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Charles Ryan: Joining me today is Sima Porten, Assistant Professor of the Department of Urology at the University of California, San Francisco.

Sima, thanks for joining us. You're doing some really interesting work right now looking at guided imagery as a way to guide patients or help patients through surgery. Tell us about your study.

Sima Porten: First of all I want to thank you for inviting me here today. It's great to be able to speak about this because it's not something that is out there a lot, and it's something that's becoming more and more popular as apps like Headspace and Buddhify and that become kind of part of mainstream culture.

And so, our goal was to see if we could do something that was relatively cheap, scalable, meaning available to anybody, and also something that would really decrease anxiety for patients prior to undergoing major urologic surgery. So, in collaboration with our Helen Diller Osher Center, which is our integrative medicine center and some wonderful people like Dr. Marty Rossman, who's very well known within the integrative medicine field, and another younger collaborator named Dr. Sanjay Reddy, we were able to design a study, a randomized control trial, looking at this kind of intervention.

So, Dr. Rossman does these guided imagery tapes and MP3s, actually, and that's the way we decided to go because we didn't want someone to have an iPhone or a special player or even access to the internet to be able to play these, because some of our patients tend to be older, and we wanted to make it as easy to use as possible. So he created a tape that walks someone through relaxation techniques, visualizing that their tumor will be removed, visualizing that they'll do really well with surgery, having trust in the team doing surgery, and it's pretty short. It's about 10 to 15 minutes tape that you can listen to daily or more than once a day.

And so we gave that to patients who were randomized to the intervention to listen to about two weeks before surgery. We then used a company called CareMessage which provides a text messaging app that lets you be able to collect data on patients. It will send them a message to say, "Hey, remember to do your imagery recording today," and they can write back and let us know how many times they did it that week. So, in that way, we're able to also remotely collect data.

That can be done on an old flip phone. Doesn't have to be a smartphone.

Charles Ryan: A flip phone.

Sima Porten: Mm-hmm (affirmative). About 10% of my patients have flip phones still.

Charles Ryan: Really?

Sima Porten: Yes.

Charles Ryan: That's the most exciting data I've heard all day.

Sima Porten: It's so, yeah.

Charles Ryan: In the guided imagery, is the intervention listening to the tape or can somebody, if you've done the tape every day for 12 days, do you need to keep listening to it? I mean-

Sima Porten: So, yeah.

Charles Ryan: ... is that the intervention itself?

Sima Porten: The intervention is the listening to the tape as much as possible, at least daily, prior to surgery, and we timed our intervention to be about two weeks long. So patients were given an anxiety survey right before they got the tape, and also the day before surgery, and with that, we were able to meet our endpoint in meaningfully reducing anxiety prior to surgery just with those two weeks.

The question you ask is interesting. What do you do after surgery? Do you continue to listen to this on a daily basis in the hospital? How about when you get home? And we didn't do that intervention in this trial. It has been done before in both the colorectal literature and in some of the OB-GYN literature as well. Looking at it in the peri-operative period, meaning while they're in the hospital, as well as post-operatively.

What was interesting is when we did the anxiety survey 30 days after surgery, it was pretty much same across the board for patients who got the intervention and those that didn't. As a way to entice people to do the trial, anybody who participated got a post-operative guided imagery tape as well that focused a lot more on recovery, overcoming potential side effects that could have happened with surgery, and then, also, long-term survivorship.

Charles Ryan: What types of surgeries were these patients having? Any urologic surgery? Urologic cancer?

Sima Porten: Any major urologic cancer surgery, so radical prostatectomy, radical cystoprostatectomy, or radical cystectomy, any nephrectomy, open or robotic, so some patients were having caval thrombus, some were having an open partial, some were having robotic partial, but anything that was considered a major urologic oncology operation.

Charles Ryan: And did you select for, or do you identify or score the anxiety level in the patient before you start? I mean, that's your pinpoint-

Sima Porten: Yes. Yeah.

Charles Ryan: ... but are there some patients who are not anxious enough to be eligible and some who are too anxious? Do you have a parameter around that?

Sima Porten: Yeah. Most people had moderate to severe anxiety right at the time of enrollment in the trial because they were just given pretty significant diagnosis. We were able to get a lot of those patients down to mild. There was a couple of outliers where some people had very, very severe anxiety scores and a few didn't have very much anxiety at all.

I would say some of the comments afterwards, we let people give a free text of what they thought, and some of the interesting themes that came out were a lot of people were noticing that it helped them sleep better, in general, and that they really liked it and they started looking into some of the other, more available apps like Headspace and Buddhify and some of those types of apps.

There are some people who, for them, they thought that it did not help as much, it wasn't within their value system, that they used more their faith as a way to bring down anxiety, so I think that would be an interesting area to explore, how those two can intersect or complement each other. There were others who felt that overall it helped them in a lot of other ways-

Charles Ryan: Yeah.

Sima Porten: ... with coping. They had some unexpected benefits-

Charles Ryan: Yeah.

Sima Porten: ... in terms of that. And there were some people who made some very real, I would say, comments. These were probably not as positive as the vast majority of them, but they were saying, "This is great," but really a lot of the stress comes from some of the financial toxicity with their treatment, and that obviously no amount of meditation or relaxation will take that away. And so I think that was interesting as well.

It's always interesting what you get when you ask patients.

Charles Ryan: Yeah. Exactly.

Sima Porten: They think. Right? 

Charles Ryan: Well, I was going to address this question of, do you think absent this app and this study, patient anxiety around surgery may in part be a function of their level of communication and comfort with their physician, and how the healthcare team is communicating with them. So, do you account for that in your study, and is that something that is studied independently?

Sima Porten: Yes. It's, actually, a really great question there. Having a lot of interventions like this, Blue Cross Blue Shield did a large one, but it was very high-touch. A nurse navigator called and said, "How's the imagery going?" And also, kind of talked to them about surgery and things around that, and so did a lot of very high-touch personal speaking with patients, and so the criticisms of that intervention were that there was so much one-on-one time, that that's what was bringing down anxiety.

For this one, we purposefully tried to make it not ... We literally had no communication with the patient aside from, "Okay, you're enrolled. Here's your MP3," and then these anonymized text messages would come and say, "How many times you did it." And they were told that we just didn't know any of that, and so was a little bit disconnected from the actual team providing care. And so ...

Charles Ryan: Well, that was ... sort of, I was going with this, is to say, that if you had this app that's working really well, are the physicians in the care team going to say, "Well, the app will take care of the anxiety. We're not going to talk to you about anxiety."

Sima Porten: Yeah. I don't ...

Charles Ryan: I mean ... right?

Sima Porten: I don't know if it would feedback in that way. I hope physicians would continue doing what they did-

Charles Ryan: Right.

Sima Porten: ... and that we would still be able to see that decrease. People knew that this was going on, but they didn't know who was randomized to what group. But I wonder if the results come out if they'll be like, "Okay, you can do this app instead of-

Charles Ryan: Right.

Sima Porten: ... doing the work as a doctor and sort of mitigating some of the stress

Charles Ryan: Well, I would suggest that in the early days of this technology, assuming this is technology that was rolled out, you'll have the really dedicated physicians who have a high baseline touch factor with their patients who will adopt this technology and those are precisely the ones who may need it the least.

Sima Porten: Yes.

Charles Ryan: And then you'll have the people on the other end of the spectrum who aren't high-touch surgeons, who will say, "Okay, now I don't have to worry about even trying to be high-touch because I've got this app." Right?

Sima Porten: I've got this app instead. Yeah.

Charles Ryan: And then you'll have, you know, you probably won't have the scenario that you described through Blue Cross and Blue Shield where the health system kicks in with even additional touch factors.

Sima Porten: Yeah.

Charles Ryan: But just to wrap up, there's intrinsic value, I think, in seeing this reducing anxiety for patients, but if you were asked to say, "How is this going to affect the bottom line of your hospital, how is this going to affect care in the long run?" What would be the argument for doing this?

Sima Porten: In previous studies that focus more on the post-operative period, they were able to show a decrease in ER visits and complications and readmissions. We're still looking at our data on that if there's any kind of a signal. We weren't powered for looking at that.

Charles Ryan: How many patients did you enroll?

Sima Porten: 164.

Charles Ryan: And they were all at UCSF?

Sima Porten: All UCSF. Yeah. Within about four, five months. It enrolled really quick. Everybody wanted to-

Charles Ryan: That's a remarkable rate.

Sima Porten: Patients wanted to do it.

Charles Ryan: Sure. That's a remarkable rate of 

Sima Porten: And so, it was, it was ...

Charles Ryan: Incredible.

Sima Porten: Not slow at all.

Charles Ryan: Well, we look forward to hearing and reading more about it, and thank you for taking the lead on this. A really important issue. You know, as a medical oncologist, this has been studied a little bit around chemotherapy and some of the toxic medical therapies, but even integrating this further into the earlier in the treatment course for patients, I think it's going to have, as I said before intrinsic benefits.

So, thank you for your work and thank you for joining us here today.

Sima Porten: Thanks for having me.