Bantum, E.O.C., Albright, C.L., White, K.K., Berenberg, J.L., Layi, G., Ritter, P.L., . . . Lorig, K. (2014). Surviving and thriving with cancer using a Web-based health behavior change intervention: Randomized controlled trial. Journal of Medical Internet Research, 16(2).

To test the effectiveness of a six-week, web-based, multiple health behavior change program called Surviving and Thriving With Cancer (STC) for adult cancer survivors

STC was a six-week online patient education course with modules on nutrition, changes in body, sleep, and other side effects associated with cancer treatment recovery. Nine online cohorts consisted of 20–25 survivors. Sessions had 30–35 webpages of material geared toward skills building with specific content to build self-efficacy. Each week, users identified a health behavior to change and were guided to set realistic, achievable goals. Action plans were posted in a discussion center where two trained cancer survivor facilitators provided feedback and help. Participants were prompted at the middle and end of the week via an automated message to update progress and give feedback to other participants. The website contained components called \"Discussion Center,\" \"My Tools,\" \"Post Office,\" and \"Help.\" The discussion center facilitated social networking through four threaded bulletin boards: action planning, problem solving, difficult emotions, and celebrations. Randomization occurred by groups of 40–50 participants after the completion of baseline a questionnaire. Half were assigned to treatment and half to a wait-list control group. Data collection occurred at baseline and after six months during follow-up.

• N = 352  
• MEAN AGE = 49.3 years (control); 52.4 years (intervention)
• MALES: 16% (control); 20% (intervention), FEMALES: 84% (control); 80% (intervention)
• KEY DISEASE CHARACTERISTICS: Adult cancer survivors recruited online, though referrals, or by mailings; 18 years of age or older; after completion of primary cancer treatment at least four weeks prior but not more than five years before joining the study; diagnosis with only one cancer and no recurrence; access to the Internet; ability to read English
• OTHER KEY SAMPLE CHARACTERISTICS: 85%–89% Caucasian; 83%–84% breast cancer (early stage); majority were healthy; highly educated and well-adjusted

• SITE: Multi-site
• SETTING TYPE: Other
• LOCATION: Recruited from oncology clinics, a tumor registry, and online mechanisms such as Facebook and the Association of Cancer Online Resources

• PHASE OF CARE: Late effects and survivorship

Randomized, controlled, delayed-treatment design

• Demographic and clinical information
• Brief Fatigue Inventory (BFI)
• Women’s Health Initiative Insomnia Rating Scale (WHIIRS)
• Godin Exercise Questionnaire
• The Block Food Frequency Questionnaire (number of servings of fruits and vegetables per week)
• Patient Health Questionnaire (PHQ-8)

In total, 303 survivors completed the follow-up survey (six months after completion of the baseline survey), and participants in the intervention arm reported significantly greater reductions in insomnia and greater increases in minutes per week of vigorous exercise and stretching compared to patients in the control arm. Compared to the control group, the intervention group experienced an improvement in insomnia from baseline to six months 9.6–9.2 versus 9.6–10.1 (p = 0.03). There were no significant changes in fruit and vegetable consumption or other outcomes.

The intervention affected insomnia and exercise; however, the majority of the sample met or exceeded national recommendations for health behaviors and were not suffering from depression or fatigue at baseline. Participants’ ability to make substantial health behavior changes may have been limited.

• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (sample characteristics)
• Measurement validity/reliability questionable
• Findings not generalizable
• Subject withdrawals ≥ 10%
• Other limitations/explanation: Roughly 14% of participants who were randomized did not provide any data at six months (but groups did not differ). Sixty percent of the interested participants were highly educated and were recruited from online social networking sites, suggesting that participants were active on the Internet. Therefore, the sample characteristics may bias the results. Overall, the participants were healthy and well-adjusted with little to no need for significant changes in their health behaviors. The majority of participants were Caucasian (87.2%) and female (82.1%), limiting generalizability. A significant difference in age was found among the treatment and wait-list groups. The mean number of sessions logged on at least once was 5.3 (SD = 1.28, range = 0–6), and 67% of participants attended all six sessions, which may have affected the outcomes. Health behaviors were self-reported, and there may have been over- and underestimation of exercise and fruit and vegetable intake because of social desirability or recall bias. The significance level was not adjusted for the multiple comparisons of numerous outcomes.

Web-based interventions are relevant for people who are not near facilities that could offer face-to-face interventions. Health behavior change interventions are relevant for cancer survivors, so continuing to test and refine interventions is imperative in the area of cancer survivorship.