Background
Psychological well-being is vital to every aspect of treatment and recovery following hematopoietic stem cell transplantation (HSCT).1 Although HSCT is a potentially curative treatment for patients with malignant hematologic conditions, HSCT survivors grapple with enormous physical (eg, fatigue) and psychological symptoms (eg, anxiety) due to high-dose chemotherapy, with significant toxicities and potentially life-threatening complications during a prolonged hospitalization in physical isolation.2–8 Additionally, HSCT survivors report low levels of positive psychological well-being (PPWB; eg, gratitude), which individuals use to evaluate their lives and to function well.9
Psychological distress and PPWB may independently impact outcomes, such as quality of life (QoL) and mortality, throughout the entire HSCT care and recovery continuum.2–8,10 However, psychosocial interventions that reduce psychological distress while enhancing PPWB are lacking for the HSCT population. In fact, the few tailored psychosocial interventions for the HSCT population primarily focus on alleviating psychological distress during the acute HSCT hospitalization and the immediate recovery period.11–14 Additionally, the shortage of mental health clinicians has been a major barrier to the accessibility and scalability of existing interventions for this population.15 Hence, accessible and scalable psychosocial interventions are needed that help patients manage and cope with the various challenges of allogeneic HSCT recovery, especially beyond the transplant hospitalization.
Positive psychology interventions consist of simple exercises (eg, writing a gratitude letter) completed systematically and deliberatively to cultivate PPWB, buffer against psychological distress, promote health behaviors (eg, physical activity), and boost QoL.16–20 Compared with the few existing psychosocial interventions for HSCT recipients, which are labor-intensive, positive psychology interventions are well accepted, cost-effective, and scalable.16–21 Because positive psychology interventions have yet to be developed and rigorously tested in HSCT survivors, we followed the NIH Stage Model for Behavioral Intervention Development22 to develop the Positive Affect for the Transplantation of Hematopoietic stem cells intervention (PATH)23 and conducted a pilot randomized clinical trial (RCT) to assess its feasibility, acceptability, and preliminary efficacy for improving patient-reported outcomes (PROs) in allogeneic HSCT survivors.
Methods
Study Design
A comprehensive account of the methods for this trial has been previously published.24 In summary, this was a single-center pilot RCT conducted at Dana-Farber Cancer Institute (DFCI). We followed the CONSORT guidelines for reporting (Figure 1). The Dana-Farber/Harvard Cancer Center Institutional Review Board approved the study. All participants provided informed consent. The study was preregistered on ClinicalTrials.gov (NCT05147311).
CONSORT diagram.
Abbreviation: PATH, Positive Affect for the Transplantation of Hematopoietic stem cells.
Citation: Journal of the National Comprehensive Cancer Network 22, 2D; 10.6004/jnccn.2023.7117
Participants
From August 2021 to August 2022, eligible patients were recruited for study participation. Inclusion criteria were adult patients (age ≥18 years) with hematologic malignancies undergoing allogeneic HSCT at DFCI who were approaching 100 days posttransplant and were able to speak, read, and write English, and had access to a telephone. Due to different recovery trajectories, patients were excluded if they were undergoing HSCT for benign hematologic conditions, undergoing outpatient HSCT, or diagnosed with severe psychiatric or medical conditions that their treating oncologist believed would prohibit compliance with study procedures.
Recruitment and Enrollment
Eligible patients were approached approximately 70 to 80 days posttransplant after approval by their transplant oncologist, with day 0 being the date of graft infusion. We chose patients approaching 100 days post-HSCT because of limited psychosocial interventions beyond the HSCT hospital stay, when patients are beginning to pursue ways of re-engaging with meaningful activities.
Randomization
Participants were randomized equally to the PATH intervention or usual care control arms using computer-generated random allocation, and stratified by the presence/absence of acute graft-versus-host disease (GVHD) because HSCT survivors with GVHD have significantly different courses, and GVHD treatment, such as steroids, may impact the psychological well-being of patients.25–27
Usual Care Control
We used as-needed 1:1 in-person psychosocial support from social work as the usual care control. At DFCI and most US HSCT centers, social work completes a pretransplant evaluation to assess psychosocial risk factors. However, posttransplant social work involvement does not occur automatically, although social work is available throughout the HSCT recovery to meet with patients and families for supportive care. Additionally, social work support does not typically involve PPWB skill-building. Receipt of social work and other mental health services were tracked for participants in both arms.
PATH Intervention
PATH, a 9-week, phone-delivered manualized positive psychology intervention that consists of 3 modules focused on gratitude, personal strengths, and meaning,19,28–30 has been described in a previous publication24 and is summarized in Table 1. The third week of each module is an integration exercise in which patients practice how to use skills in each module in their daily routines to promote sustainability of the skills learned in PATH.31 Using the NIH Stage Model for Behavioral Intervention Development,22 we developed PATH after a comprehensive review of the literature on positive psychology interventions in medical populations1,10,32; a review of theoretical frameworks on positive emotions and their impact on outcomes, such as the Broaden-and-Build Theory of Positive Emotions33; a qualitative analysis of patients’ descriptions of positive experiences during the course of HSCT34; patients’ feedback from our open pilot trial on tailoring positive psychology exercises for HSCT23; and expert input from clinicians and researchers who work with the HSCT population. Each PATH session was approximately 15 to 20 minutes long, and the 9-week duration was chosen to balance skill-building and acceptability.31 Although we considered using video to deliver PATH, in qualitative exit interviews from our pilot trial of PATH,23 patients explicitly reported a preference for phone delivery over video due to less anxiety about personal appearances with phone sessions in the setting of fatigue and physical symptoms.23 Patients randomly assigned to PATH received usual care in addition to PATH sessions. Starting at 100 days post-HSCT, a psychosocial oncology clinician delivered the intervention via phone. To establish fidelity of the intervention delivery, the interventionist met weekly with a positive psychology intervention expert who reviewed 10% of recorded intervention sessions using an established fidelity checklist (see Table S1 in the supplementary materials, available online with this article).35,36
The PATH Intervention Components
Demographics
At baseline, patients completed a sociodemographic questionnaire detailing their age, sex, race, ethnicity, religion, relationship status, educational level, annual household income, and living situation. The electronic health record was used to confirm disease and clinical factors.
Feasibility
The primary outcome of this study was feasibility. Informed by prior psychological intervention studies in the HSCT population, this was defined as >60% of eligible patients enrolling in the study and >75% of enrolled participants in the PATH group completing ≥6 of 9 positive psychology sessions.35–39
Acceptability
At the end of each weekly intervention session, we measured acceptability with weekly ratings of ease and utility of each positive psychology exercise with a 10-point Likert scale (ranging from 0 = very difficult/not helpful to 10 = very easy/very helpful) used in prior positive psychology intervention trials.35,36
Measures
PRO measures were administered at baseline (ie, day 85–90 post-HSCT) and at 9 and 18 weeks. We chose these time points to assess the immediate (ie, week 9) and sustained (ie, week 18) preliminary effects of the intervention on outcomes, consistent with other positive psychology feasibility trials.40,41
PPWB Assessments
We used the 10-item Revised Life Orientation Test (LOT-R) to measure dispositional (trait) optimism. Higher scores indicate greater optimism.42 We used the positive affect subscale of the 10-item Positive and Negative Affect Schedule (PANAS) to measure positive affect. Higher scores indicate greater positive affect.43 We used the 6-item Gratitude Questionnaire (GQ-6) to measure dispositional gratitude. Higher scores indicate greater proneness to experience gratitude in daily life.44
Physical Function and QoL
We used the 20-item Patient-Reported Outcomes Measurement Information System-Physical Function-20 (PROMIS-PF-20) to measure physical function; higher scores indicate better physical function.45 We used the 47-item Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT), validated for use in patients undergoing HSCT, to assess QoL.46 The FACT-BMT consists of 5 subscales assessing well-being across 4 domains (physical, functional, emotional, and social) and bone marrow transplant symptoms.
Psychological Distress
We used the Hospital Anxiety and Depression Scale (HADS) to assess symptoms of depression and anxiety. The HADS is a 14-item questionnaire that contains two 7-item subscales assessing depression and anxiety symptoms during the past week.47 Scores on each subscale range from 0 to 21, with a score ≥8 denoting clinically significant anxiety or depression. We used the Posttraumatic Stress Disorder Checklist to assess symptoms of posttraumatic stress in patients. The PCL is a 17-item self-reported measure that evaluates symptoms of PTSD according to the criteria of the DSM-IV.48
Physical Activity
Physical activity was an exploratory health behavior outcome for PATH because PPWB is associated with enhanced physical activity.40,49 We used the well-validated ActiGraph GT3X+ accelerometer50 for 7 days of wear at baseline and week 9. Minimum acceptable use is ≥4 days with ≥10 hours of recorded data as per prior guidelines.51–53 The accelerometer was used to measure minutes per day of moderate to vigorous physical activity (1,040–1,952 counts/minute41) as our primary activity measure along with overall physical activity (steps per day), given their association with health outcomes.41
Statistical Methods
We used Stata 17.0 (StataCorp LLC) for all statistical analyses. Descriptive statistics (eg, means) and proportions were used for participant characteristics and feasibility estimates. For acceptability, we calculated the mean and standard error using a random intercept model to account for the repeated measurements of ease and utility from each subject. We used the intention-to-treat principle for all randomized patients.
Because feasibility was the primary endpoint, our power calculations were based on a sample size of 70 patients informed by prior positive psychology intervention feasibility trials.40,41 Based on a 15% attrition rate from transplant-related medical complications and mortality, and prior intervention trials in which 80% completed the majority of the intervention sessions,40,41 we targeted at least 30 eligible patients to complete PATH. From this estimate of 30 PATH completers, we had 95% power (2-sided α=.05, binomial proportion test) to show that the proportion who would complete ≥6 of 9 PATH sessions would be >50%. For acceptability, with 30 patients in both arms, we had 95% power to detect a true mean score of >7.0 based on prior work (in which mean utility scores were 7.8 ± 1.8).20
For secondary outcomes, we determined between-group differences in change over time in all PROs at the baseline and week 9 time points, with repeated measures regression models and maximum likelihood to account for missing data, to investigate the preliminary efficacy of PATH on psychological outcomes (eg, anxiety, optimism), QoL, physical function, fatigue, and physical activity compared with usual care. We used time as a categorical variable and examined time–group interaction to estimate intervention effects on study outcomes, and we accounted for the within-subject covariance using an unstructured covariance matrix. We estimated the effect sizes (Cohen’s d) for all change in outcomes by dividing the estimated difference in the mean change in outcomes between the groups by the estimated standard deviation of the baseline measurement from the repeated measures model. Effect size estimates can be translated as small (0.20–0.49), medium (0.50–0.80), or large (>0.80).
Results
Participant Characteristics
Figure 1 depicts the study CONSORT diagram. Of the 193 eligible patients, we approached 105 and 72 consented to participate, with an enrollment rate of 68.6%. The primary reason for an eligible patient not consenting was their declining participation in any research study. Of the 72 patients who consented, 70 were randomized because 1 did not complete baseline measures and 1 was no longer interested in the study.
Overall, the mean [SD] age of study participants was 56.8 [13.7] years, and 50% (n=35) were female (Table 2). Most of the participants identified as White (91.4%; n=64), were married or living with a partner (71.4%; n=50), had at least a college education (67.1%; n=47), and were on disability or retired (87.1%; n=61). Most patients had a diagnosis of leukemia (68.6%; n=48). There were no meaningful differences in baseline characteristics between the 2 groups.
Baseline Characteristics by Treatment Group
Feasibility and Acceptability
Of the 33 participants who started the intervention, 94% (n=31; 95% CI, 80%–99%) met the feasibility endpoint by completing ≥6 of 9 sessions, well above our a priori threshold for feasibility. Further, 91% (n=30; 95% CI, 76%–98%) completed 100% (9/9) of PATH sessions. Of the 4 participants who did not complete 6 of 9 intervention sessions, 2 did not start PATH at all, 1 stopped due to worsening physical symptoms, and another was lost to follow-up. The PATH sessions also met our a priori acceptability threshold, with mean ease scores of 7.40 (95% CI, 6.87–7.92) and mean utility scores of 8.23 (95% CI, 7.83–8.63) on a scale of 0 to 10.
Preliminary Effects of PATH Secondary Outcomes
Table 3 provides details of the preliminary effects of PATH on PPWB from repeated measures regression models examining the data longitudinally across all time points. At 9 weeks, PATH resulted in small-sized greater increases in gratitude (β = 1.38; d = 0.32). However, at 18 weeks, PATH resulted in small- to medium-sized greater increases in all PPWB (ie, gratitude [β = 0.97; d = 0.22], positive affect [β = 2.02; d = 0.27], life satisfaction [β = 1.82; d = 0.24], and optimism [β = 2.70; d = 0.49]).
Impact of PATH Intervention on Positive Psychological Well-Being Constructs
Table 4 summarizes the preliminary effect of PATH on other secondary outcomes from repeated measures regression models examining data longitudinally across all time points. At 9 weeks, PATH resulted in small-sized greater reductions in anxiety (β = −1.43; d = −0.40) and small-sized greater increases in physical function (β = 2.15; d = 0.23) than usual care. However, at 18 weeks, we observed small- to medium-sized greater decreases in anxiety (β = −1.62; d = −0.46), depression (β = −1.04; d = −0.33), PTSD (β = −2.50; d = −0.29), and fatigue (β = −2.54; d = −0.33) as well as medium-sized greater increases in QoL (β = 7.70; d = 0.41) and physical function (β = 5.21; d = 0.56) in PATH patients versus the control condition.
Impact of PATH Intervention on Patient-Reported Outcomes
Discussion
In this pilot RCT, PATH, a phone-delivered positive psychology intervention tailored to HSCT survivors, was feasible and well accepted among allogeneic HSCT survivors. Overall, 91% of participants completed all PATH sessions, and such sessions were rated as easy to complete and subjectively helpful. We also observed promising signals of PATH’s efficacy for improving psychological distress symptoms, physical function, and QoL.
This is the first RCT to assess a positive psychology intervention in HSCT survivors, who have a high burden of comorbidities, frequent routine clinic visits, prolonged recovery, and persistent unmet psychosocial needs. Notably, PATH’s feasibility ratings (ie, 94%) exceeded those of other existing psychosocial HSCT interventions (eg, 24% reported feasibility for a group-based, stress-alleviating intervention).54–56 PATH’s feasibility ratings were also higher than those of other positive psychology interventions among patients with diabetes (75%)57 and those with heart failure (73%).58 PATH’s emphasis on reflective experiences (as opposed to more intensive intervention activities) likely reduced well-known barriers to psychosocial intervention engagement and completion in the HSCT population.54,55,59
Although this pilot trial was not powered to establish the efficacy of PATH on our secondary patient-reported outcomes compared with usual care, we observed signals for preliminary efficacy on proximal (eg, PPWB, such as gratitude) and distal outcomes (eg, anxiety) at 9 weeks and sustained at 18 weeks. Numerous studies in other medical populations show that positive psychological interventions yield small-to-large-sized improvements in PPWB (eg, positive affect), which are associated with fewer psychological distress symptoms (eg, depression) and more physical activity.40,49 Sustained gains in PPWB, improvement in anxiety symptoms, and increases physical function at 18 weeks suggest that skills from PATH may be durably incorporated into patients’ routines during the vulnerable recovery period from HSCT. Larger efficacy trials are needed to establish the effect of PATH more fully on psychological distress, physical function, and QoL.
Several notable features of PATH highlight its promise for future scalability in routine psychosocial support for HSCT survivors. First, the remote delivery of PATH via phone enables access for patients who travel long distances to HSCT centers for routine care.60,61 Second, PATH may be delivered successfully by interventionists with less professional training.31,34,62,63 Although we used a behavioral health expert for this study due to limited funding, similar interventions have successfully used diverse interventionists.31,34,62,63 Third, psychosocial interventions tailored specifically to the needs of patients in the acute recovery period (ie, at 100 days post-HSCT) are lacking,64–67 because most existing psychosocial interventions focus on the needs of patients preparing to undergo HSCT or those admitted for the acute HSCT hospitalization.64–67 Most existing psychosocial interventions are not accessible to patients with lengthy commutes for routine follow-up care,68 and PATH may fill an important gap in psychosocial resources for HSCT survivors.
Several limitations of this study are worth discussing. First, although the sample size of 70 was sufficiently robust to establish the feasibility and acceptability of PATH,61,69,70 we had limited power to discover between-group differences of PATH on outcomes. Second, the study participants were recruited from a single academic cancer center and comprised mostly educated and non-Hispanic White patients. Future larger efficacy studies should examine the impact of PATH in a more geographically, socioeconomically, and ethnically diverse population of patients. Third, although we used validated measures for PPWB, these measures have not been validated in oncology populations with a high burden of physical and psychological distress.
Conclusions
A novel phone-delivered positive psychology intervention—PATH—was feasible and well accepted and demonstrated promising signals for preliminary efficacy on psychological, physical function, and QoL outcomes. Larger RCTs, powered to establish the efficacy of PATH, are warranted.
References
- 1.↑
Kubzansky LD, Huffman JC, Boehm JK, et al. Positive psychological well-being and cardiovascular disease: JACC Health Promotion series. J Am Coll Cardiol 2018;72:1382–1396.
- 2.↑
Gratwohl A, Baldomero H, Frauendorfer K, et al. EBMT activity survey 2004 and changes in disease indication over the past 15 years. Bone Marrow Transplant 2006;37:1069–1085.
- 3.↑
Majhail NS, Mau LW, Chitphakdithai P, et al. National survey of hematopoietic cell transplantation center personnel, infrastructure, and models of care delivery. Biol Blood Marrow Transplant 2015;21:1308–1314.
- 4.↑
Gratwohl A, Baldomero H, Aljurf M, et al. Hematopoietic stem cell transplantation: a global perspective. JAMA 2010;303:1617–1624.
- 5.↑
Zimmermann C, Yuen D, Mischitelle A, et al. Symptom burden and supportive care in patients with acute leukemia. Leuk Res 2013;37:731–736.
- 6.↑
Rodin G, Yuen D, Mischitelle A, et al. Traumatic stress in acute leukemia. Psychooncology 2013;22:299–307.
- 7.↑
Zittoun R, Achard S, Ruszniewski M. Assessment of quality of life during intensive chemotherapy or bone marrow transplantation. Psychooncology 1999;8:64–73.
- 8.↑
El-Jawahri AR, Abel GA, Steensma DP, et al. Health care utilization and end-of-life care for older patients with acute myeloid leukemia. Cancer 2015;121:2840–2848.
- 9.↑
Amonoo HL, El-Jawahri A, Deary EC, et al. Yin and yang of psychological health in the cancer experience: does positive psychology have a role? J Clin Oncol 2022;40:2402–2407.
- 10.↑
Amonoo HL, Barclay ME, El-Jawahri A, et al. Positive psychological constructs and health outcomes in hematopoietic stem cell transplantation patients: a systematic review. Biol Blood Marrow Transplant 2019;25:e5–16.
- 11.↑
El-Jawahri A, LeBlanc T, VanDusen H, et al. Effect of inpatient palliative care on quality of life 2 weeks after hematopoietic stem cell transplantation: a randomized clinical trial. JAMA 2016;316:2094–2103.
- 12.↑
El-Jawahri A, Traeger L, Greer JA, et al. Effect of inpatient palliative care during hematopoietic stem-cell transplant on psychological distress 6 months after transplant: results of a randomized clinical trial. J Clin Oncol 2017;35:3714–3721.
- 13.↑
El-Jawahri A, Traeger L, Kuzmuk K, et al. Quality of life and mood of patients and family caregivers during hospitalization for hematopoietic stem cell transplantation. Cancer 2015;121:951–959.
- 14.↑
El-Jawahri A, VanDusen H, Traeger L, et al. Quality of life and mood predict posttraumatic stress disorder after hematopoietic stem cell transplantation. Cancer 2016;122:806–812.
- 15.↑
El-Jawahri A, Nelson AM, Gray TF, et al. Palliative and end-of-life care for patients with hematologic malignancies. J Clin Oncol 2020;38:944–953.
- 16.↑
Ogedegbe GO, Boutin-Foster C, Wells MT, et al. A randomized controlled trial of positive-affect intervention and medication adherence in hypertensive African Americans. Arch Intern Med 2012;172:322–326.
- 17.↑
Peterson JC, Charlson ME, Hoffman Z, et al. A randomized controlled trial of positive-affect induction to promote physical activity after percutaneous coronary intervention. Arch Intern Med 2012;172:329–336.
- 18.↑
Robertson SM, Stanley MA, Cully JA, et al. Positive emotional health and diabetes care: concepts, measurement, and clinical implications. Psychosomatics 2012;53:1–12.
- 19.↑
Seligman ME, Steen TA, Park N, et al. Positive psychology progress: empirical validation of interventions. Am Psychol 2005;60:410–421.
- 20.↑
Huffman JC, Millstein RA, Mastromauro CA, et al. A positive psychology intervention for patients with an acute coronary syndrome: treatment development and proof-of-concept trial. J Happiness Stud 2016;17:1985–2006.
- 21.↑
Weiss LA, Oude Voshaar MA, Bohlmeijer ET, et al. The long and winding road to happiness: a randomized controlled trial and cost-effectiveness analysis of a positive psychology intervention for lonely people with health problems and a low socio-economic status. Health Qual Life Outcomes 2020;18:162.
- 22.↑
Onken LS, Carroll KM, Shoham V, et al. Reenvisioning clinical science: unifying the discipline to improve the public health. Clin Psychol Sci 2014;2:22–34.
- 23.↑
Amonoo HL, El-Jawahri A, Celano CM, et al. A positive psychology intervention to promote health outcomes in hematopoietic stem cell transplantation: the PATH proof-of-concept trial. Bone Marrow Transplant 2021;56:2276–2279.
- 24.↑
Amonoo HL, Daskalakis E, Deary EC, et al. Feasibility of a positive psychology intervention (PATH) in allogeneic hematopoietic stem cell transplantation survivors: randomized pilot trial design and methods. Contemp Clin Trials 2023;131:107272.
- 25.↑
Wong FL, Francisco L, Togawa K, et al. Long-term recovery after hematopoietic cell transplantation: predictors of quality-of-life concerns. Blood 2010;115:2508–2519.
- 26.↑
Lee SJ, Onstad L, Chow EJ, et al. Patient-reported outcomes and health status associated with chronic graft- versus -host disease. Haematologica 2018;103:1535–1541.
- 27.↑
Jim HS, Sutton SK, Jacobsen PB, et al. Risk factors for depression and fatigue among survivors of hematopoietic cell transplantation. Cancer 2016;122:1290–1297.
- 28.↑
Selimbegovic L, Régner I, Sanitioso RB, et al. Influence of general and specific autobiographical recall on subsequent behavior: the case of cognitive performance. J Exp Soc Psychol 2011;47:72–78.
- 29.↑
Peterson C, Park N, Seligman ME. Orientations to happiness and life satisfaction: the full life versus the empty life. J Happiness Stud 2005;6:25–41.
- 30.↑
Sheldon KM, Lyubomirsky S. How to increase and sustain positive emotion: the effects of expressing gratitude and visualizing best possible selves. J Positive Psychol 2006;1:73–82.
- 31.↑
Celano CM, Albanese AM, Millstein RA, et al. Optimizing a positive psychology intervention to promote health behaviors after an acute coronary syndrome: the Positive Emotions After Acute Coronary Events III (PEACE-III) randomized factorial trial. Psychosom Med 2018;80:526–534.
- 32.↑
Feig EH, Madva EN, Millstein RA, et al. Can positive psychological interventions improve health behaviors? A systematic review of the literature. Prev Med 2022;163:107214.
- 33.↑
Fredrickson BL. The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions. Am Psychol 2001;56:218–226.
- 34.↑
Amonoo HL, Brown LA, Scheu CF, et al. Positive psychological experiences in allogeneic hematopoietic stem cell transplantation. Psychooncology 2019;28:1633–1639.
- 35.↑
Huffman JC, DuBois CM, Millstein RA, et al. Positive psychological interventions for patients with type 2 diabetes: rationale, theoretical model, and intervention development. J Diabetes Res 2015;2015:428349.
- 36.↑
Huffman JC, Mastromauro CA, Boehm JK, et al. Development of a positive psychology intervention for patients with acute cardiovascular disease. Heart Int 2011;6:e14.
- 37.↑
Siddiqi AE, Sikorskii A, Given CW, et al. Early participant attrition from clinical trials: role of trial design and logistics. Clin Trials 2008;5:328–335.
- 38.↑
Steinhauser KE, Clipp EC, Hays JC, et al. Identifying, recruiting, and retaining seriously-ill patients and their caregivers in longitudinal research. Palliat Med 2006;20:745–754.
- 39.↑
Bowen DJ, Kreuter M, Spring B, et al. How we design feasibility studies. Am J Prev Med 2009;36:452–457.
- 40.↑
Huffman JC, Feig EH, Millstein RA, et al. Usefulness of a positive psychology-motivational interviewing intervention to promote positive affect and physical activity after an acute coronary syndrome. Am J Cardiol 2019;123:1906–1914.
- 41.↑
Huffman JC, Golden J, Massey CN, et al. A positive psychology- motivational interviewing intervention to promote positive affect and physical activity in type 2 diabetes: the BEHOLD-8 controlled clinical trial. Psychosom Med 2020;82:641–649.
- 42.↑
Scheier MF, Carver CS, Bridges MW. Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the Life Orientation Test. J Pers Soc Psychol 1994;67:1063–1078.
- 43.↑
Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol 1988;54:1063–1070.
- 44.↑
Mccullough ME, Emmons RA, Tsang JA. The grateful disposition: a conceptual and empirical topography. J Pers Soc Psychol 2002;82:112–127.
- 45.↑
Cella D, Riley W, Stone A, et al. The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008. J Clin Epidemiol 2010;63:1179–1194.
- 46.↑
McQuellon RP, Russell GB, Cella DF, et al. Quality of life measurement in bone marrow transplantation: development of the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) scale. Bone Marrow Transplant 1997;19:357–368.
- 47.↑
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–370.
- 48.↑
Smith MY, Redd W, DuHamel K, et al. Validation of the PTSD Checklist– Civilian Version in survivors of bone marrow transplantation. J Trauma Stress 1999;12:485–499.
- 49.↑
Duque L, Brown L, Celano CM, et al. Is it better to cultivate positive affect or optimism? Predicting improvements in medical adherence following a positive psychology intervention in patients with acute coronary syndrome. Gen Hosp Psychiatry 2019;61:125–129.
- 50.↑
Copeland JL, Esliger DW. Accelerometer assessment of physical activity in active, healthy older adults. J Aging Phys Act 2009;17:17–30.
- 51.↑
Sylvester BD, Ahmed R, Amireault S, et al. Changes in light-, moderate-, and vigorous-intensity physical activity and changes in depressive symptoms in breast cancer survivors: a prospective observational study. Support Care Cancer 2017;25:3305–3312.
- 52.↑
Helgadóttir B, Forsell Y, Ekblom Ö. Physical activity patterns of people affected by depressive and anxiety disorders as measured by accelerometers: a cross-sectional study. PLoS One 2015;10:e0115894.
- 53.↑
Garriguet D, Colley RC. A comparison of self-reported leisure-time physical activity and measured moderate-to-vigorous physical activity in adolescents and adults. Health Rep 2014;25:3–11.
- 54.↑
Baliousis M, Rennoldson M, Dawson DL, et al.Group psychological intervention for emotional distress in haematopoietic stem cell transplantation: a feasibility randomised clinical trial. Eur J Oncol Nurs 2023;65:102359.
- 55.↑
Camacho Pérez E, Mayo S, Lipton JH, et al. Evaluation of a group-based exercise and relaxation rehabilitation program during hospitalization for allogeneic hematopoietic stem cell transplant. PM R 2023;15:51–64.
- 56.
Kim WS, Langer S, Todd M, et al. Feasibility of a digital storytelling intervention for hematopoietic cell transplant patients. J Cancer Educ 2022;37:1275–1285.
- 57.↑
DuBois CM, Millstein RA, Celano CM, et al. Feasibility and acceptability of a positive psychological intervention for patients with type 2 diabetes. Prim Care Companion CNS Disord 2016;18:10.4088/PCC.15m01902.
- 58.↑
Celano CM, Freedman ME, Harnedy LE, et al. Feasibility and preliminary efficacy of a positive psychology-based intervention to promote health behaviors in heart failure: the REACH for Health study. J Psychosom Res 2020;139:110285.
- 59.↑
Yu MS, An KY, Byeon J, et al. Exercise barriers and facilitators during hematopoietic stem cell transplantation: a qualitative study. BMJ Open 2020;10:e037460.
- 60.↑
Syrjala KL, Yi JC, Artherholt SB, et al. An online randomized controlled trial, with or without problem-solving treatment, for long-term cancer survivors after hematopoietic cell transplantation. J Cancer Surviv 2018;12:560–570.
- 61.↑
Vallerand JR, Rhodes RE, Walker GJ, et al. Feasibility and preliminary efficacy of an exercise telephone counseling intervention for hematologic cancer survivors: a phase II randomized controlled trial. J Cancer Surviv 2018;12:357–370.
- 62.↑
Celano CM, Gianangelo TA, Millstein RA, et al. A positive psychology-motivational interviewing intervention for patients with type 2 diabetes: proof-of-concept trial. Int J Psychiatry Med 2019;54:97–114.
- 63.↑
Amonoo HL, Guo M, Boardman AC, et al. A positive psychology intervention for caregivers of hematopoietic stem cell transplantation survivors (PATH-C): initial testing and single-arm pilot trial. Transplant Cell Ther 2024;30:448.e1–448.e14.
- 64.↑
Baliousis M, Rennoldson M, Snowden JA. Psychological interventions for distress in adults undergoing haematopoietic stem cell transplantation: a systematic review with meta-analysis. Psychooncology 2016;25:400–411.
- 65.↑
Bevans M, El-Jawahri A, Tierney DK, et al. National Institutes of Health hematopoietic cell transplantation late effects initiative: the Patient- Centered Outcomes Working Group report. Biol Blood Marrow Transplant 2017;23:538–551.
- 66.↑
Chakraborty R, Savani BN, Litzow M, et al. A perspective on complementary/alternative medicine use among survivors of hematopoietic stem cell transplant: benefits and uncertainties. Cancer 2015;121:2303–2313.
- 67.↑
DuHamel KN, Mosher CE, Winkel G, et al. Randomized clinical trial of telephone-administered cognitive-behavioral therapy to reduce post- traumatic stress disorder and distress symptoms after hematopoietic stem-cell transplantation. J Clin Oncol 2010;28:3754–3761.
- 68.↑
Persoon S, Buffart LM, Chinapaw MJM, et al. Return to work experiences of patients treated with stem cell transplantation for a hematologic malignancy. Support Care Cancer 2019;27:2987–2997.
- 69.↑
Cheung DST, Takemura N, Lam TC, et al. Feasibility of aerobic exercise and tai-chi interventions in advanced lung cancer patients: a randomized controlled trial. Integr Cancer Ther 2021;20:15347354211033352.
- 70.↑
Palesh O, Scheiber C, Kesler S, et al. Feasibility and acceptability of brief behavioral therapy for cancer-related insomnia: effects on insomnia and circadian rhythm during chemotherapy: a phase II randomised multicentre controlled trial. Br J Cancer 2018;119:274–281.
