Step Up is an intervention that pairs psychosocial symptom management and activity coaching for patients with cancer who have undergone stem cell transplants. Following transplant, patients are deconditioned and struggle to engage in physical activity. In addition to significant physical disability, patients often experience physical and psychological symptoms such as pain, fatigue, and stress. These symptoms are also major barriers to activity. Teaching transplant patients to cope with symptoms and engage in physical activity is critical for their recovery and quality of life.
Step Up is a digital cognitive behavioral theory-based intervention that pairs virtual psychologist and occupational therapist-led sessions with supplemental content delivered via Pattern Health’s app. The app helps extend the intervention into the patient’s home with personalized content and messaging.
In this interview, Sarah Kelleher, Ph.D. discusses behavioral pain management, her experience designing a digital intervention, and moments of inspiration along the way.
Could you speak a bit about your professional journey and path to the Step Up project?
In my first job as a clinical researcher in Washington DC, I worked closely with patients at Georgetown’s cancer center — specifically, women newly diagnosed with breast cancer. I witnessed the impact of our work on patients’ treatment-related decision making, psychological health and well-being, and overall quality of life. This line of clinical research felt incredibly important and rewarding. It motivated me to pursue a graduate degree in clinical psychology and specialize in behavioral medicine.
At the end of my graduate training, I came to Duke and spent a lot of time with patients in the Adult Blood and Marrow Transplant (ABMT) clinic. Stem cell transplant patients have a unique cancer journey and go through such intensive treatments. They often struggle both physically and emotionally.
I was involved in clinical and research programs at the ABMT clinic. I loved working with this patient population and was eager to continue the team’s work. STEP UP grew out of early behavioral pain management initiatives with ABMT patients. We recognized a need to address fatigue and stress, in addition to pain, and target patients’ physical functioning more directly.
Could you tell us about the app?
Our program combines evidence-based behavioral symptom management delivered by a clinical health psychologist with activity coaching led by an occupational therapist. The program is designed to help patients effectively cope with their symptoms so they can safely engage in physical activity and reduce disability following transplant. Our goal is to concurrently and synergistically decrease symptom burden and increase physical activity. We’ve loved partnering with Pattern Health to build the study’s mobile app. It has been an exciting journey to see all that is possible in the digital health space.
The study’s app delivers personalized content, including audio/video coping skills resources, dynamic weekly step count goals, and messaging based on patients’ symptoms and step count. The use of digital health technology also allows patients to remain connected to their medical team while transitioning from the hospital to their home. The continuity of care is essential.
Why did you add a digital piece to the Step Up intervention?
This is where the field is headed. Digital health interventions can increase access to treatment and decrease patient burden. It’s also a more sustainable model for the growing number of patients with chronic disease.
Cognitive behavioral symptom management interventions are traditionally delivered in person at academic medical centers. That presents system, provider, and patient-level barriers. Digital health technologies, including mobile apps, can make these interventions available to more patients.
Also, due to the COVID-19 pandemic, there are new opportunities in the digital health space and increased familiarity with technology and remote healthcare. We wanted to capitalize on that.
Was there a moment in the development process where you felt especially proud of what your team had accomplished?
In the early stages of STEP UP development, we conducted focus groups with transplant patients and healthcare providers. In those meetings, patients and providers were enthusiastic about the program and the study app, and gave overwhelmingly positive feedback.
The patients bonded with each other during those meetings. They spoke about how they wish they had access to this type of resource during their own transplant journey.
Managing pain, fatigue, and stress is a challenge for transplant patients. These symptoms are distressing and they impact patients’ lives on every level. We wanted to make these evidence-based symptom management strategies more accessible by digitizing the intervention. I’m excited about the work we’ve done, especially since it really seems to resonate with patients.
Do you have advice for teams that are designing a digital intervention?
It is essential to focus on patient engagement and meet the end user’s needs. I think it is important to tailor the app content for the patient demographic and capitalize on using patient data for real-time personalization. I think this increases engagement and will likely lead to better outcomes.
It often feels like there’s an app for everything now. But, our programs deliver intervention content that is grounded in scientifically proven concepts. I think this is critical. Though you might see a lot of apps out there, they may not have that evidence-based piece.
What was the last book/podcast/movie that you found inspiring?
Kate Bowler is a professor at Duke, and she has a podcast called “Everything Happens
for a Reason.” It’s one of my favorites. She has gone through treatment for stage IV cancer, and she discusses her journey and what she has learned over the years. She interviews really interesting people and their conversations are heartwarming. She’s an optimist and also really down-to-earth. She has a great sense of humor that balances her philosophical insight. Her podcast is thought-provoking and inspiring.
About Sarah A. Kelleher, Ph.D.
Sarah A. Kelleher, PhD is a Clinical Psychologist and Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center. Dr. Kelleher is a member of the Duke Pain Prevention and Treatment Research Program, the Duke Cancer Control and Population Sciences Program at the Duke Cancer Institute, and the Palliative Care Research Cooperative Group (PCRC). Dr. Kelleher completed her graduate training in clinical psychology at Virginia Tech and her clinical internship and postdoctoral fellowship at Duke University Medical Center. Her research focuses on developing, testing, and implementing behavioral symptom management interventions for patients with chronic disease.