Introduction

Integrative oncology focuses on physical, social, and mind–body aspects of patients’ health, and aims to optimize health, quality of life, and clinical outcomes across the cancer-care continuum [1]. Support groups are a key component within integrative oncology to help deliver education and lifestyle counseling to cancer patients and survivors. Supportive-expressive group therapy ameliorates and prevents new onset depressive disorders, reduces hopelessness and helplessness, reduces trauma symptoms, and improves social functioning in patients with metastatic breast cancer [2]. Additionally, individuals in supportive-expressive groups giving higher levels of support to others reframed their own problems in a positive light [3]. Research on breast cancer patients has shown that even after treatment is complete, survivors endorse significant fear of cancer recurrence and report numerous unmet needs [4]. Patients want to receive psychological support [5, 6] as well as information on healthy lifestyle (e.g., nutrition) [7, 8]. Evidence suggests that psychological and lifestyle support, such as increasing exercise and improving diet, can improve multiple cancer outcomes [9,10,11,12,13].

Telehealth or internet-based groups have also been shown to benefit cancer survivors. A study of a computer-mediated social support group (chat-based) showed that the participants who received higher levels of emotional support from others reported lower breast cancer related concerns [3]. Early results from a clinic working with gynecologic cancers found that transitioning support groups from in-person to telehealth over the pandemic more than doubled attendance and reached a broader group of women [14].

As most group programs stopped in-person visits in March 2020, patients had an even greater need for a social connectedness while coping with a cancer diagnosis during a global pandemic. The American Cancer Society Cancer Action Network deployed a survey in 2020 and reported that cancer patients and survivors were experiencing increases in psychological distress; nearly half of respondents (48% of 1228 participants) stated the combination of cancer in the context of a pandemic was affecting their emotional well-being [15]. Higher anxiety and perceived susceptibility to COVID-19 was associated with increased patient cancellation of appointments to oncology clinics [16]. Not only did the pandemic have a negative impact on emotional health, but it also was correlated with increases in unhealthy eating, decreases in exercise, and increases in sedentary lifestyle [17].

The Integrative Medicine Center (IMC) at the MD Anderson Cancer Center provides evidence-based, patient-centered approaches for both oncology patients and caregivers [18, 19]. The IMC includes a multi-disciplinary team consisting of physicians, health psychologists, advanced practice providers, nurses, a physical therapist, mind–body specialists (e.g., yoga therapist, music therapist), a dietitian, oncology massage therapists, and oncology acupuncturists. Patients are typically referred to health psychology services if they are endorsing emotional distress related to cancer and/or for healthy lifestyle changes (e.g., diet, exercise, weight loss, sleep) [20].

Health psychologists in the IMC differ from other mental health providers in the institution and the community as they focus on the role cancer plays in patients’ lives and the importance of addressing not only mental health concerns, but also overall physical health and helping patients to be successful in engaging in a healthy diet, adopting good physical activity habits, managing stress, and having good sleep health. Typically, therapists aim to diagnose and treat mental disorders (e.g., anxiety and depression), whereas health psychologists highlight the bidirectional relationship between physical and mental health. Furthermore, by improving patients’ physical health, IMC health psychologists hope to decrease risk of cancer recurrence, new cancers, cancer progression, and improve overall cancer mortality [10]. The IMC provides multiple group programs. In one such program, called IM FIT, cancer survivors meet weekly in a closed group format with a physical therapist, dietitian, and health psychologist over 12 weeks and findings revealed the program led to weight loss, increases in exercise, improved diet, and decreased emotional distress [21]. After the 12-week program, patients noted they wanted the classes to continue. Providing lifestyle counseling in a less restrictive open group format would be helpful for patients who could not commit to a full 12-week program. The IMC also noted the importance of modifying services to deliver telehealth interventions to meet patient needs during the COVID-19 pandemic.

The aim of the present study was to describe the development and initial implementation of the IM Healthy program, a telehealth support group intervention for cancer survivors delivered by an integrative oncology team to facilitate emotional coping and healthy lifestyle change, such as improved diet and exercise. A retrospective chart review was conducted of patients who have attended at least one IM Healthy group to examine patient characteristics, patient feedback, and outcomes, as well as describe qualitative patient feedback and perceptions. Real-world data, both qualitative and quantitative, is of increasing importance when considering patient-centered care and the value of intervention programs.

Methods

Patient recruitment

During routine clinic consultations, IMC physicians referred patients who reported psychological distress or interest in behavioral/lifestyle changes to health psychology, as deemed appropriate per our referral guidelines [20]. Patients then completed a video consultation with one of the health psychologists in the IMC. Health psychologists selected appropriate patients for IM Healthy if they requested additional support for lifestyle change or would benefit from group intervention. If considered appropriate, the IM Healthy group program was described to the patient to gauge interest. Patients had to be available during one of the three offered group times. As identified during clinical interview in the consultation appointment, patients with severe psychological distress, eating disorders, or personality disorders that would possibly negatively impact group dynamics were not considered appropriate referrals. Information was not collected regarding patients screened or reasons for declining, but patients overwhelmingly agreed to participate. Due to this being a real-world program in our clinic, we did not have a target number for patient enrollment and instead adjusted number of groups to address patient interest. Recruitment for IM Healthy was rolling and patients could be added at any time. The current study examines all patients who attended IM Healthy from Sept 1, 2021 to August 31, 2022. This study was conducted in accordance with the Declaration of Helsinki and was approved by IRB (UT MD Anderson Cancer Center, Protocol #DR11-0149 and Protocol #2022–0977).

Intervention

The IM Healthy program was designed to increase social support for cancer patients, improve accessibility to care by the health psychologists, provide education on healthy lifestyle changes, and offer skill-building in a collaborative setting. Prior to the COVID-19 pandemic, the group program was delivered in-person in the cancer hospital. IM Healthy emphasizes fitness, health, and stress management in terms of risk reduction for cancer recurrence or progression. Topics included teaching patients how to cook nutritious foods, increase physical activity, decrease sedentary lifestyle, manage stress, utilize social support, and improve sleep. The group allowed patients to connect with other cancer survivors who were interested in facilitating healthy lifestyle change at any point in the cancer journey. Meetings were held weekly and were primarily led by a health psychologist, who taught skills and facilitated group member interactions, with intermittent weeks led by a dietitian or physical therapist. Weekly topics were primarily skills stemming from evidence-based therapies, such as Cognitive-Behavioral Therapy and Acceptance and Commitment Therapy. At the end of each session, patients were encouraged to consider how to incorporate the skill of the week into their lives using SMART (specific, measurable, achievable, relevant, time-bound) goals The groups were well attended for the six months they were running and appeared to be liked by patients. Unfortunately, at the time of the COVID-19 pandemic, our IM Healthy group programs were suspended. In September of 2021, the IM Healthy program was relaunched using Zoom. We developed the telehealth version of the IM Healthy program to help patients engage in healthy lifestyle change during the global pandemic.

The group was designed as an open-enrollment group, meaning patients could attend as few or as many weekly sessions as they preferred. Groups were capped at 10 patients per week due to billing requirements. The program began offering the same group twice a week and later expanded to three times per week due to an increase in interest. Patients only attended one of the three groups per week, but patients could change the day of the week if needed. Group times were mid-mornings during weekdays, coinciding with the work schedules of the providers. Also, patients were able to attend sessions as their schedules allowed since sessions were not educationally cumulative.

A registered dietician led some sessions, following the American Institute for Cancer Research’s dietary guidelines. Groups included a combination of didactic lectures on healthy eating as well as telehealth cooking demonstrations from the dietitian’s kitchen. Patients were encouraged to eat a plant-based, whole food, low glycemic load diet. They were taught ways to increase vegetables, beans, legumes, pulses (e.g., dried peas or lentils), whole grains, and fruits in their diet while decreasing animal proteins, especially red meat, high-sugar foods and drinks, processed foods, and highly refined foods.

A physical therapist also led some sessions, following guidelines for exercise established by the American College of Sports Medicine which have been deemed as safe and appropriate for cancer patients. Topics included the benefits of exercise, how to form exercise habits, aerobic versus strength training, anatomy, measuring exercise training, and improving bone health. The physical therapist led patients in brief exercises as well as didactic presentations during the sessions.

Two health psychologists facilitated the remainder of the groups. They each ran one group and alternated by month running the third group. Skills from cognitive behavior therapy, motivational interviewing, and mindfulness approaches were utilized. Health psychologists facilitated group cohesion, particularly to encourage social support between participants. Program content included executing self-monitoring of weight and food intake, making SMART goals, managing food cues, practicing mindful eating, changing maladaptive thoughts, identifying social support, and addressing slips. Stress management skills included deep breathing, progressive muscle relaxation, mental imagery, self-compassion practice, and mindfulness of emotions. A list of session topics is included in Supplemental Table 1.

Table 1 Patient characteristics and demographics (n = 50)
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Costs related to sessions with the health psychologists and physical therapist were covered through the patient’s insurance. Health psychologists were in-network providers on several health insurance plans (e.g., Blue Cross Blue Shield, Medicare) for the majority of patients seen in the IMC, but not all plans (e.g., Medicaid, United Healthcare). Nutrition sessions were provided at no cost to the patient. Patients were responsible for covering their co-payment fees. Although uninsured patients were not excluded, no uninsured patients attended the groups. Patients were encouraged to use the Zoom application on a computer, smart phone, or tablet, but a call-in feature was also available to patients who did not have internet access.

Measures

Demographics (e.g., sex, age, race, ethnicity, marital status, employment status) and additional clinical data (cancer diagnosis, diagnosis date, cancer staging, weight, height, and BMI − [kg/cm2] × 10,000) were extracted from the electronic medical record using Clinical Data Interoperability Services [22]. Frequency of encounters were captured from the medical records, specifically: psychology sessions prior to starting IM Healthy, psychology sessions after starting IM Healthy, integrative oncology appointments after starting IM Healthy, and number of IM Healthy sessions. Data extraction also included reasons for referral to the IM Healthy group, as well as whether patients were in active treatment, in the year following active treatment, or > 1 year after active treatment. Questionnaires were completed verbally by the patient and provider during a telehealth appointment and entered into the medical records.

Edmonton Symptom Assessment System with financial distress and spiritual pain (ESAS-FS, 12-item)

Recent experience of patient symptom burden was assessed using the ESAS-FS [23] which asks patients to rate 12 core symptoms (listed alphabetically): anxiety, appetite, depression, drowsiness, fatigue, financial distress, nausea, pain, shortness of breath, sleep, spiritual pain, and well-being over the past 24 h on a scale of 0 (no problem) to 10 (most severe problem). The ESAS-FS Global Distress Score is the sum of 9 core items including pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, sense of well-being, and shortness of breath (total score 0–90). The Physical Symptom Score is the sum of pain, fatigue, nausea, drowsiness, appetite, and shortness of breath scores (total 0–60). The Psychological Distress Score is the sum of depression and anxiety scores (total 0–20). For predetermined subscales, clinical significance is defined as differences ≥ 3 for Global Distress Score and Physical Symptom Score and ≥ 2 for Psychological Distress Score [24].

Patients completed the ESAS-FS during appointments with the health psychologists as well as at other IMC appointments. The study evaluated the ESAS-FS scores from the Psychology visit at the time closest to but prior to starting the group and the ESAS-FS scores closest to their last IM Healthy group attended (+ / − 60 days). ESAS scores from psychology visits were prioritized, but if unavailable, then ESAS-FS scores from other IMC providers completed prior to the session were utilized (n = 5).

Patient-Reported Outcomes Measurement Information System (PROMIS10)

The PROMIS10 [25] is a general assessment of global healthcare-related quality of life assessed by 10 self-report items. Patients completed this questionnaire during the IMC consult with their physician prior to beginning IM Healthy. Sample items are, “In general, how would you rate your physical health?” and “In general, how would you rate your satisfaction with your social activities and relationships.” Responses are on a 5-point scale (i.e., poor, fair, good, very good, excellent) and one item that rates pain is on an 11-point scale. Items are summed to create the subscales of global physical health and global mental health. Higher scores represent better global mental or physical health. Subscale scores can also be converted to t-scores for ease of interpretation.

Program feedback

Program feedback data were collected and managed using REDCap electronic data capture tools hosted at the MD Anderson Cancer Center [26, 27]. The consent form and questionnaire were sent to IM Healthy participants approximately six months following the specified data collection period, although many patients were still participating in IM Healthy at that time. Patients were asked the following open-ended questions: (1) Why did you choose to join IM Healthy? (2) Please describe any obstacles or challenges you experienced from the virtual group. (3) Do you see any positive changes to your lifestyle due to the group? If so, what/how? (4) What other benefits have you received from the virtual group? (5) What are some important differences for you between the in-person versus virtual group (for those who attended in-person IM Healthy prior to the pandemic)? (6) How is this group different from other social support groups you may have participated in? (7) Any future suggestions for future IM Healthy groups? 8) Anything else you would like to share?

The survey included three closed-ended questions: (1) How would you rate your success with participation in exercise? (2) How would you rate your success with managing stress, emotional upset, and/or anxiety? (3) How would you rate your success with eating a healthy diet or eating in a healthy way? Responses were on a 7-point Likert scale ranging from extremely dissatisfied to extremely satisfied.

Statistical analysis

Data were summarized using standard descriptive statistics such as mean, standard deviation, median, and range for continuous variables and frequency and proportion for categorical variables. As some outcome variables collected in this study were not normally distributed and the sample size was small, the Wilcoxon signed-rank test was applied to examine the changes pre- and post-intervention, specifically frequency of psychology sessions, ESAS-FS subscale scores, weight, and BMI. Kendall’s tau correlation, a non-parametric test, was used to evaluate associations between demographic and clinical characteristics and IM Healthy session frequency. Due to small cell sizes, several categorical variables were collapsed. Independent variables included the following: age (continuous), sex (male v. female), race (White v. all other races), ethnicity (Hispanic v. non-Hispanic), marital status (married/significant other v. divorced/separated/widowed/single), education (bachelor’s degree or higher v. less than bachelor’s degree), employment (retired/not employed v. working full-time/self-employed), religion (Christian v. all others religions/unknown), cancer diagnosis (breast v. all other diagnoses), stage (stage 0/II/unstaged v. stage III/IV), additional cancers (one cancer v. two or more cancers), recurrence (yes v. no), ESAS-FS pre subscale scores (continuous) and PROMIS10 pre subscales (continuous), change scores for ESAS-FS subscales (continuous), and change in BMI (continuous). Dependent variable was IM Healthy session frequency (continuous). Kendall’s tau was also used to examine associations between ratings of perceived success and IM Healthy session frequency. The sample size for perceived success analyses were limited to patients who completed the patient feedback questionnaire (n = 30). Patient feedback data was assessed for common themes and described briefly with examples.

Results

Over the 1-year period from September 2021 to August 2022, 50 unique patients participated in the IM Healthy program. Patients were excluded from relevant analyses if missing quantitative data, although there was minimal missing data. Two patients were missing education, one patient did not complete the ESAS-FS premeasure, and four patients did not complete the ESAS-FS post measure. One patient did not complete the PROMIS10 measure. Two patients were missing weights after their final IM Healthy session and so weights from just prior to the final IM Healthy session were used. Three patients died within the 1-year time-period. One patient out of the sample had a non-cancerous lesion of the cranial meninges but was included in the full sample.

Table 1 displays patient characteristics. Most patients self-identified as female (90%), with mean age of 57.9 years (SD = 11.2), non-Hispanic (82%), and 20% African American. Patients tended to be married or have a significant other and were not working (i.e., retired or not employed/disabled). Christian was the most common endorsed religion, and the majority of the sample had a college degree or higher. Patients’ BMI primarily fell in the overweight or obese categories. Table 1 also shows the breakdown of cancer diagnoses and stage, with most patients having breast cancer and between stages I–III. Twenty percent of the patients had more than one cancer diagnosis, and about 18% of the sample had a cancer recurrence when starting IM Healthy. About half of the sample were > 1 year after the end of active treatment.

There were multiple indications for referral (a patient could have more than one, resulting in a sum over 100%) and the percentage for each concern included the following: lifestyle changes (94%), anxiety (92%), stress (88%), depression (74%), weight management (64%), and insomnia (22%). An adjustment disorder was the most common mental health diagnosis (n = 34, 68%) followed by a depressive disorder (n = 11, 22%) and then anxiety disorder (n = 5, 10%). The PROMIS10 showed global physical health scores (M = 13.3, SD = 2.8, Mean T-score = 43.5, SD = 7.9) and global mental health scores (M = 11.7, SD = 2.9, Mean T-score = 42.8, SD = 7.4) were on the low side, but within the normal range, based on the mean t-scores. ESAS-FS scores prior to starting IM Healthy indicated the highest symptom score for anxiety and the lowest score for nausea (see Table 2). Throughout the patients’ time in IM Healthy, there was a broad range of appointments with other integrative oncology providers (M = 12.6, Mdn = 3, SD = 26.3, range = 0–124). The number of months between cancer diagnosis and first IM Healthy group showed a broad range (M = 42.6, Mdn = 23.0, SD = 43.7, range 3–177 months) in duration.

Table 2 Edmonton Symptom Assessment System (ESAS-FS) scores prior to starting IM Healthy, n = 49
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Patients attended a mean of 13.1 (Mdn = 10.5, SD = 10.8; range = 1–45) IM Healthy group sessions. There were two outliers in IM Healthy session frequency (≥ 39 sessions, defined by 1.5 of the interquartile range above the third quartile), which were excluded from all analyses examining associations with the variable of IM Healthy session frequency. There were no significant correlations between IM Healthy session frequency and demographic or clinical characteristics, clinic utilization, psychology utilization, symptom burden, or BMI (ps > 0.14; data not shown).

Regarding changes in variables over the time period between a patient’s first and last IM Healthy session, there were non-significant reductions in ESAS-FS subscale scores between first and last IM Healthy session [Global Distress Score Pre Mdn = 16.0 and Post Mdn = 13.5, z = − 0.81, p = 0.42], [Physical Symptom Score Pre Mdn = 8.0 and Post Mdn = 7.0, z = − 0.39, p = 0.70], [Psychological Distress Score Pre Mdn = 6.0 and Post Mdn = 4.0, z = − 1.62, p = 0.11]. Weight showed non-significant reduction over the course of IM Healthy participation [Weight (kg) Pre Mdn = 81.3 and Post Mdn = 77.8, z = − 0.79, p = 0.43], and no changes for BMI [Pre Mdn = 28.4 and Post Mdn = 28.7, z = − 0.74, p = 0.46]. Frequency of psychology sessions was significantly lower after starting IM Healthy (Mdn = 8.0) than the year prior (Mdn = 10.0), z = − 2.17, p = 0.03.

Regarding patients’ self-ratings of perceived success on exercise, stress management, and nutrition, zero patients endorsed the rating of “extremely dissatisfied,” “moderately dissatisfied,” or “slightly dissatisfied.” Most patients who responded to these questions endorsed self-ratings of “moderately satisfied” and “extremely satisfied” (see Fig. 1). Perceived success ratings were correlated with each other but not with IM Healthy session frequency (see Table 3).

figure 1

Self-rated perceived success on exercise, stress management, and nutrition

Table 3 Kendall’s tau correlations between perceived success items and IM Healthy session frequency
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Program feedback

Thirty participants (64% response rate excluding deceased patients) responded to all or part of the patient feedback questionnaire. The qualitative feedback overwhelmingly supports patients having a positive experience with IM Healthy (see Supplemental Table 2). Patients tended to respond to the first question, “Why did you choose to join IM Healthy?” with four main themes: (1) doctor recommended (e.g., “My doctor recommended it and I felt I would benefit from it”); (2) lifestyle change/desire to lose weight (e.g., “To get help and information getting back to a healthy lifestyle after cancer treatment”); (3) coping/emotional (e.g., “I was struggling with recovery from chemo and surgery for breast cancer and just wanted to feel "normal" again”); and (4) wanting to be around other cancer survivors/group experience (e.g., “I felt I needed a positive support system with people who were going through a similar experience”).

Of the 30 patients who responded to the second question, “please describe any obstacles or challenges you experienced from the virtual group,” 16 patients denied any obstacles or challenges with the group. For those who did report challenges/obstacles, three themes emerged: (1) preference for in-person groups (e.g., “I think I'm happier with in person meetings. I can't really feel honest with myself on a zoom call. I can hide my true feelings.”); (2) technological issues (e.g., “Occasional issue with some participants internet connections, trouble understanding what they are saying.”); and (3) scheduling issues/out of state/remembering to log on (e.g., “Remembering to log on in a timely manner is my personal challenge with virtual appts. Appreciate all the reminders via text, emails, MyChart.”).

The third question, “Do you see any positive changes to your lifestyle due to the group? If so, what/how?” was also completed by 30 patients, with 27 patients noting a positive change due to the IM Healthy group. The themes for this question included the following: (1) improved exercise and nutrition (e.g., “my nutrition is better, incorporating grains and more veggies. I am doing weight training 3 days/week, following all the fundamentals; I walk daily over 10,000 steps and drink plenty water. I am trying to take care of my sleep quality.”); (2) accountability/social connection (e.g., “It made me feel less alone as I was able to see that others were going through the same thing. I thought I was the only one to experience it, I could see others were too and learned if a different approach was better fit for me too. Listen to other ideas and experiences taught me too.”); and (3) better coping skills and emotional control (e.g., “YES!!! I am much better at managing stress and anxiety. I still have challenges, but because of the things I’ve learned by participating in IMH, I am better!”). Three patients denied any positive change.

Twenty-seven participants (54% response rate) completed the next open-ended question, “What other benefits have you received from the virtual group.” The responses were primarily related to social benefits (e.g., “Excitement and anticipation! IMH gives me something to look forward to. It just feels good to see the people on the zoom call, to share to vent to encourage each other and the instructors are amazing!” and “The group has provided me more insight into myself and my past and the difficulties I have faced and the journey I have had so far. I have learned to appreciate my strengths and the group has just empowered me overall.”). There were additional comments such as “Because we addressed some big, common mental/behavioral issues and themes in IM Healthy, it freed up time in my one-on-one talk therapy sessions to focus and dig deeper on issues that were specific to me. I think that just boosted my ability to heal and cope during and after treatment because I was able to address a lot of things faster due to the synergy of the two.”

Eight patients reported that they had attended an in-person IM Healthy group prior to the pandemic. Those patients were asked “what are some important differences for you between the in-person versus virtual group?” The responses reflected an overall preference for in-person (e.g., “Not as easy to have conversations before or after as you walk to the next appointment or grab a coffee. Feedback on techniques and ease of using handouts takes more work—can't just put notes down on paper.”).

Thirty-one patients answered the question “How is this group different from other social support groups you may have participated in?” of which four patients noted they had not attended other social support groups before IM Healthy. Themes for this question included that it was specific to cancer (e.g., “Main difference is shared diagnosis of cancer”), has topics/structure each week (e.g., “The structure of the group is very much appreciated with various topics, and the facilitators are always willing to adjust the content of the topic to suit and fit in with the needs of the group. The group is both didactic and experiential. I am able to take the information that is presented and learn from the group and apply it to my daily living”), and a more relaxed/supportive environment (“It offers a more relaxing environment. Instructors are very personable and engaging”).

The last two open ended questions, “Any suggestions for future IM Healthy groups?” and “Anything else you would like to share?” had 27 and 24 patients respond, respectively. Although several patients reported “none/NA;” several others responded as follows:

  • “Health it is a never-ending topic, so, my suggestion is to continue with all the state of the art related with cancer prevention and longevity. Maybe could be nice have occasionally guest (specialists) to share their knowledge.”

  • “I cannot thank everyone that has made IM Healthy available enough. I started thinking I was going to get some help with eating healthier and exercising but the impact on my entire emotional wellbeing has been a very powerful and positive one!”

  • “I have thoroughly enjoyed this program. I really appreciate the care that was taken to group us together. I have new friends for life. I like the fact that we all have experienced some form of cancer, but we have different diagnoses. From that aspect we have learned the unique characteristics of cancer. We also could talk about fears, hopes, and wishes to our own unique nonjudgmental cheering squad. This provides peer support that I needed. Thanks for such a good program and please keep it going. Thanks for including me.”

Discussion

The clinical team successfully transitioned the IM Healthy in-person group program to a telehealth group program for accessibility during the COVID-19 pandemic. The advantages of offering a telehealth program extend beyond the COVID-19 pandemic and can be applied to other situations of limited access to healthcare, such as patients in rural areas and patients with comprised immune systems. Patients were on average about 60 years old, which is older than the average age of patients referred to health psychology in our clinic (mean 53 years old) [20] and slightly older than a previous report of total patients in the IMC clinic (mean 56 years old) [19, 28]. Older patients may have more flexible schedules, less work and family obligations. Indeed, many of the participants were not employed, which would have increased their availability to attend mid-morning weekly group sessions either due to retirement or not having job requirements. Although the majority (66%) of IM Healthy participants were White, this is lower than the 77% reported in the Texas census [29] and the 76% of Whites reported in a large MD Anderson cohort [30], suggesting a more diverse sample of individuals participated in the group program. Patients also were mostly women (90%), which reflects similar rates of referred patients to health psychology (85% female) [20] and the majority of IMC patients being women (60%) [19]. This result is also in line with women being more likely to participate in cancer support groups both virtually and face-to-face [31,32,33]. Interestingly, one study found that people who attend support groups are more likely to use complementary and alternative medicine, suggesting that the IMC clinic may be more likely to have participants open to groups [32].

The average number of sessions attended was 13, with a wide range of sessions from participants included in this study. In fact, this may be an under-representation of number of sessions attended because the end date of the data collection period does not necessarily reflect the last session attended by each group member. Results from this study do not show conclusive evidence of the appropriate dosage of IM Healthy. As seen in Supplemental Table 1, patients can attend for approximately one year without repeating a session topic. Patients tend to self-select when they are ready to discontinue group sessions either due to achieving maximal benefits from IM Healthy or wanting to devote the weekly time to other personal demands. Having 30 available slots per week for patients to attend IM Healthy (3 groups with 10 slots each) appears to allow patients to attend in ways that address their psychosocial and educational needs.

There were no significant associations between patient characteristics and session frequency. One aim of this study was to understand what demographic, clinical, and utilization factors were linked to higher attendance at IM Healthy. Interestingly, data suggests that there does not appear to be a target audience for IM Healthy. Nearly all participants who responded with feedback assessed the program very favorably. An alternative explanation for the lack of significant findings is that perhaps the screening process completed by a health psychologist was effective at identifying a match between what patients needed and what the group offered.

Results examining intrapersonal changes in individual psychology session frequency showed that once patients began attending group, their individual therapy sessions decreased. In practice, IM Healthy is at times used to transition patients out of one-on-one psychology while continuing to provide support and education, which likely accounts for the findings. Mild anxiety and depression scores, as seen in the current sample, are often normalized and validated in patients meeting with health psychology, rather than pathologized. Transitioning social support from a primary expert to a group of peers is valuable from both an institution standpoint, in terms of efficiently utilizing resources, as well as from a patient standpoint, in terms of increasing independence and self-efficacy in facing cancer survivorship.

Reductions in symptoms, measured by the ESAS-FS subscale scores, were nonsignificant from before to after attending IM Healthy. Mild symptoms were reported at the first IM Healthy group, which suggests a possible floor effect. Prior findings note that IMC patients have reported mild symptoms [19]. Furthermore, symptom severity is a factor in the health psychology decision process of referral to IM Healthy; patients endorsing moderate to severe symptoms were more likely to be offered individual sessions for a tailored treatment plan. Given the current data available at the time of the study, we were not able to test differences between health psychology patients referred and not referred to IM Healthy.

As IM Healthy was not focused on weight loss per se, but instead lifestyle change, it is not surprising that weight and BMI did not significantly change. Although many patients had a BMI over 25, some patients had normal BMIs. Lifestyle change was encouraged (e.g., exercise, physical activity, and healthy nutrition), but patients were not instructed to track weight loss unless this was a personal goal for them. Patients prioritizing weight loss are referred to our multidisciplinary intensive lifestyle change program, IM FIT [21]. Despite weight loss not being a treatment goal of IM Healthy, patients perceived themselves as successful with changes in exercise, stress management, and nutrition. Questions related to perceived success were only given during the program feedback questionnaire, after patients had participated within the 1-year time frame. It is unknown whether participation in IM Healthy helped to increase perceived success by increasing skills and self-efficacy. Alternatively, perhaps patients who prioritize nutrition, activity, and stress management may be more likely to attend IM Healthy. In fact, data showed that the outcomes of perceived success were not significantly associated with IM Healthy session frequency. This may be due to the social component of the group (as indicated by the program feedback), or the greater number of psychology sessions presented in IM Healthy (Supp Table 1), or the fact that patients were typically receiving concurrent individual psychotherapy treatment. Indeed, patients reported the highest levels of perceived success in the category of managing stress. Future research could examine changes in perceived success and actual behavior changes over time.

The program feedback and subjective perceptions of the IM Healthy group was overwhelmingly positive (Supp Table 2). A predominant theme centered on social connectedness and feeling less alone. The bond between group members was evident. It appears that the group allowed patients to feel less alone in not only their lifestyle change journey, but also with being a cancer survivor. IM Healthy delivered via telehealth came at a particularly critical time for patients given the isolation associated with the COVID-19 pandemic. Apart from the social connection, IM Healthy group members endorsed numerous changes in healthy lifestyle and stress management. They described the group as being well-balanced between a psychoeducation group and an interpersonal group (“didactic and experiential”). Many patient responses expressed appreciation and gratitude toward the group leaders, suggesting the importance of having licensed or qualified experts who demonstrate compassion and humor.

Some patient feedback reflected that there was a preference for in-person sessions, suggested by patients who previously attended in-person group visits. These responses may have been biased because these individuals had the capability to attend in person (e.g., time available, financial means, local resident). Many of the group members reside outside of Houston and across the state of Texas, work jobs that would not allow them to commute to and from group sessions on a regular basis, have medical issues that make traveling frequently into the medical center difficult, or have financial concerns that make traveling and parking less feasible. IM Healthy may benefit by adding intermittent in-person sessions or having a co-occurring group that is only in-person, thus patients can choose their preferred modality. Regardless of in-person or telehealth delivery, previous studies have shown that psychosocial groups for oncology patients can be beneficial for quality of life as well as survival [10] and providing support for patients is critical.

One limitation of the present study is the small sample size of 50 participants. The sample of mostly White, highly educated, older, non-working women may limit generalizability of IM Healthy program’s success to other oncology populations. Another limitation is that only 64% of IM Healthy participants completed the program feedback questionnaire via REDCap survey. A recent study of online surveys showed an average response rate of 44% [34] and noted that online surveys tend to have a 12% lower response rate than other modes [35], suggesting that the current study’s response rate is better than expected. Importantly, there were no demographic or medical characteristic differences between those who did and did not provide the qualitative feedback.

Interestingly, patients provided overwhelmingly positive feedback. Perhaps responses were biased due to patients engaging in impression management, which is the act of controlling how others perceive you. Alternatively, patients with more positive experiences may have been more likely to respond to the questionnaire, which has been shown in healthcare studies [36]. To examine this speculation further, we tested if there was a correlation between IM Healthy session frequency and any response to the program feedback questionnaire and found non-significant results (p = 0.23). Although we attempted to ask questions to elicit a wide range of experiences (e.g., asking for obstacles, barriers, and suggestions), patients tended to respond with suggestions without providing negative feedback.

Although not formally collected, patients reported to IM Healthy providers reasons for drop-out, including difficulty with scheduling, no longer needing support for lifestyle change, not being able to continue to pay weekly co-payments or insurance denying services, and no longer residing in Texas. Although telehealth services generally increase access [37], psychosocial support groups can expand to meet additional patient needs. For example, groups could be offered after typical work hours, providers without state license restrictions could run additional classes, or providers could increase licensure in other states.

This study has provided valuable information about our IM Healthy program and opened the door to further research. Given that 50 patients completed this program, future research should examine a larger sample size to replicate these findings. To improve insight on patient self-efficacy, a future study could ask patients explicitly what they identify as being the drivers behind perceived success in the areas of exercise, stress management, and nutrition. Furthermore, we noted that patients in the program tended to report low psychological and physical distress and therefore the findings may not be generalizable to patients with higher symptom burden.

Conclusion

The IM Healthy telehealth group program was successfully launched during the COVID-19 pandemic with high patient satisfaction and perceived success in lifestyle changes. The group program was reimbursable for many and therefore financially sustainable. No identifying characteristics were associated with IM Healthy session frequency, suggesting that all cancer survivors equally benefit or appreciate the program. Participants’ program feedback demonstrated consistent and overwhelmingly positive responses, with particular emphasis on the benefits of social support and positive changes for healthy lifestyle.