although much of the effort to manage side effects and maintain quality of life during chemotherapy has focused on pharmacological agents (e.g., anti-emetic medications), several nonpharmacological approaches have also been evaluated. Two more widely studied approaches are stress management training and exercise.

Beginning in the 1980s, stress management training was evaluated as a treatment for anticipatory nausea and vomiting. Research showed that several professionally administered interventions, including progressive muscle relaxation with guided imagery [4, 5] and systematic desensitization [6] administered after chemotherapy started, were effective in relieving nausea and emotional distress. Subsequent research showed that professionally administered stress management training provided before chemotherapy started was also effective in preserving quality of life over the course of treatment [7-9].

Despite evidence of efficacy, training and resources required to provide professionally administered psychosocial interventions can be major barriers to their routine use. To address this issue, several investigators developed and evaluated self-administered forms of stress management training for cancer patients [10-14]. Of particular relevance to the current study is an intervention our team designed for chemotherapy patients [15]. It provides instruction in three techniques (abdominal breathing, progressive muscle relaxation with guided imagery, and coping self-statements) using audiovisual materials distributed to patients before chemotherapy starts. We previously showed that, compared with patients randomized to usual care only, patients who received this intervention reported significantly better physical functioning, vitality, and mental health, and fewer role limitations due to emotional problems [15].

Could the benefits of self-administered stress management training for chemotherapy patients be augmented by combining it with an exercise intervention? Stress and coping theory suggests that these two modes of intervention can provide patients with complementary ways of coping with the stress of cancer treatment [16]. Support can be found in the growing body of evidence demonstrating the benefits of exercise during cancer treatment. A recent meta-analysis reported significant effect sizes for the impact of exercise interventions on several quality of life outcomes during treatment, including functional well-being, anxiety, and positive mood [17]. Trials of home-based exercise are of particular relevance for efforts to develop interventions requiring limited training and resources to deliver. Two trials included in the meta-analysis reported nonsignificant effects for home-based exercise on quality of life outcomes [18, 19]; however, a third trial reported a significant impact on fatigue [20]. In addition, a study published subsequently reported significant beneficial effects on symptom severity and mood disturbance [21]. To the best of our knowledge, a combined stress management training and exercise intervention on quality of life conducted during cancer treatment has not been evaluated in a randomized controlled trial. This approach has, however, been pilot-tested by the authors [22] and others [23], and found to be feasible, acceptable to patients, and potentially efficacious.

Building on these findings, we conducted a randomized controlled trial in which patients about to start chemotherapy were assigned to the following: usual care only (UCO), usual care plus stress management training (SM), home-based exercise (EX), or stress management training plus home-based exercise (SMEX). Analyses were designed to test the hypotheses that the three intervention conditions would be superior to UCO in maintaining or improving quality of life over a 9- to 14-week follow-up period. If more than one intervention was found to be superior to UCO, additional analyses were planned to evaluate the relative efficacy of these conditions. Of particular interest was whether SMEX was superior to SM or EX. Primary outcomes were composite measures of the physical and mental quality of life, and secondary outcomes were measures of depressive and anxiety symptoms. Additionally, we examined whether the stress management and/or exercise conditions had expected effects on levels of stress reduction activity and/or exercise activity.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
  9. Supporting Information

Participants

To be eligible, patients had to be ≥18 years old, be diagnosed with cancer, be scheduled to receive chemotherapy for at least 9 weeks at Moffitt Cancer Center (MCC), have not received chemotherapy within the past 2 months, be medically cleared for engaging in moderate intensity exercise (including Eastern Cooperative Oncology Group performance status ≤ 2), and be fluent in English.

Procedures

Study coordinators identified patients scheduled for consultation with a medical oncologist and then reviewed medical records of these patients to evaluate eligibility. For those eligible, clearance was sought from the oncologist confirming ability to engage in moderate intensity exercise. Coordinators approached eligible participants after the oncology consultation to explain the institutional review board-approved study, answer questions, and obtain written informed consent from those wishing to participate. After consenting and before the first infusion, participants completed a baseline (T1) questionnaire and were randomized using a computerized program. Randomization was stratified by gender, physical activity level (i.e., inactive, minimally active, or active), chemotherapy administration schedule (e.g., 21 or 28 days), and concurrent radiotherapy (i.e., yes or no).

Intervention materials were distributed by a doctoral-level psychologist whose adherence to standardized protocols for each of the four conditions was monitored by an interventionist trainer via live observation of 12% of meetings. Immediately following intervention delivery, coordinators administered a single item (‘How important do you think that it is that we make this program available to other chemotherapy patients?’; 0 = not at all important to 6 = extremely important) [15] to confirm that the four intervention conditions were perceived as equally credible forms of assistance. Approximately 1 week later, the interventionist telephoned participants to ask if they had reviewed the materials and address any questions. Those participants who indicated they had not reviewed the materials were encouraged to do so. Participants completed follow-up questionnaires approximately 6 (T2) and 12 weeks (T3) following their initial infusions. Questionnaires were administered to participants during scheduled clinic visits or were completed at home.

Usual care only participants had access to the full range of psychosocial services provided to MCC patients. These included opportunities to meet with a social worker and attend support groups free of charge. In addition, patients could be referred or self-refer to in-house psychiatrists and psychologists on a fee-for-service basis. Specific to this condition, patients also met with the interventionist for approximately 5 min before the first infusion, at which time they received the National Cancer Institute booklet titled ‘Chemotherapy and You’. This 62-page booklet includes information about chemotherapy and ways to manage side effects.

In addition to usual care, SM participants met with the interventionist for approximately 10 min before the first infusion. As in our previous study [15], they were provided with a 15-min video, 12-page booklet, and 30-min audio recording titled ‘Coping with Chemotherapy’. The video and booklet included information, demonstrations, and instructions regarding paced breathing [24], progressive muscle relaxation with guided imagery [25], and use of coping self-statements to manage stress [26]. Comments by chemotherapy patients about benefits of using stress management techniques were interspersed throughout the video and booklet. Participants were instructed to follow directions for how to learn and practice the techniques and use them during chemotherapy. Directions included listening to the audio recording, which led participants through an abbreviated form of progressive muscle relaxation training.

In addition to usual care, EX participants met with the interventionist for approximately 10 min before the first infusion. They were provided with a 12-min video and 14-page booklet titled ‘Stepping Forward: A Guide to Exercise During Chemotherapy’ developed for this study. The video and booklet included information and instructions on engaging in regular exercise while undergoing chemotherapy. The emphasis was on walking because it is well suited to home-based exercise. For this reason, participants were also provided with electronic pedometers (Digi-Walker SW-651-04, New-Lifestyles Inc., Lees Summit, MO, USA) on the basis of evidence suggesting that self-monitoring with pedometers promotes greater physical activity [27-29]. Topics covered in the materials included warming up and cooling down, pulse and exertion monitoring, and use of the pedometer to monitor numbers of steps taken and exercise duration. Comments by chemotherapy patients about benefits of exercising were interspersed throughout the video and the booklet. Participants were advised to exercise 3–5 times per week for 20 to 30 min at approximately 50% to 75% of their estimated heart rate reserve, a goal consistent with exercise recommendations for cancer patients published prior to study initiation [30]. The interventionist calculated and provided each participant an exercise heart rate ‘training zone’, based on age and resting heart rate, and demonstrated how to use pulse rate to monitor exercise intensity. Participants were also instructed how to monitor intensity using the Rating of Perceived Exertion (RPE) Scale [31] and were advised to achieve a level between light (RPE = 11) and somewhat hard (RPE = 13).

In addition to usual care, SMEX participants met with the interventionist for approximately 15 min before the first infusion. They were provided with a 20-min video and a 20-page booklet titled ‘Stepping Forward: A Guide to Stress Management and Exercise During Chemotherapy’ developed for this study that combined content from SM and EX videos and brochures. Participants also received the same audio recording provided to SM participants and pedometer provided to EX participants. Instructions for exercising and for learning, practicing, and using stress management techniques mirrored those in the SM and EX conditions.

Measures

Demographic data were obtained at baseline through the use of a standard self-report questionnaire. Medical information was obtained through review of patient records.

The acute (1-week) version of the Medical Outcomes Survey 36-item Short Form (SF-36) [32] served as the primary outcome measure. Analyses focused on the physical component summary (PCS) and the mental component summary (MCS) scores. The 20-item Center for Epidemiological Studies Depression (CES-D) Scale [33] and 21-item Beck Anxiety Inventory (BAI) [34] served as secondary outcome measures. Items on both instruments are keyed to the past week.

Exercise activity was assessed using the Leisure Score Index of the Godin Leisure-Time Exercise Questionnaire (LTEQ) [35], which assesses the frequency and duration of mild, moderate, and strenuous exercise in the past week. Responses are scored to yield an estimate of weekly metabolic equivalent tasks (METs). Stress reduction activity was assessed using the Stress Reduction Checklist (SRC) [15], which assesses the use of the stress reduction methods that comprise SM. Questions are worded so that participants in any study condition could complete the checklist.

Data analysis

To examine longitudinal changes in quality of life across the three time points, we applied random effects models by using SAS Proc Mixed (SAS Institute, Cary, NC, USA). The planned analyses focused on comparing each intervention separately with UCO. For each outcome, initial analysis consisted of three separate 2 (group comparison: UCO versus SM, UCO versus EX, and UCO versus SMEX) by 3 (time: T1, T2, and T3) random effects analyses. The main effects of group and time, and the group-by-time interaction, quadratic time effect, and quadratic-group-by-time interaction were evaluated. Quadratic terms were included to determine if there were nonlinear intervention effects (e.g., plateaus or decrements in quality of life following improvement). Of principal interest was the significance of group-by-time and quadratic-group-by-time interactions, which would indicate differential improvement in quality of life as a function of group. If more than one intervention condition performed better than UCO, then similar analyses were conducted comparing those interventions. Principal analyses were performed using data from 286 participants who completed all three assessments. To examine the potential effects of attrition on findings, we conducted additional analyses by using data from 351 participants who completed at least one follow-up assessment. A p-value of 0.05 (two-tailed) was used for statistical significance. The study was powered at .80 to detect an effect size of f = 0.25 for the interaction between an intervention condition versus UCO and time, assuming a per group sample size of 80 and alpha = 0.05. The study was also powered at 0.80 to detect an effect size of f = 0.14 for within group change across the three measurement points.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
  9. Supporting Information

Preliminary analyses

Of 4822 patients assessed for eligibility, 4117 did not meet eligibility requirements, 177 declined participation, 57 were unable to be consented before their first infusion, 471 provided consent, 11 withdrew or became ineligible before randomization, and 460 were randomized. Disposition of patients randomized is shown in an online appendix. There were no differences across groups in retention rates at first follow-up (p = 0.945), at second follow-up (p = 0.682), or across both follow-ups (p = 0.680). Comparison of 286 participants who completed all three assessments with 150 participants who did not complete all assessments showed that the latter group scored lower on the PCS at T1 (p < 0.001) and were more likely to have received concurrent radiotherapy (p < 0.001). There were no other differences on demographic, clinical, or baseline outcome variables (p-values > 0.068).

Demographic and clinical characteristics of participants are presented in Table 1. There were no differences across groups for demographic or clinical characteristics, except that Hispanic participants were more likely to receive UCO (χ2 = 13.91, p = 0.003). Because there were no group-by-ethnicity interactions for any outcome (p-values > 0.129), ethnicity was not included as a control variable. There were no differences across conditions at T1 on any outcome measures (p-values > 0.183) or in credibility (p = 0.239).

Table 1. Characteristics of study participants (N = 286)
 UCO (n = 78)SM (n = 69)EX (n = 62)SMEX (n = 77)pa
  1. UCO, usual care only; SM, stress management; EX, exercise; SMEX, stress management + exercise; SD, standard deviation; METs, metabolic equivalent tasks; SCLC, small cell lung cancer

  2. a

    p-values are based on chi square analyses for categorical variables and one-way analyses of variance for continuous variables.

  3. b

    Interval between first chemotherapy infusion and final study assessment.

Age (years)    0.877
Mean57.2257.4258.7257.71 
SD10.9810.5811.7711.98 
Baseline exercise activity (METs)    0.972
Mean18.0019.2318.2417.62 
D19.9320.8324.7518.22 
Gender (%)    0.421
Males26333931 
Females74676169 
Education (%)    0.131
<High school27413747 
High school graduate26202713 
College graduate47393640 
Race (%)    0.474
White91909792 
Non-white91038 
Ethnicity (%)    0.003
Hispanic172104 
Non-Hispanic83989096 
Relationship status (%)    0.257
Married or partnered63776974 
Not married or partnered37233126 
Disease stage (%)    0.999
Non-metastatic/limited67676868 
Stage I84316 
Stage II24252323 
Stage III32363729 
Limited SCLC3250 
Metastatic/extensive33333232 
Stage IV32303230 
Extensive SCLC1302 
Cancer type (%)    0.871
Breast33352932 
Lung26332729 
Other41324439 
Bladder4978 
Colon4335 
Endometrial4403 
Gastric0020 
Kidney2000 
Larynx1000 
Lip/oral1000 
Mesothelioma0164 
Ovarian18131013 
Prostate0033 
Rectal/anal0051 
Sarcoma1000 
Testicular1031 
Unknown primary3051 
Uterine1000 
Oropharynx1200 
Chemotherapy regimen (%)    0.945
7 or 14 days interval18141817 
21 or 28 days interval82868283 
Concurrent radiotherapy (%)    0.282
Yes9633 
No91949797 
Previous chemotherapy (%)    0.865
Yes14161916 
No86848184 
Participation intervalb (days)    0.907
Mean86.1386.1085.6587.10 
SD11.0812.2912.5811.61 

Quality of life outcomes

Analyses for the SF-36 PCS and MCS yielded no significant group-by-time or quadratic-group-by-time interactions (p-values > 0.060; Table 2).

Table 2. Summary of analyses of interaction effects (N = 286)
InteractionUCO versus SMUCO versus EXUCO versus SMEX
tptptp
  1. UCO, usual care only; SM, stress management; EX, exercise; SMEX, stress management + exercise.

Physical component
Group * Time0.990.3230.770.445−0.110.910
Group * Time * Time−1.890.060−1.230.222−0.540.588
Mental component
Group *  Time1.010.3121.110.2681.300.195
Group * Time * Time−1.260.210−1.360.175−0.680.498
Depression
Group * Time−1.580.116−1.630.105−2.380.019
Group * Time * Time1.730.0861.590.1131.970.051
Anxiety
Group * Time−0.250.805−1.640.102−1.920.057
Group * Time * Time0.840.4021.840.0691.990.049
Exercise
Group * Time0.000.9991.460.1462.750.007
Group * Time * Time0.200.838−1.110.271−2.320.022
Stress reduction
Group * Time5.48<0.001−0.890.3734.16<0.001
Group * Time * Time−3.77<0.0011.320.189−2.520.013

Analyses for the CES-D yielded a group-by-time interaction comparing UCO and SMEX (p = 0.019) (Table 2). Evaluation of time effects for each group separately showed a decrease over time in depressive symptoms in SMEX (p = 0.048) but not UCO (p > 0.186) (Figure 1). The magnitude of the effect at its maximum (T2) was d = 0.25, corresponding to a small effect size [36].

image

Figure 1. Changes in depression and anxiety over time. UCO, usual care only; SMEX, stress management + exercise

Download figure to PowerPoint

Analyses for the BAI yielded a quadratic-group-by-time interaction comparing UCO and SMEX (p = 0.049; Table 2). Evaluation of quadratic time effects for each group separately showed a trend for changes over time in anxiety scores in SMEX (p = 0.116) but not UCO (p = 0.283). A decline in the SMEX group between T1 and T2 was followed by an increase between T2 and T3 (Figure 1). The magnitude of the effect at its maximum (T2) was d = 0.22, corresponding to a small effect size [36].

For analyses conducted with participants who completed T1 and at least one subsequent assessment (N = 351), the same pattern of significant results was observed for the CES-D. That is, there was a group-by-time interaction (p = 0.030) for comparison of UCO and SMEX. With regard to the BAI, the quadratic-group-by-time interaction for UCO and SMEX was no longer significant (p = 0.195). The same pattern of nonsignificant results was found for the PCS and MCS (p-values > 0.142).

Exercise activity and use of stress reduction techniques

Analyses for the LTEQ yielded a group-by-time interaction (p = 0.007) and a quadratic-group-by-time interaction (p = 0.022) comparing UCO and SMEX (Table 2). Evaluation of quadratic time effects for each group separately indicated that MET scores changed over time in SMEX (p = 0.020) but not UCO (p > 0.231). An increase in the SMEX group between T1 and T2 was followed by a modest decrease between T2 and T3 (Figure 2). There were no group-by-time (p = 0.146) or quadratic-group-by-time (p = 0.271) interactions comparing UCO and EX. The same pattern of significant results was obtained on the basis of the 351 participants who completed at least one follow-up assessment. Additional analyses in which participants (N = 286) were categorized into those who reported no or moderate exercise less than three times per week versus those who reported moderate exercise more than three times per week or strenuous exercise yielded similar results. No changes in exercise activity between T1 and T3 were evident for the UCO, SM, or EX groups (p > 0.527); in contrast, there was a trend (p = 0.083) for the SMEX group, reflecting an increase in more intense exercise activity from 12% to 20%.

image

Figure 2. Changes in exercise and use of stress reduction techniques over time. UCO, usual care only; SM, stress management; SMEX, stress management + exercise

Download figure to PowerPoint

Analyses for the SRC yielded a group-by-time interaction (p < 0.001) and a quadratic-group-by-time (p < 0.001) interaction comparing UCO and SM. There was also a group-by-time interaction (p < 0.001) and a quadratic-group-by-time (p = 0.013) interaction comparing UCO and SMEX (Table 2). Evaluation of quadratic time effects for UCO, SM, and SMEX indicated use of stress reduction techniques changed over time in the SM (p < 0.001) and SMEX groups (p < 0.001) but not in the UCO group (p > 0.171). On the basis of this pattern of results, a comparison of SM and SMEX was performed. There was no group-by-time interaction (p =0.240) or quadratic-group-by-time interaction (p = 0.275), suggesting that changes in the use of stress reduction techniques were comparable in the two groups. As shown in Figure 2, an increase in the SM and SMEX groups between T1 and T2 was followed by a modest decrease between T2 and T3. A similar pattern of significant results was obtained for analyses based on the 351 participants. Additional analyses in which participants (N = 286) were categorized into those reporting no versus some use of stress management techniques yielded similar results. No changes in the use of these techniques were evident between T1 and T3 for the UCO and EX groups (p > 0.180); in contrast, there were increases from 67% to 86% in the SM group (p = 0.007) and 69% to 87% in the SMEX group (p = 0.002).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
  9. Supporting Information

In this study, we found that a combined stress management and exercise intervention was effective in improving depressive and anxiety symptomatology over the course of chemotherapy. Compared with patients who received usual care only, patients who received the combined intervention reported less depression and anxiety. Contrary to expectations, patients who received just the exercise or stress management portion of the combined intervention did not experience less anxiety or depression than patients who received usual care only. Also contrary to expectations, none of the intervention conditions had a beneficial impact on composite measures of physical and mental quality of life relative to usual care only.

Among the negative results, those for the stress management intervention are most surprising. In previous research, we found that this intervention yielded significant benefits relative to usual care only for many of the same outcomes [15]. Possible explanations for this pattern include sample sizes in the current study that were approximately half those in the previous study and differences in patient characteristics. With regard to the latter, the previous study featured a higher percentage of breast cancer patients than the current study (58% vs. 33%). Intervention effects may be more likely to be detected in these patients because chemotherapy is used primarily to prevent disease recurrence rather than control active disease; consequently, their symptoms are more likely to reflect acute treatment side effects than ongoing disease burden. Lack of intervention effects for the exercise intervention is less surprising. As noted earlier, several previous trials of home-based exercises during treatment have yielded negative results for quality of life outcomes [18, 19].

Results of additional analyses suggest why the combined intervention was the only intervention to yield positive effects for depression and anxiety. Specifically, it was the sole intervention to produce increases in both exercise activity and use of stress reduction techniques. Taken together with other findings, these results suggest that increases in both forms of activity were necessary to have an impact on depression and anxiety. This pattern is consistent with results of a recent meta-analysis of the effects of exercise on depressive symptoms in cancer survivors [37]. Although exercise yielded an overall significant effect on depressive symptoms, effect magnitudes were smaller for programs that were unsupervised and performed at home [37]. Results of the current study suggest that the addition of stress management training can increase the impact programs of this type have on depressive symptoms.

The current study is characterized by several strengths. These include heterogeneous disease characteristics of the study sample, multiple follow-up assessments, and evaluation of a combined stress management and exercise intervention as well as its two separate components. There are also several weaknesses present. First, attrition was relatively high, with 34% of patients who completed the baseline not completing all subsequent assessments. Because attrition was related to overall physical well-being at baseline, findings may not generalize to patients who begin chemotherapy in worse physical condition. Second, the lack of an increase in exercise activity among participants who received the exercise intervention and the modest increase among participants who received the combined intervention raise the possibility that the amount of time the interventionist spent with these participants was too brief for achieving the desired goals. Third, adherence to recommendations for exercising and using stress management techniques during the course of chemotherapy was not monitored. Consequently, it is not known how much of the ‘dose’ of these interventions patients received. It should be noted, however, that reports obtained from all patients suggest that those in the combined intervention condition increased their exercise activity and that those in both the combined and stress management intervention conditions increased their use of stress management techniques. Fourth, the magnitude of the effects on anxiety and depression observed for the combined intervention was small and may not be clinically significant. This limitation must be balanced, however, against the limited time and resources required to provide the intervention to patients.

Study findings suggest several future research directions. One direction would be to examine the impact of the separate and combined intervention approaches on quality of life outcomes in other cancer treatment populations. A study, sponsored by the Blood and Marrow Transplant Clinical Trials Network, is currently underway in which modified versions of the three intervention conditions are being tested with patients undergoing blood and marrow transplantation. Another direction would be to introduce enhancements to the existing intervention approaches to increase their efficacy in improving quality of life. One strategy would be to add resistance training to the home-based exercise intervention based on evidence of its benefits for cancer patients [38]. A second strategy would be to include ‘booster sessions’ during which an interventionist would determine how much the patient was exercising or using stress management techniques and provide appropriate feedback. This strategy has been used in other studies of exercise [39] and stress management training [40] to promote and maintain intervention uptake. A third strategy would be to adapt the separate and combined intervention components for delivery via the Internet. A growing body of research suggests that the Internet can be used effectively to deliver psychosocial interventions [41]. Possible advantages specific to this line of research include greater ability to tailor and personalize intervention strategies and to monitor patients' use of intervention components by using electronically delivered prompts [41].

Acknowledgement

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
  9. Supporting Information

This research was supported by the American Cancer Society (grant no. RSGPB-05-243-01 CPPB).

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  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
  9. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
  9. Supporting Information

Supporting information may be found in the online version of this article.

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pon_3122_sm_Online_Appendix.docWord document43KCONSORT diagram

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