What models of care for teleoncology are available to allied health services?

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Guideline developer:

Clinical Oncological Society of Australia

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Professor Liz Ward, Clare Burns, Laurelie Wall, COSA Teleoncology Guidelines Working Group. Clinical question:What models of care for teleoncology are available to allied health services? . In: Clinical practice guidelines for teleoncology. Sydney: Clinical Oncological Society of Australia. [Version URL: https://wiki.cancer.org.au/australiawiki/index.php?oldid=127444, cited 2023 Jun 2]. Available from: https://wiki.cancer.org.au/australia/COSA:Teleoncology.


Last modified:
17 February 2016 23:50:13

Introduction

Reviewing the models of care used by allied health professions in the area of teleoncology revealed variations in the types of technology currently used. The following sections are grouped by technological approach, with separate evidence summaries and recommendations made regarding: telephone-based services; computerised screening and assessment, hybrid education and health monitoring services; and videoconferencing services.

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Telephone-based services

There have been a number of Level II (most with moderate bias)[1][2][3][4][5][6][7][8][9][10][11][12] and lower level III/IV[13][14][15][16][17][18][19][20][21][22][23][24] studies confirming positive effects of telephone services to support allied health interventions across a range of oncology populations. Despite this, it is important to note that no studies have directly compared the delivery of the same intervention by traditional face-to-face services with the telephone-based service. As such, the current evidence supports the feasibility and benefit of delivering aspects of allied health care by telephone, however, their equivalence to face-to-face services is unproven.

Most of the research in this area has been conducted with breast cancer patients. Studies have documented the positive impact of telephone education and counselling sessions targeting psychosocial functioning for individuals (including males)[1][2][13][3][4][14][7], or their first degree relatives.[15] Such services were typically delivered by social workers,[1][2][13][4] masters level psychosocial counsellors[4][15] or experienced group therapists.[13]

Other studies have demonstrated improved physical activity using telephone support programs administered by exercise physiologists.[5][16] Individuals also experienced positive treatment effects for functioning, emotional state and quality of life from occupational therapy interventions.[7]

Telephone-based interventions have some benefits for lifestyle change,[19] for reducing behavioural risk factors[17] and improving sexual and intimacy outcomes in patients with colorectal cancer and their partners.[8][18] Use of telephone contact to support home-based exercise programs[20][9], deliver combined exercise, nutrition and counselling services[21][10][11] or psychological therapy[22], have demonstrated improved nutritional states,[21][10][11] enhanced physical wellbeing[20][9][21][11] and positive psychological benefits[21][10][11][22] in both population specific[10][23] and mixed groups of cancer survivors.[20][9][21][11]

Telephone counselling services were not found to enhance smoking abstinence rates amongst people in the social networks of patients with lung cancer.[12] A pilot trial of a pharmacist-led service using telephone SMS monitoring was found to be a feasible method for monitoring chemotherapy induced side effects in ambulatory outpatients receiving chemotherapy.[24]

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Computerised screening and assessment

The use of technology-assisted screening tools for the assessment and monitoring of oncology patients is still in an early stage of development. Five lower level evidence (IV) studies have reported on the use of computerised screening tools as a model of care in oncology outpatient settings.[25][26][27][28][29] Three of these studies specifically focused in the head and neck cancer population[26][27][28] and two in generalised ambulatory oncology patients.[25][29]

All these studies reported on purpose-built touch screen computer systems delivering patient-reported outcome measurements, including speech and swallowing function, pain, distress, and overall quality of life. Only one study has investigated the implementation of a computerised screening tool to direct psycho-oncology services. This resulted in a greater numbers of referrals and a reduction in overall patient-reported distress post-service implementation.[29] One investigation reported on the feasibility of a computerised quality of life screening program as a model of care.[25] The three remaining studies reported on utilisation of screening tools to collect prevalence data on patient-reported functional deficits or concerns. These studies contained limited discussion on the integration of the tools into their own clinical service model.[26][27][28]

Overall, the evidence for the use of computerised screening and assessment tools by allied health professionals is still emerging. However, preliminary findings suggest that it is feasible to integrate these models into clinical services.

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Hybrid education and health monitoring services

There is a limited body of evidence for the use of technology-enabled hybrid systems by allied health professional working in oncology services.[30][31][32][33][34] A Level II randomised controlled trial demonstrated favourable quality of life outcomes for patients who received a combination of computer-based support and face-to-face mentoring by clinicians.[32] A lower level follow-up study of the same system reported improvements in caregiver burden and mood.[30]

A Level IV study reported the value of a computer-based support and monitoring system in communicating emergent clinical issues as well as facilitating patient education.[34] Two studies investigated the use of web-based support groups for breast cancer survivors moderated by allied health professionals, with high participant satisfaction and a moderate positive effect on depression and cancer-related trauma.[31][33]

While the evidence-base is preliminary at best, the use of hybrid teleoncology systems incorporating web-based education and remote interaction by allied health professionals may have merit for enhancing the reach of finite health resources.

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Videoconferencing services

The allied health professions that currently use videoconferencing for oncology care are pharmacy, physiotherapy, psychology, social work, and speech pathology.[1][35][36][37][38][39][40][41][42][43][44] The technology used is standard hardware and videoconferencing software with specialised peripheral devices such as head-set microphones[43] and medical camera systems[35] to enable remote assessment of routine clinical structures and features such as voice quality or oral cavity.

Of the eleven published studies, two were Level II, three were Level III randomised controlled trials, while the remaining were Level IV case series. Both Level II studies evaluated the use of videoconferencing to improve patient access to a psychosocial intervention. One study compared the effectiveness of telephone health education and interpersonal counselling delivered by videophone or telephone for breast cancer survivors and their supportive partners.[1] While increased quality of life was noted for all participants, individuals in the telephone or video teleconferencing counselling groups experienced increased social well-being. The other study evaluated the outcomes of an online mindfulness-based cancer recovery group program compared with a usual treatment group. Moderate positive effects in mood disturbance, stress symptoms and some aspects of mindfulness was experienced by the group accessing treatment by videoconference.[44]

Both Level III studies reported successful use of videoconferencing in the provision of telerehabilitation. These included a reliable clinical model for the remote assessment of swallowing and communication function in patients post laryngectomy[43] and the validation of an online assessment method used by carers to monitor and detect lymphoedema in breast cancer survivors.[37]

The remaining lower level studies (Level IV) describe case series using videoconferencing for multidisciplinary allied health assessment and treatment in a head and neck cancer clinic[41] and palliative care.[42] These studies described the benefits of videoconferencing in enabling better access to specialist care and support,[35][38] and positive patient outcomes for communication and swallowing rehabilitation[35] as well as psychological benefits.[36][39][40]

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Evidence summary and recommendations

Recommendation One

Evidence summary Level References
Telephone-based services have demonstrated benefit in the delivery of allied health cancer care services for psychology, social work, occupational therapy, exercise physiology, physiotherapy, nutrition/dietetics and pharmacy models of care. II, III-1, III-2, III-3, IV [1], [2], [13], [3], [4], [14], [15], [5], [6], [16], [7], [17], [8], [18], [19], [20], [9], [21], [10], [11], [22], [23], [12], [24]
Evidence-based recommendationQuestion mark transparent.png Grade
Telephone-based support systems are feasible and can help facilitate changed behaviours (eg. diet, exercise), improved function (eg., fitness, health related function), and improved psychological/psychosocial states. 		B


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Recommendation Two

Evidence summary Level References
Computerised screening models have demonstrated benefit in the assessment and monitoring of speech, swallowing, quality of life, pain and distress in allied health oncology outpatient settings. IV [25], [26], [27], [28], [29]
Evidence-based recommendationQuestion mark transparent.png Grade
Computerised screening/assessment is feasible and can be used as a model of care to collect information on patient status and assist referral to allied health oncology services. 		C


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Recommendation Three

Evidence summary Level References
Hybrid telepractice systems have demonstrated benefit in the delivery of allied health cancer care services for psychology models of care, and multidisciplinary patient education. II, IV [31], [30], [32], [33], [34]
Evidence-based recommendationQuestion mark transparent.png Grade
Hybrid telepractice systems can offer alternative models of care for the provision of allied health education and support to oncology patients. 		C


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Recommendation Four

Evidence summary Level References
Videoconferencing has demonstrated benefit in the delivery of allied health cancer care services for pharmacy, physiotherapy, psychology, and speech pathology telepractice models of care. II, III-1, III-2, III-3, IV [1], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44]
Evidence-based recommendationQuestion mark transparent.png Grade
Videoconferencing services can be used to deliver allied health assessment and treatment services for oncology patients. 		C


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Practice Point

Practice pointQuestion mark transparent.png

Equivalency to standard/usual care has been reported for some allied health telepractice models. Clinicians should refer to individual studies to determine the similarity in outcomes with their chosen model of care.

Comments

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Badger T, Segrin C, Pasvogel A, Lopez AM. The effect of psychosocial interventions delivered by telephone and videophone on quality of life in early-stage breast cancer survivors and their supportive partners. J Telemed Telecare 2013 Jul;19(5):260-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24163235.
  2. ↑ 2.0 2.1 2.2 2.3 Badger TA, Segrin C, Hepworth JT, Pasvogel A, Weihs K, Lopez AM. Telephone-delivered health education and interpersonal counseling improve quality of life for Latinas with breast cancer and their supportive partners. Psychooncology 2013 May;22(5):1035-42 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22573418.
  3. ↑ 3.0 3.1 3.2 Heiney SP, McWayne J, Hurley TG, Lamb LS Jr, Bryant LH, Butler W, et al. Efficacy of therapeutic group by telephone for women with breast cancer. Cancer Nurs 2003 Dec;26(6):439-47 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15022975.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Marcus AC, Garrett KM, Cella D, Wenzel L, Brady MJ, Fairclough D, et al. Can telephone counseling post-treatment improve psychosocial outcomes among early stage breast cancer survivors? Psychooncology 2010 Sep;19(9):923-32 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19941285.
  5. ↑ 5.0 5.1 5.2 Eakin EG, Lawler SP, Winkler EA, Hayes SC. A randomized trial of a telephone-delivered exercise intervention for non-urban dwelling women newly diagnosed with breast cancer: exercise for health. Ann Behav Med 2012 Apr;43(2):229-38 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22109352.
  6. ↑ 6.0 6.1 Pinto BM, Frierson GM, Rabin C, Trunzo JJ, Marcus BH. Home-based physical activity intervention for breast cancer patients. J Clin Oncol 2005 May 20;23(15):3577-87 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15908668.
  7. ↑ 7.0 7.1 7.2 7.3 Hegel MT, Lyons KD, Hull JG, Kaufman P, Urquhart L, Li Z, et al. Feasibility study of a randomized controlled trial of a telephone-delivered problem-solving-occupational therapy intervention to reduce participation restrictions in rural breast cancer survivors undergoing chemotherapy. Psychooncology 2011 Oct;20(10):1092-101 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20821373.
  8. ↑ 8.0 8.1 8.2 Barsky Reese J, Porter LS, Regan KR, Keefe FJ, Azad NS, Diaz LA Jr, et al. A randomized pilot trial of a telephone-based couples intervention for physical intimacy and sexual concerns in colorectal cancer. Psychooncology 2014 Sep;23(9):1005-13 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24615831.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Ligibel JA, Meyerhardt J, Pierce JP, Najita J, Shockro L, Campbell N, et al. Impact of a telephone-based physical activity intervention upon exercise behaviors and fitness in cancer survivors enrolled in a cooperative group setting. Breast Cancer Res Treat 2012 Feb;132(1):205-13 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22113257.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 Hung YC, Bauer JD, Horsely P, Coll J, Bashford J, Isenring EA. Telephone-delivered nutrition and exercise counselling after auto-SCT: a pilot, randomised controlled trial. Bone Marrow Transplant 2014 Jun;49(6):786-92 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24710562.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 Morey MC, Snyder DC, Sloane R, Cohen HJ, Peterson B, Hartman TJ, et al. Effects of home-based diet and exercise on functional outcomes among older, overweight long-term cancer survivors: RENEW: a randomized controlled trial. JAMA 2009 May 13;301(18):1883-91 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19436015.
  12. ↑ 12.0 12.1 12.2 Bastian LA, Fish LJ, Peterson BL, Biddle AK, Garst J, Lyna P, et al. Assessment of the impact of adjunctive proactive telephone counseling to promote smoking cessation among lung cancer patients' social networks. Am J Health Promot 2013 Jan;27(3):181-90 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23286595.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Heiney SP, Adams SA, Wells LM, Johnson H, King JM. Participant evaluation of teleconference support for African American women with breast cancer. Cancer Nurs 2012 Mar;35(2):E24-30 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21760497.
  14. ↑ 14.0 14.1 14.2 Farrell E, Borstelmann N, Meyer F, Partridge A, Winer E, Ruddy K. Male breast cancer networking and telephone support group: a model for supporting a unique population. Psychooncology 2014 Aug;23(8):956-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24700635.
  15. ↑ 15.0 15.1 15.2 15.3 Bloom JR, Stewart SL, Chang S, You M. Effects of a telephone counseling intervention on sisters of young women with breast cancer. Prev Med 2006 Nov;43(5):379-84 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16916540.
  16. ↑ 16.0 16.1 16.2 Ligibel JA, Partridge A, Giobbie-Hurder A, Campbell N, Shockro L, Salinardi T, et al. Physical and psychological outcomes among women in a telephone-based exercise intervention during adjuvant therapy for early stage breast cancer. J Womens Health (Larchmt) 2010 Aug;19(8):1553-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20629579.
  17. ↑ 17.0 17.1 17.2 Reese JB, Porter LS, Somers TJ, Keefe FJ. Pilot feasibility study of a telephone-based couples intervention for physical intimacy and sexual concerns in colorectal cancer. J Sex Marital Ther 2012;38(5):402-17 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22900623.
  18. ↑ 18.0 18.1 18.2 Hawkes AL, Patrao TA, Green A, Aitken JF. CanPrevent: a telephone-delivered intervention to reduce multiple behavioural risk factors for colorectal cancer. BMC Cancer 2012 Nov 27;12:560 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23181756.
  19. ↑ 19.0 19.1 19.2 Hawkes AL, Gollschewski S, Lynch BM, Chambers S. A telephone-delivered lifestyle intervention for colorectal cancer survivors 'CanChange': a pilot study. Psychooncology 2009 Apr;18(4):449-55 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19241477.
  20. ↑ 20.0 20.1 20.2 20.3 20.4 Wilson RW, Jacobsen PB, Fields KK. Pilot study of a home-based aerobic exercise program for sedentary cancer survivors treated with hematopoietic stem cell transplantation. Bone Marrow Transplant 2005 Apr;35(7):721-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15696182.
  21. ↑ 21.0 21.1 21.2 21.3 21.4 21.5 21.6 Garrett K, Okuyama S, Jones W, Barnes D, Tran Z, Spencer L, et al. Bridging the transition from cancer patient to survivor: pilot study results of the Cancer Survivor Telephone Education and Personal Support (C-STEPS) program. Patient Educ Couns 2013 Aug;92(2):266-72 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23647980.
  22. ↑ 22.0 22.1 22.2 22.3 Watson M, White C, Davolls S, Mohammed A, Lynch A, Mohammed K. Problem-focussed interactive telephone therapy for cancer patients: a phase II feasibility trial. Psychooncology 2013 Jul;22(7):1485-91 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23080374.
  23. ↑ 23.0 23.1 23.2 Kilbourn KM, Anderson D, Costenaro A, Lusczakoski K, Borrayo E, Raben D. Feasibility of EASE: a psychosocial program to improve symptom management in head and neck cancer patients. Support Care Cancer 2013 Jan;21(1):191-200 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22699303.
  24. ↑ 24.0 24.1 24.2 Yap KY, Low HX, Koh KS, Un M, Shih V, Chan A. Feasibility and acceptance of a pharmacist-run tele-oncology service for chemotherapy-induced nausea and vomiting in ambulatory cancer patients. Telemed J E Health 2013 May;19(5):387-95 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23531095.
  25. ↑ 25.0 25.1 25.2 25.3 Carlson LE, Speca M, Hagen N, Taenzer P. Computerized quality-of-life screening in a cancer pain clinic. J Palliat Care 2001;17(1):46-52 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11324185.
  26. ↑ 26.0 26.1 26.2 26.3 Ghazali N, Kanatas A, Scott B, Lowe D, Zuydam A, Rogers SN. Use of the Patient Concerns Inventory to identify speech and swallowing concerns following treatment for oral and oropharyngeal cancer. J Laryngol Otol 2012 Aug;126(8):800-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22698382.
  27. ↑ 27.0 27.1 27.2 27.3 Verdonck-de Leeuw IM, de Bree R, Keizer AL, Houffelaar T, Cuijpers P, van der Linden MH, et al. Computerized prospective screening for high levels of emotional distress in head and neck cancer patients and referral rate to psychosocial care. Oral Oncol 2009 Oct;45(10):e129-33 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19362038.
  28. ↑ 28.0 28.1 28.2 28.3 Cnossen IC, de Bree R, Rinkel RN, Eerenstein SE, Rietveld DH, Doornaert P, et al. Computerized monitoring of patient-reported speech and swallowing problems in head and neck cancer patients in clinical practice. Support Care Cancer 2012 Nov;20(11):2925-31 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22395211.
  29. ↑ 29.0 29.1 29.2 29.3 Carter G, Britton B, Clover K, Rogers K, Adams C, McElduff P. Effectiveness of QUICATOUCH: a computerised touch screen evaluation for pain and distress in ambulatory oncology patients in Newcastle, Australia. Psychooncology 2012 Nov;21(11):1149-57 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21780241.
  30. ↑ 30.0 30.1 30.2 DuBenske LL, Gustafson DH, Namkoong K, Hawkins RP, Atwood AK, Brown RL, et al. CHESS improves cancer caregivers' burden and mood: results of an eHealth RCT. Health Psychol 2014 Oct;33(10):1261-72 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24245838.
  31. ↑ 31.0 31.1 31.2 Winzelberg AJ, Classen C, Alpers GW, Roberts H, Koopman C, Adams RE, et al. Evaluation of an internet support group for women with primary breast cancer. Cancer 2003 Mar 1;97(5):1164-73 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12599221.
  32. ↑ 32.0 32.1 32.2 Hawkins RP, Pingree S, Shaw B, Serlin RC, Swoboda C, Han JY, et al. Mediating processes of two communication interventions for breast cancer patients. Patient Educ Couns 2010 Dec;81 Suppl:S48-53 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21081261.
  33. ↑ 33.0 33.1 33.2 Lieberman MA, Golant M, Giese-Davis J, Winzlenberg A, Benjamin H, Humphreys K, et al. Electronic support groups for breast carcinoma: a clinical trial of effectiveness. Cancer 2003 Feb 15;97(4):920-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12569591.
  34. ↑ 34.0 34.1 34.2 van den Brink JL, Moorman PW, de Boer MF, Pruyn JF, Verwoerd CD, van Bemmel JH. Involving the patient: a prospective study on use, appreciation and effectiveness of an information system in head and neck cancer care. Int J Med Inform 2005 Oct;74(10):839-49 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16043392.
  35. ↑ 35.0 35.1 35.2 35.3 35.4 Burns CL, Ward EC, Hill AJ, Malcolm K, Bassett L, Kenny LM, et al. A pilot trial of a speech pathology telehealth service for head and neck cancer patients. J Telemed Telecare 2012 Dec;18(8):443-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23209274.
  36. ↑ 36.0 36.1 36.2 Collie K, Kreshka MA, Ferrier S, Parsons R, Graddy K, Avram S, et al. Videoconferencing for delivery of breast cancer support groups to women living in rural communities: a pilot study. Psychooncology 2007 Aug;16(8):778-82 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17253594.
  37. ↑ 37.0 37.1 37.2 Galiano-Castillo N, Ariza-García A, Cantarero-Villanueva I, Fernández-Lao C, Sánchez-Salado C, Arroyo-Morales M. Agreement between telerehabilitation involving caregivers and face-to-face clinical assessment of lymphedema in breast cancer survivors. Support Care Cancer 2014 Jan;22(1):253-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24043290.
  38. ↑ 38.0 38.1 38.2 Gordon HL, Hoeber M, Schneider A. Telepharmacy in a rural Alberta Community Cancer Network. J Oncol Pharm Pract 2012 Sep;18(3):366-76 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22378811.
  39. ↑ 39.0 39.1 39.2 Passik SD, Kirsh KL, Leibee S, Kaplan LS, Love C, Napier E, et al. A feasibility study of dignity psychotherapy delivered via telemedicine. Palliat Support Care 2004 Jun;2(2):149-55 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16594244.
  40. ↑ 40.0 40.1 40.2 Shepherd L, Goldstein D, Whitford H, Thewes B, Brummell V, Hicks M. The utility of videoconferencing to provide innovative delivery of psychological treatment for rural cancer patients: results of a pilot study. J Pain Symptom Manage 2006 Nov;32(5):453-61 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17085271.
  41. ↑ 41.0 41.1 41.2 Savage SA, Nixon I, MacKenzie K. Teleconferencing in the management of head and neck cancer. Clin Otolaryngol 2007 Apr;32(2):130-2 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17403234.
  42. ↑ 42.0 42.1 42.2 Watanabe SM, Fairchild A, Pituskin E, Borgersen P, Hanson J, Fassbender K. Improving access to specialist multidisciplinary palliative care consultation for rural cancer patients by videoconferencing: report of a pilot project. Support Care Cancer 2013 Apr;21(4):1201-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23161339.
  43. ↑ 43.0 43.1 43.2 43.3 Ward E, Crombie J, Trickey M, Hill A, Theodoros D, Russell T. Assessment of communication and swallowing post-laryngectomy: a telerehabilitation trial. J Telemed Telecare 2009;15(5):232-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19590028.
  44. ↑ 44.0 44.1 44.2 Zernicke KA, Campbell TS, Speca M, McCabe-Ruff K, Flowers S, Carlson LE. A randomized wait-list controlled trial of feasibility and efficacy of an online mindfulness-based cancer recovery program: the eTherapy for cancer applying mindfulness trial. Psychosom Med 2014 May;76(4):257-67 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24804884.

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