Freeman, L.W., White, R., Ratcliff, C.G., Sutton, S., Stewart, M., Palmer, J.L., . . . Cohen, L. (2014). A randomized trial comparing live and telemedicine deliveries of an imagery-based behavioral intervention for breast cancer survivors: Reducing symptoms and barriers to care. Psycho-Oncology. Advance online publication. 

To determine the effects of guided imagery training on quality of life (QOL) for survivors of breast cancer

Trained professionals facilitated five weekly live (LD) or teleconference (TD) group sessions. The initial four sessions each included four one-hour modules of training in guided imagery (i.e., four hours per week). Each module was divided equally between a didactic lesson and an interactive small group activity. Didactic lessons provided education on the mind-body connection, particularly the influence of mental imagery and corresponding sensory experiences on physiologic processes. Small group activities incorporated opportunities to process lessons and to practice active and targeted imagery aimed at improving QOL. Each week, participants were given a guided imagery CD to reinforce current lessons and to promote the practice of imagery techniques daily. The fifth week provided a final group check-in for individuals to share their future plans for incorporating imagery into daily life. Weekly calls were made to encourage daily practice during the intervention and for three months postintervention. Waitlist controls (WLs) received no intervention. Outcome measures were assessed before the behavioral intervention and at one and three months after the intervention.

• N = 118    
• MEAN AGE: 55.4 years (SD = 8.39 years) 
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer survivors of all stages at least six weeks postcompletion of treatment
• OTHER KEY SAMPLE CHARACTERISTICS: Sample was an average of 50.9 (44.45) months from diagnosis.

• SITE: Multi-site    
• SETTING TYPE: Multiple settings    
• LOCATION: Anchorage and Seattle in community centers for group sessions and participants’ homes for daily practice of guided imagery

• PHASE OF CARE: Late effects and survivorship

Randomized, waitlist-controlled trial

• Functional Assessment of Cancer Therapy, Cognitive Scale (FACT-Cog) version 2
• Pittsburgh Sleep Quality Index (PSQI)
• Functional Assessment of Chronic Illness Therapy Fatigue scale (FACIT-F) version 4
• Medical Outcomes Study Short-Form survey (SF-36)
• Functional Assessment of Cancer Therapy, Breast (FACT-B)
• Functional Assessment of Chronic Illness Therapy, Spiritual Well-Being Expanded Scale (FACIT-Sp-Ex) version 4
• Brief Symptom Inventory-Global Severity Index (BSI-SI)

Both intervention groups (LD and TD) reported better cognitive function, less fatigue, and less sleep disturbance than waitlist controls (p < .01 for both). The LD and TD groups did not differ in any outcomes. No group effects were found for the other QOL outcomes. No time or group-by-time effects were found for any outcomes. A smaller portion of LD and TD participants reported clinically meaningful sleep disturbances (p < .01 for both) and fatigue (p < .05 for both) at the follow-up assessments.

After five weeks, the group guided imagery course provided by a trained facilitator may improve patient-reported cognitive impairment, sleep disturbances, and fatigue in breast cancer survivors. The delivery of this intervention in person or via teleconference produced the same results, suggesting that the intervention may be appropriate for use in telemedicine.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Findings not generalizable
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: Participants were not blinded, and it is unclear whether the research assistants who did the QOL assessments were blinded to group assignment. The nonspecific effects of social support or attention may have been responsible for the improvement of symptoms given the lack of an active control group. The sample was mostly white and well-educated, limiting generalizability. The TD group was half the size of the LD group, limiting the study's ability to demonstrate a difference between these modes of delivery. The intervention would require training for facilitators to maintain fidelity; feasibility may be an issue in practice because of the time commitment required from facilitators and participants. Cognitive function was measured only with self-report instruments. The duration of the intervention effect is unknown because of the lack of long-term follow-up assessments.

A group guided imagery course, delivered live or via teleconference by a trained facilitator, may improve cognitive impairment, sleep disturbance, and fatigue for breast cancer survivors. However, more research with larger samples and a longer follow-up is warranted to determine whether the intervention is effective and practical.