JMIR FORMATIVE RESEARCH

Huberty et al

Original Paper

Smartphone-Based Meditation for Myeloproliferative Neoplasm
Patients: Feasibility Study to Inform Future Trials
Jennifer Huberty1, PhD; Ryan Eckert2, MS; Linda Larkey3, PhD; Jonathan Kurka1, PhD; Sue A Rodríguez De Jesús1,
PhD; Wonsuk Yoo1, PhD; Ruben Mesa2, MD
1

College of Health Solutions, Arizona State University, Phoenix, AZ, United States

2

Mays Cancer Center, University of Texas Health MD Anderson, San Antonio, TX, United States

3

College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, United States

Corresponding Author:
Jennifer Huberty, PhD
College of Health Solutions
Arizona State University
500 North 3rd St
Phoenix, AZ, 85004
United States
Phone: 1 402 301 1304
Email: jhuberty@asu.edu

Abstract
Background: Myeloproliferative neoplasm (MPN) patients often report high symptom burden that persists despite the best
available pharmacologic therapy. Meditation has gained popularity in recent decades as a way to manage cancer patient symptoms.
Objective: The aim of this study was to examine the feasibility of 2 different consumer-based meditation smartphone apps in
MPN patients and to examine the limited efficacy of smartphone-based meditation on symptoms compared with an educational
control group.
Methods: Patients (n=128) were recruited nationally through organizational partners and social media. Eligible and consented
patients were enrolled into 1 of 4 groups, 2 of which received varying orders of 2 consumer-based apps (10% Happier and Calm)and 2 that received one of the apps alone for the second 4 weeks of the 8-week intervention after an educational control condition.
Participants were asked to perform 10 min of meditation per day irrespective of the app and the order in which they received theapps. Feasibility outcomes were measured at weeks 5 and 9 with a Web-based survey. Feasibility outcomes were acceptability,
demand, and limited efficacy for depression, anxiety, pain intensity, sleep disturbance, sexual function, quality of life, global
health, and total symptom burden.
Results: A total of 128 patients were enrolled across all 4 groups, with 73.4% (94/128) patients completing the intervention.
Of the participants who completed the 10% Happier app, 61% (46/76) enjoyed it, 66% (50/76) were satisfied with the content,
and 77% (59/76) would recommend to others. Of those who completed the Calm app, 83% (56/68) enjoyed it, 84% (57/68) weresatisfied with the content, and 97% (66/68) would recommend to others. Of those who completed the educational control, 91%(56/61) read it, 87% (53/61) enjoyed it, and 71% (43/61) learned something. Participants who completed the 10% Happier app
averaged 31 (SD 33) min/week; patients completing the Calm app averaged 71 (SD 74) min/week. 10% Happier app participants
saw small effects on anxiety (P<.001 d=−0.43), depression (P=.02; d=−0.38), sleep disturbance (P=.01; d=−0.40), total symptom
burden (P=.13; d=−0.27), and fatigue (P=.06; d=−0.30), and moderate effects on physical health (P<.001; d=0.52). Calm app
participants saw small effects on anxiety (P=.29; d=−0.22), depression (P=.09; d=−0.29), sleep disturbance (P=.002; d=−0.47),
physical health (P=.005; d=0.44), total symptom burden (P=.13; d=−0.27), and fatigue (P=.13; d=−0.27). Educational control
participants (n=61) did not have effects on any patient-reported outcome except for a moderate effect on physical health (P<.001;
d=0.77).
Conclusions: Delivering meditation via the Calm app is feasible and scored higher in terms of feasibility when compared withthe 10% Happier app. The Calm app will be used to implement a randomized controlled trial, testing the effects of meditation
on symptom burden in MPNs.
Trial Registration: ClinicalTrials.gov NCT03726944; https://clinicaltrials.gov/ct2/show/NCT03726944 (Archived by WebCite
at http://www.webcitation.org/77MVdFJwM)
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Huberty et al(JMIR Form Res 2019;3(2):e12662) doi: 10.2196/12662
KEYWORDS
mindfulness; meditation; smartphone; mHealth; cancer; quality of life

Introduction
Myeloproliferative neoplasms (MPNs) are a rare blood cancer
with the most common subtypes including polycythemia vera,
essential thrombocythemia, and myelofibrosis. Those afflictedwith MPN report a high prevalence of fatigue, anxiety,depression, pain, and sleep disturbance [1,2]. The vast majorityof MPN patients (81% to 95%) report fatigue as the mostprevalent and severe symptom reducing physical, social, andcognitive functioning as well as quality of life [2-4]. MPN
patients often have a favorable life expectancy, with as manyas 60% of patients living up to 15 years after diagnosis. Manypatients even have the same life expectancy as the general
population [5,6]. This means that MPN patients live much of
their lives with fatigue, other symptoms, and the associateddetrimental effects on overall functioning and quality of life[3,7].
There has been significant advancement in the pharmacologicaltreatment of MPNs; however, for most patients, residual
symptoms (ie, fatigue, anxiety, depression, pain, and sleep
disturbance) persist, even with active pharmacologic therapy[8,9]. Additionally, standard-of-care treatments for MPN,
including medication/drug therapy (ie, hydroxyurea),
phlebotomy, and bone marrow transplant (the only curative
therapy, reserved for those with severely reduced life
expectancy), are associated with worsened symptoms and areduced quality of life [10]. There is a need for research
examining adjuvant, nonpharmacologic approaches (eg,mindfulness-based therapies) for MPN patients that may
improve symptoms and that are not accompanied by negativeside effects.
Extensive research in recent decades demonstrates the benefitsof mindfulness-based therapies for alleviating fatigue, anxiety,depression, and sleep disturbance in both cancer and noncancer
populations [11-16]. Mindfulness meditation has gained
increasing attention as a complementary therapy for cancer
patients, particularly for alleviating psychological comorbidities
associated with cancer and its treatment [17]. Mindfulness
meditation is the practice of moment-to-moment awareness inwhich the person purposefully focuses on the present moment
without judgment [18]. Mindfulness meditation (hereinafterreferred to as meditation) may be a potentially beneficial
complementary therapy that improves MPN symptoms throughincreased nonjudgmental awareness of thoughts, feelings, andbody sensations. These increases in awareness may help reduce
feelings of anxiety and depression and may also help alleviate
sleep disturbances resulting from sleep-interfering cognitive
processes (ie, ruminating thoughts while trying to sleep) [12,16].
However, there has been minimal research investigating theeffects of mindfulness meditation as a complementary therapy
in hematological cancer patients and, specifically, no research
conducted on MPN patients [19].

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There has been a growing trend in recent decades toward digital(ie, Web-based and smartphone-based) interventions for healthcare access and to improve well-being. MPN patients may be
a population that can greatly benefit from a digital intervention
owing to (1) the rarity of MPNs, (2) the lack of specialized
treatment centers in the United States, (3) the increasing
prevalence of smartphone ownership in the United States, and(4) reported limitations to participation in in-person interventions
among cancer patients. In a recent study, it was demonstrated
that only 64% (18/28) and 29% (8/28) of MPN patients received
their specialty care in the same state or city, respectively, inwhich they resided [20]. Additionally, the vast majority ofAmericans (more than 77%) own a smartphone, with 62% using
their smartphones to get health information and 30% accessinga Web-based/mobile app to get educational content [21-23].
Finally, cancer patients report barriers to participating in
in-person interventions, including fatigue, pain, andtransportation/scheduling difficulties [24]. This asserts MPN
patients as a population with the potential to benefit from digital
meditation because they are more readily accessible andimplemented with fewer resources than in-person meditationinterventions.
As of January 2018, there were almost 6 million consumer-based
smartphone apps available across both the Google Play Storeand Apple’s App Store, the 2 leading app stores in the world[25]. Of these, there are over 500 mindfulness/meditation-based
smartphone apps available [26]. Despite the large number ofconsumer-based smartphone mindfulness/meditation apps
available, very little research has investigated the feasibility
and efficacy of these apps. Components and features acrossmeditation apps may be more feasible (ie, acceptable, demanded,and practical) than others, potentially impacting user outcomessuch as frequency of use and long-term compliance [27].
Although research is limited investigating the desired featuresof a consumer-based smartphone meditation app, there arereports about desired features in physical activity smartphone
apps (eg, automatic tracking of activity, tracking of progress
toward goals, and integrated features) [28] and across healthbehavior change apps more broadly (eg, accuracy of
information, security of personal information, effort required
to track progress, and immediate effects on mood) that help to
inform interventions [29]. However, no research has specificallyinvestigated the feasibility and desirability of one meditation
app compared with another, especially to inform futureinterventions in specific populations.
Owing to the potential beneficial effects that meditation may
have on residual MPN symptoms, the potential ease of delivery
to a rare cancer such as MPNs, and the potential for
dissemination of a consumer-based smartphone meditation app
across other cancer populations, there is a need to examine
meditation delivered via consumer-based smartphone apps in
MPN patients. Therefore, the aim of this study was to examine
the feasibility of 2 different consumer-based meditation
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smartphone apps in MPN patients and to examine the limited
efficacy of smartphone-based meditation on symptoms
compared with an educational control group. According to
Bowen et al [30], limited efficacy refers to testing theintervention with limited statistical power and is appropriate
for feasibility studies.

Methods
This study was approved by the Institutional Review Board at
Arizona State University, and all participants signed an informed
consent before participating in the study. All personal
information was collected electronically and was stored in a
password-protected computer at Arizona State University. The
study was retrospectively registered with ClinicalTrials.gov.

Study Design
This was a 4-group randomized controlled trial (RCT) with across-over design. A convenience sample of eligible andconsented MPN patients was recruited and enrolled into 1 of 4groups with varying order of receiving 2 consumer-based
meditation smartphone apps (ie, 10% Happier app or Calm app)in 4-week increments over 8 weeks. Group 1 received the 10%
Happier app followed by the Calm app; Group 2 received theCalm app followed by the 10% Happier app; Group 3 received
educational control followed by the 10% Happier app; andGroup 4 received educational control followed by the Calmapp. We chose the 4-group design to maximize the number ofparticipants who use both apps. We did not have a washout
period because the primary goal was to assess feasibility, notefficacy.
We used the Calm app for this study because Calm is one of
the most popular consumer-based mobile apps (ie, Apple’s appof the year in 2017), the lead author developed a relationshipwith Calm to conduct research using the app, and Calm agreed
to provide the memberships to the app and share the tracking
data with the research team without cost. The 10% Happier app
was chosen because they were one of the competing meditation
mobile apps of Calm and they agreed to provide thememberships to the app and share the tracking data with the

Huberty et al
research team without cost. Additionally, both smartphone apps
are available across all major smartphone platforms (ie, Android
and iOS).

Recruitment and Enrollment
MPN patients (n=128) were recruited online through MPN
organizational partners with a flier outlining the study and its
requirements. The study was advertised as a smartphone app
meditation study. MPN patients interested in the study wereasked to complete a Web-based eligibility questionnaireadministered via Qualtrics. Textbox 1 describes the eligibility
criteria. Researchers checked the eligibility questionnaires as
they were completed and emailed patients their eligibility status.
Eligible patients were invited to participate in a 20-min phone
appointment in which the study details and informed consent
were described in detail. MPN patients who completed the intake
appointment were then sent an informed consent electronically
via Qualtrics that included a place for their electronic signature.
Ineligible patients received an email stating their ineligibility
status as well as links to both consumer-based apps used in the
study, in case the ineligible participant was interested in trying
meditation.
Upon receipt of the completed informed consent, participants
were randomly assigned to one of 4 groups. A group assignment
list was computationally generated through randomizer.org bya research assistant to randomly allocate participants to one of
4 equally sized groups before study commencement This
pre-generated list was then used by the same research assistant
to place eligible, consented MPN patients into their groupassignment in the order in which they consented to participate.
Randomized participants were provided with a welcome emailthat contained (1) a welcome letter introducing them to thestudy, (2) a calendar detailing important study dates, and (3)instructions specific to the first assigned condition (ie, CB app,
Calm app, or educational control) to be introduced for the first
4 weeks. After participants completed the first of their 2 4-week
conditions (ie,10% Happier app, Calm app, or control), they
were provided with another email that included instructions
specific to their final condition (ie, 10% Happier app, Calmapp, or educational control).

Textbox 1. Eligibility criteria.
Inclusion criteria:•

Had a diagnosis of essential thrombocythemia, polycythemia vera, or myelofibrosis identified by the treating physician•

Owned a mobile smartphone and were willing to download and use a meditation app (ie, 10% Happier or Calm)•

Could read and understand English•

Were aged 18 years or older•

Were willing to be randomized to one of 4 groups: (1) 10% Happier 4 weeks/Calm 4 weeks, (2) Calm 4 weeks/10% Happier app 4 weeks, (3)educational material 4 weeks/10% Happier app 4 weeks, and (4) educational material 4 weeks/Calm 4 weeks

Exclusion criteria:•

Engaged in ≥10 min/day of meditation on ≥5 days/week for the past 6 months•

Engaged in ≥60 min/week of tai chi, qigong, or yoga each week•

Utilized either the 10% Happier app or the Calm app•

Resided outside of the United States

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Procedures

Calm AppAll participants were instructed to listen to the app’s introduction
to meditation and, following this, were instructed to participate
in a 10-min meditation each day, which they selected from theapp’s library of meditations. The dose for the intervention waschosen because (1) the Calm and 10% Happier app currently
offer 10-min meditations (daily and series meditations), thus
representing the length of time users are most likely to meditateusing the app; and (2) to date, the ideal dose for mindfulness
meditation interventions has not been established and effective
mindfulness meditation interventions have ranged from 10-min
sessions to 2-hour sessions and from one day per week to a daily
practice [31-33]. Practical guidelines recommend that beginners
start with short meditations lasting between 10 min and 30 min
per session [34].

The Calm app’s introduction to meditation incorporated basic
educational information for those new to meditation while
introducing brief experiential practices. Daily meditations werecalled the Daily Calm and were new and unique, provided by
the app each day. The daily meditations had a different focus(eg, practicing patience, loving kindness, and gratitude) andwere approximately 10 to 12 min in length. Meditations werealso selected from a library of meditations with the app.

All study participants were asked to complete Web-based
surveys at baseline, Week 5, and Week 9 via Qualtrics to assess
feasibility outcomes (described in detail below), including study
satisfaction and patient-reported outcomes. The survey consistedof 40 to 50 questions (depending on the condition the participant
just completed and whether it was at baseline or post-condition)
and was developed and tested internally among the researchteam for usability and functionality before use in the study. At
the end of each 4-week condition, participants were emailed aunique survey link specific to their study identification number
and were asked to complete the survey within 24 to 48 hours,
if possible. Responses were collected electronically in Qualtrics
and were then entered manually into a de-identified Excel
spreadsheet for later data analysis. All participants received thesame surveys in the same question order each time. The only
difference between surveys was the wording of the satisfaction
questions based on which condition they completed. Participants
were able to scroll back through their survey responses bynavigating back and forth through pages with a back button,
giving them the flexibility to revise questions if they needed.
Participants were only allowed to complete the survey once,
and after it was submitted, they were not allowed access backinto the survey.
Additionally, all study participants were instructed to wear a
Fitbit (Fitbit Inc) device on their nondominant wrist throughout
the 8-week intervention to measure physical activity and sleep;
however, these data are not reported here. The intervention was
8 weeks because this is an appropriate length of time for afeasibility study in which the primary purpose was not todetermine efficacy. Similar lengths have been used in otherfeasibility studies [30,35].

Description of the Apps and the Control
10% Happier App
The 10% Happier app’s introduction to meditation incorporated
basic information for those new to meditation. Daily meditations
were selected from a library of meditations included within theapp. Each of the meditations had a different focus (eg, grief,
gratitude, choice, and letting go) and were approximately 10 to
12 min in length.

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Educational Control
The control condition was provided with a 7-page educational
handout that was developed by the research team before thestudy. The handout addressed MPN patient fatigue (eg, whatcauses fatigue?) as well as examples of and information related
to evidence-based fatigue management strategies.

Feasibility Outcomes
Feasibility (ie, acceptability, demand, and limited-efficacy
testing) was defined according to Bowen et al [30]. Acceptability
was measured with an investigator-developed set of satisfaction
survey questions at Week 5 and Week 9 after participants
completed each of their 4-week group assignments. Satisfaction
questions were the same for all 3 conditions, with the exceptionof the wording that was altered slightly so that the question fit
each condition. For example, a question asked in the satisfaction
survey included: “How likely are you to continue using the(insert condition here) on a 1 to 5 scale (1 being very poor; 5
being excellent)”. Benchmarks for acceptability included ≥70%
satisfaction with the apps’ content, ≥70% intending to continue
using the app, ≥70% enjoying using the app, and ≥70%
recommending it for other MPN patients. Demand was measured
using adherence to the meditation intervention. Meditation
participation was tracked by the smartphone app developers
and reported weekly to the research team. Reports included (1)the date and time of each meditation participated in, (2) the titleof the meditation, and (3) the duration of participation (ie, thetime spent viewing the meditation) for each participant.
Adherence benchmarks were defined as an average of ≥49
min/week of meditation across all participants (ie, ≥70% ofprescribed meditation). There is little research suggesting
appropriate benchmarks for acceptability and demand [30]. We
based our benchmarks on a recently published methods paper
for a National Institute of Health–funded study for the feasibilityof a Web-based yoga intervention [36]. Patient-reported
outcomes were assessed in all study participants via a Qualtrics
questionnaire at baseline, Week 5, and Week 9. Demographics
and MPN-related health history were included within thebaseline questionnaire only. The National Institutes of HealthPatient Reported Outcomes Measurement Information System(NIH PROMIS) and the MPN Symptom Assessment Form
(MPN-SAF) were used to measure patient-reported outcomes.
MPN-SAF measures included total symptom score and fatigue(Question 1 on MPN-SAF). NIH PROMIS measures included
anxiety, depression, pain intensity, sleep disturbance, sexualfunction, global health, and quality of life (Question 2 on the
global health scale). Table 1 describes each of these outcome
measures.

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Table 1. Summary of self-report outcome measures.
Measure, outcome

Scoring

MPN SAFa
Total symptom score

10 items (0-10 scale); total score range of 0-100 with higher score indicating worse symptom burden

Fatigue

Item #1 from MPN SAF; 0-10. Scale with higher score indicating more fatigue

NIH PROMISbaAnxiety

8-item measure with each question asked on a 1-5 scale; total cumulative raw score converted to standardized t-score;higher t-score represents more of the construct being measured

Depression

8-item measure with each question asked on a 1-5 scale; total cumulative raw score converted to standardized t-score;higher t-score represents more of the construct being measured

Pain intensity

3-item measure with each question asked on a 1-5 scale; total cumulative raw score converted to standardized t-score;higher t-score represents more of the construct being measured

Sleep disturbance

8-item measure with each question asked on a 1-5 scale; total cumulative raw score converted to standardized t-score;higher t-score represents more of the construct being measured

Sexual function

11-item measure with each question asked on a 1-5 scale; total cumulative raw score converted to standardized t-score;higher t-score represents more of the construct being measured

Global health

10-item measure with each question asked on a 1-5 scale; total cumulative raw score converted to standardized t-score;higher t-score represents more of the construct being measured

Quality of life

Item #2 on the Global Health scale; scored on a 1-5 scale with a higher raw score indicating a lower quality of life

MPN-SAF: MPN Symptom Assessment Form.

b

NIH PROMIS: National Institutes of Health Patient Reported Outcomes Measurement Information System.

Data Analysis
Descriptive analyses were performed for baseline demographic
characteristics using means and SDs of continuous data andusing frequencies and proportions of discrete data for the 2 apps
and 2 control groups, and dropouts. To test the limited efficacyof the intervention, a series of analysis of covariance analyses
were performed for each of the NIH PROMIS outcomes using
raw scores on measures of pain intensity, anxiety, depression,
sleep disturbance, sexual function and discomfort indicators,
global health, and quality of life. The analysis was adjusted forbaseline PROMIS levels and covariates of the groupmembership (sequence effects), gender, education, and marital
status. Race was not considered as a covariate as less than 5%of the sample was non-white Dunnett’s post hoc tested
differences between treatment outcomes compared with baseline.
A 2-tailed alpha error of .05 was the threshold for statisticalsignificance. In addition, effect sizes (Cohen d) were calculated
and classified as small (d=0.2), medium (d=0.5), and large(d=0.8) to examine differences at postcondition time. A negative
effect size indicates the outcome measure decreased between
the baseline and postcondition measure [37]. All analytical andhttp://formative.jmir.org/2019/2/e12662/

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Results
Recruitment and Enrollment
A total of 289 MPN patients were recruited and completed theeligibility survey between July 31 and October 18, 2017 (ie,two-and-a-half months). Of the 289 MPN patients whocompleted the eligibility survey, 33.2% (96/289) were ineligible
and 44.2% (128/289) signed the informed consent and wereenrolled into the study (see Multimedia Appendix 1). Eligible
participants were enrolled into the study in the order they
completed the eligibility questionnaire. A total of 73.4%(94/128) patients across all 4 groups completed the intervention.
See Table 2 for protocol adherence and completion rates acrossgroups. The results below are reported for participants whocompleted the intervention (ie, completed both postcondition
surveys at Week 4 and Week 8).

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Table 2. Protocol adherence.

a

Group

N (signed informed consent)Completed post-Week 4 surveya, n (%) Completed post-Week 8 surveya, n (%)

10% Happier followed by Calm

33

28 (85)26 (79)Calm followed by 10% Happier32

26 (81)26 (81)

Control followed by 10% Happier35

24 (69)24 (69)Control followed by Calm

28

18 (64)18 (64)

Total

128

96 (75)

94 (73)

These surveys include satisfaction questions related to the completed 4-week group assignment.

There were no significant differences between groups on any
demographic variable. Across all participants (n=128), average
age was 58 (SD 12) years (F1,126=2.45; P=.12) and averageχ29=9.8; P=.36), well-educated with a bachelor’s education or

enjoyed it, 66% (50/76) were satisfied with the content, and
77% (59/76) would recommend it to others. Of those whocompleted the Calm app, 83% (56/68) enjoyed it, 84% (57/68)
were satisfied with the content, and 97% (66/68) would
recommend it to others. Of those who completed the educational
control, 91% (56/61) read it, 87% (53/61) enjoyed it, and 71%(43/61) learned something.

higher (79/128; χ215=15.7; P=.40), and married (95/128;

Demandbody mass index was 27 (SD 6) kg/m2 (F1,123=.28; P=.60). The
majority were female (104/128; χ23=4.0; P=.26), white (123/128;

χ215=14.4; P=.49). In addition, the most common diagnosis
among all participants was Essential Thrombocythemia (54/128)
followed by Polycythemia Vera (48/128) and Myelofibrosis(26/128). Most participants had been diagnosed with their MPN
for more than 3 years (81/128).

Feasibility Outcomes

Participants who completed the 10% Happier app averaged 31(SD 33) min/week and 30% (23/76) averaged ≥49 min/week of
meditation, whereas participants who completed the Calm app
averaged 71 (SD 74) min/week and 56% (38/68) averaged ≥49
min/week of meditation. See Figure 1 depicting average weekly
meditation minutes completed by participants.

Acceptability
See Multimedia Appendix 2 for satisfaction survey responses.
Of the participants who used the 10% Happier app, 61% (46/76)
Figure 1. Weekly meditation participation.

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Limited Efficacy Testing
Mean differences in patient-reported outcomes from baseline
to postcondition are reported in Multimedia Appendix 3. Aftercompleting 4 weeks of meditation using the 10% Happier app(n=76), significant differences were found between baseline
and postcondition for anxiety (P<.001; d=−0.43), depression(P=.02; d=−0.38), sleep disturbance (P=.01; d=−0.40), andphysical health (P<.001; d=0.52). Mental health (P=.07;
d=−0.30) and fatigue (P=.06; d=−0.30) were approachingsignificance. Although not statistically significant, asmall-to-medium effect size and the 95% CI indicate differencesin total symptom burden (d=−0.27; 95% CI −11.75 to −0.09).
After completing 4 weeks of meditation using the Calm app(n=68), significant differences were found between baseline
and postcondition for sleep disturbance (P=.002; d=−0.47),
vaginal discomfort (P=.03; d=−0.36), and physical health(P=.005; d=0.44). Small-to-medium effects and 95% CI
indicated differences for measures of depression (P=.09;
d=−0.29; 95% CI −3.49 to −0.14), total symptom burden (P=.13;
d=−0.27; 95% CI −11.81 to −0.11), and fatigue (P=.13; d=−0.27;
95% CI −1.68 to −0.02), but were not significant.
After completing 4 weeks of the educational control (n=61),
the only effect seen between baseline and postcondition wasfor physical health (P<.001; d=0.77).

Discussion
Principal Findings
The purpose of this study was to examine the feasibility of 2
different smartphone-based meditation apps in MPN patientsand to examine the limited efficacy of smartphone-based
meditation on symptoms compared with an educational control
group. The findings of this study will inform the app to be used
for a larger RCT to test for efficacy. We have identified theCalm app as being feasible for our future RCT as it met nearly
all of our a priori feasibility criteria (ie, demand, acceptability,
and limited-efficacy testing).
Our findings suggest that the Calm app had higher demand than
the 10% Happier app. Overall, the average weekly meditation
across participants that completed Calm was greater than theprescribed 70 min/week and over half averaged ≥49 min/weekof meditation (ie, demand cutoff criterion). Comparatively,
those who participated in the 10% Happier app only averaged
31 min/week of meditation and less than a third averaged ≥49
min/week of meditation. The adherence rates of the Calm appgroup are promising findings related to the potential fordelivering meditation using a consumer-based smartphone app
in MPN patients.
The adherence rates demonstrated by those completing Calmin this study are better than adherence rates of othersmartphone-based meditation app studies [38,39]. A recent
study conducted by Economides et al [38] investigated theeffects of meditation delivered using the Headspace app onstress, affect, and irritability in novice meditators and foundthat participants (n=41) averaged approximately 44 min/weekof meditation when asked to complete a total of 10 introductory
10-min meditations as they desired. Participants used the app
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Huberty et al
for a short duration (approximately 16 days). Another recent
study conducted by Bostock et al [39] that examined the effects
of a 45-day Headspace meditation app intervention on workstress and well-being in healthy workers found that participants
averaged approximately 42 min/week of meditation. Our study
was 28 days in length (ie, the length participants were asked touse each app) and the Calm app group averaged approximately
71 min/week. It is not clear why our study had better
participation in meditation as compared with the aforementioned
studies. However, Calm may have characteristics (eg, app
layout, presentation of content, and variety of content) within
the app that make it more likely to be accepted and used byparticipants [28,29] when compared with Headspace or other
meditation apps (ie, 10% Happier app).
Those who completed Calm indicated that they enjoyed it (83%),
were satisfied with the content (84%), and would recommend
it to others (97%), each of which meets our benchmarks for
acceptability. Of those that used the 10% Happier app, 61%
enjoyed it, 66% were satisfied with the content, and 77% would
recommend to others. With the exception of those that would
recommend it to others, the 10% Happier app fell short ofmeeting benchmarks for acceptability. Self-report responses
from those in Calm indicate the acceptability of the app
compared with the 10% Happier app. We conducted qualitativeinterviews related to the content and preferences for each of theapps; these data are being reported elsewhere [40]. However,briefly, the reasons Calm may have been more accepted than
the 10% Happier app were related to audio features (ie, thenarrator voice was soothing and calming background sounds
available) and other features such as pictures, stories, and a wide
range of meditation topics.
Research with physical activity and other health behavior appssuggests automatic tracking of the specific activity, tracking of
progress toward goals, and integrated features (eg, syncing withsocial media and connecting with music apps) are features most
liked by users [28]. Both the Calm app and the 10% Happierapp share similarities in terms of their tracking featuresconsistent with those reported in the literature as desired featuresof smartphone apps [28,29,41]. However, the Calm app
automatically displays the tracking information following
participation in meditation (pops up onto the screen) andincludes minutes meditated, days in a row of mediating (ie,streak), and a calendar that highlights the days in which the app
was used. To see the tracking of meditation in the 10% Happierapp, the user must navigate to their profile to look up thestatistics that are displayed as days and minutes meditated. The
differences in the way that the tracking is offered to the user
may contribute to the differences in the acceptability of theapps. More exploration about the type of tracking and how
participants prefer to interact with a tracking mechanism withina mobile app, specifically, a mediation app, is warranted.
Unlike the 10% Happier app, Calm allows users to immediately
share their meditation statistics (eg, number of meditations andtime spent in meditation) through social media platforms (eg,Facebook) or text messages and emails (called share status).
Even though we did not measure the use of the share status,
the offering of this on the app may also contribute to its
enhanced acceptability. Recent research has shown that
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participants like to share progress and that sharing progress
updates and interacting within an online social platform mayhelp increase feelings of accountability and may improveadherence rates in interventions [42,43]. In a recent qualitative
study, participants with diverse health-related goals that shared
updates on their progress via social media reported sharing their
updates helped contribute to their accountability [42].
Both the Calm and 10% Happier apps include a variety ofcontent for users outside of just listening to meditation tracks.
Calm includes sleep stories or sleep meditations to help users
fall asleep. They also offer Calm Breathe, Calm Music, CalmBody, and relaxing scenes and nature sounds. Calm has
masterclasses to educate participants about topics such as
mindful eating, gratitude, and the importance of rest. The 10%
Happier app offers some similar content but is organized anddelivered differently. For example, the content is organized on
the bottom tool bar and users scroll to find the content they want
to use (Calm organizes with a toolbar but also includes otherscreens for organization of content). The sleep content is onlyin the form of meditations (not sleep stories). Education forparticipants is in the form of courses with a meditation tofollow-up the content (eg, a short 3 to 5 min lecture-based video
followed by a meditation). On the basis of our findings, the way
in which the Calm app organizes and delivers their content may
be more appealing as compared with the 10% Happier app.
Future studies are warranted to determine what users specificallyfind most acceptable related to how content is organized andoffered.
We observed limited efficacy on symptoms across both apps.
Of note are the small effects observed in both apps on anxiety,depression, sleep disturbance, and total symptom burden.
Although this is the first meditation study to be conducted in
MPN patients, Huberty et al [20] identified that 12 weeks of
Web-based yoga (60 min/week) had limited efficacy on anxiety,depression, sleep disturbance, and total symptom burden in
MPN patients. Meditation and yoga differ in the sense that yoga
includes a component of physical postures (asanas), but yoga
does contain a meditation component and it is known that someof yoga’s benefits come from the meditation [44-48]. Meditation
has been shown to improve anxiety, depression, and sleep

Huberty et al
disturbance symptoms in both cancer and noncancer populations
through increased nonjudgmental awareness of thoughts,
feelings, and body sensations [12,16]. Therefore, it is not
surprising that this study showed limited efficacy in only 4
weeks on anxiety, depression, and sleep disturbances acrossboth meditation apps. Studies of a longer duration may show
larger effects. Our findings are preliminary in nature and RCTs
powered for effectiveness are needed to determine the effectsof consumer-based smartphone meditation on MPN patients.

Limitations
There are limitations to this study that should be noted. First,
our sample was disproportionately female (ie, 81% in this study
vs approximately 53% female being typical of the MPN
population [49]) and white (ie, 123/128, 96%). Second, we did
not have a washout period in between each condition within thegroup assignments (ie, lack of washout time period between
apps or between control and app conditions). As this was a
feasibility study and we were not determining efficacy, awashout period was not necessary [50]. Finally, it is likely thatthe study findings represent those already motivated to use
smartphones for health-related purposes. However, the literaturesuggests smartphone use is popular among cancer patientsoverall and that there is a large interest in accessing supportive
care via smartphones in cancer patients [51,52]. Importantly,
future studies could determine the effects of a mobile app to
improve health-related outcomes in cancer patients, especiallywhen cancer patients are already using mobile apps.

Conclusions
Delivering smartphone meditation via the Calm app is feasible
as it met most of our feasibility criteria (ie, demand,
acceptability, and limited-efficacy testing) and scored higher
in terms of feasibility when compared with anotherconsumer-based app (ie, 10% Happier app). Future RCTs areneeded to examine meditation with the Calm app and its effects
on MPN patient symptoms. The findings of this study will be
used to inform the development of a National Institutes of HealthR01 grant app for an RCT examining the efficacy of Calm on
MPN patient symptoms.

Acknowledgments
This study was funded with philanthropic funds. The authors would like to acknowledge both 10% Happier and Calm for donating
memberships for participants in this study.

Conflicts of Interest
RM reports research support by Incyte, Celgene, CTI BioPharma, Abbvie, and Genetech. In addition, RM acts as a consultant
for Novartis, La Jolla, and Sierra Oncology. The authors do not report any additional conflicts of interest.
Editorial note: This randomized study was only retrospectively registered. The editor granted an exception from ICMJE rules
mandating prospective registration of randomized trials because the risk of bias appears low and the study was considered
formative. However, readers are advised to carefully assess the validity of any potential explicit or implicit claims related toprimary outcomes or effectiveness, as retrospective registration does not prevent authors from changing their outcome measures
retrospectively.

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Huberty et alMultimedia Appendix 1
Enrollment.
[PDF File (Adobe PDF File), 140KB-Multimedia Appendix 1]

Multimedia Appendix 2
Satisfaction Survey Responses.
[PDF File (Adobe PDF File), 70KB-Multimedia Appendix 2]

Multimedia Appendix 3
Patient-Reported Outcomes.
[PDF File (Adobe PDF File), 76KB-Multimedia Appendix 3]

References
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.
12.

13.
14.

15.

Emanuel RM, Dueck AC, Geyer HL, Kiladjian J, Slot S, Zweegman S, et al. Myeloproliferative neoplasm (MPN) symptom
assessment form total symptom score: prospective international assessment of an abbreviated symptom burden scoring
system among patients with MPNs. J Clin Oncol 2012 Nov 20;30(33):4098-4103 [FREE Full text] [doi:10.1200/JCO.2012.42.3863] [Medline: 23071245]
Mesa RA, Niblack J, Wadleigh M, Verstovsek S, Camoriano J, Barnes S, et al. The burden of fatigue and quality of life in
myeloproliferative disorders (MPDs): an international internet-based survey of 1179 MPD patients. Cancer 2007 Jan
01;109(1):68-76 [FREE Full text] [doi: 10.1002/cncr.22365] [Medline: 17123268]
Mesa R, Miller CB, Thyne M, Mangan J, Goldberger S, Fazal S, et al. Myeloproliferative neoplasms (MPNs) have asignificant impact on patients' overall health and productivity: the MPN Landmark survey. BMC Cancer 2016 Feb 27;16:167[FREE Full text] [doi: 10.1186/s12885-016-2208-2] [Medline: 26922064]
Scherber R, Dueck AC, Johansson P, Barbui T, Barosi G, Vannucchi AM, et al. The Myeloproliferative Neoplasm Symptom
Assessment Form (MPN-SAF): international prospective validation and reliability trial in 402 patients. Blood 2011 Jul
14;118(2):401-408 [FREE Full text] [doi: 10.1182/blood-2011-01-328955] [Medline: 21536863]
Hultcrantz M, Kristinsson SY, Andersson TM, Landgren O, Eloranta S, Derolf AR, et al. Patterns of survival among patientswith myeloproliferative neoplasms diagnosed in Sweden from 1973 to 2008: a population-based study. J Clin Oncol 2012
Aug 20;30(24):2995-3001 [FREE Full text] [doi: 10.1200/JCO.2012.42.1925] [Medline: 22802311]
Tefferi A, Guglielmelli P, Larson DR, Finke C, Wassie EA, Pieri L, et al. Long-term survival and blast transformation inmolecularly annotated essential thrombocythemia, polycythemia vera, and myelofibrosis. Blood 2014 Oct
16;124(16):2507-2513 [FREE Full text] [doi: 10.1182/blood-2014-05-579136] [Medline: 25037629]
Mehta J, Wang H, Fryzek JP, Iqbal SU, Mesa R. Health resource utilization and cost associated with myeloproliferative
neoplasms in a large United States health plan. Leuk Lymphoma 2014 Oct;55(10):2368-2374. [doi:10.3109/10428194.2013.879127] [Medline: 24450579]
Geyer H, Scherber R, Kosiorek H, Dueck AC, Kiladjian J, Xiao Z, et al. Symptomatic profiles of patients with polycythemia
vera: implications of inadequately controlled disease. J Clin Oncol 2016 Jan 10;34(2):151-159. [doi:10.1200/JCO.2015.62.9337] [Medline: 26598745]
Mesa R, Verstovsek S, Kiladjian J, Griesshammer M, Masszi T, Durrant S, et al. Changes in quality of life and disease-related
symptoms in patients with polycythemia vera receiving ruxolitinib or standard therapy. Eur J Haematol 2016
Aug;97(2):192-200. [doi: 10.1111/ejh.12707] [Medline: 26608702]
Scotch A, Scherber R, Bruso M, Kosiorek H, Dueck A, Geyer H, et al. Myeloproliferative Neoplasm Quality of Life
(MPN-QOL) study group: results from the MPN Experimental Assessment of Symptoms By Utilizing Repetitive Evaluation(MEASURE) trial. Blood 2017;128(22):1641 [FREE Full text]
Christodoulou G, Black DS. Mindfulness-based interventions and sleep among cancer survivors: a critical analysis ofrandomized controlled trials. Curr Oncol Rep 2017 Sep;19(9):60. [doi: 10.1007/s11912-017-0621-6] [Medline: 28748522]
Gong H, Ni CX, Liu YZ, Zhang Y, Su WJ, Lian YJ, et al. Mindfulness meditation for insomnia: a meta-analysis ofrandomized controlled trials. J Psychosom Res 2016 Dec;89:1-6. [doi: 10.1016/j.jpsychores.2016.07.016] [Medline:
27663102]
Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic
review. J Consult Clin Psychol 2010 Apr;78(2):169-183 [FREE Full text] [doi: 10.1037/a0018555] [Medline: 20350028]
Johns SA, Brown LF, Beck-Coon K, Monahan PO, Tong Y, Kroenke K. Randomized controlled pilot study of
mindfulness-based stress reduction for persistently fatigued cancer survivors. Psychooncology 2015 Aug;24(8):885-893[FREE Full text] [doi: 10.1002/pon.3648] [Medline: 25132206]
Ong JC, Manber R, Segal Z, Xia Y, Shapiro S, Wyatt JK. A randomized controlled trial of mindfulness meditation forchronic insomnia. Sleep 2014 Sep 01;37(9):1553-1563 [FREE Full text] [doi: 10.5665/sleep.4010] [Medline: 25142566]

http://formative.jmir.org/2019/2/e12662/

XSL• FO
RenderX

JMIR Form Res 2019 | vol. 3 | iss. 2 | e12662 | p. 9
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
16.

17.

18.
19.
20.

21.
22.
23.
24.

25.
26.
27.
28.
29.

30.
31.

32.
33.

34.
35.
36.

37.
38.

39.
40.

Piet J, Würtzen H, Zachariae R. The effect of mindfulness-based therapy on symptoms of anxiety and depression in adultcancer patients and survivors: a systematic review and meta-analysis. J Consult Clin Psychol 2012 Dec;80(6):1007-1020.
[doi: 10.1037/a0028329] [Medline: 22563637]
Musial F, Büssing A, Heusser P, Choi K, Ostermann T. Mindfulness-based stress reduction for integrative cancer care: asummary of evidence. Forsch Komplementmed 2011;18(4):192-202 [FREE Full text] [doi: 10.1159/000330714] [Medline:
21934319]
Kabat-Zinn J, Hanh T. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness.
New York, NY: Delta; 2009.
Salhofer I, Will A, Monsef I, Skoetz N. Meditation for adults with haematological malignancies. Cochrane Database Syst
Rev 2016 Feb 03;2:CD011157. [doi: 10.1002/14651858.CD011157.pub2] [Medline: 26840029]
Huberty J, Eckert R, Gowin K, Mitchell J, Dueck AC, Ginos BF, et al. Feasibility study of online yoga for symptom
management in patients with myeloproliferative neoplasms. Haematologica 2017 Dec;102(10):e384-e388. [doi:10.3324/haematol.2017.168583] [Medline: 28596279]
Pew Research Center. 2018. Mobile Fact Sheet URL: http://www.pewinternet.org/fact-sheet/mobile/[WebCite Cache ID
73OOfjwns]
Pew Research Center. 2017. Key Trends in Social and Digital News Media URL: http://www.pewresearch.org/fact-tank/2017/10/04/key-trends-in-social-and-digital-news-media/ [accessed 2018-10-23] [WebCite Cache ID 73OOwkOHa]
Pew Research Center. 2015. US Smartphone Use in 2015 URL: http://www.pewinternet.org/2015/04/01/
us-smartphone-use-in-2015/[WebCite Cache ID 73OOpJTlB]
van Waart H, van Harten WH, Buffart LM, Sonke GS, Stuiver MM, Aaronson NK. Why do patients choose (not) toparticipate in an exercise trial during adjuvant chemotherapy for breast cancer? Psychooncology 2016 Dec;25(8):964-970.
[doi: 10.1002/pon.3936] [Medline: 26282696]
Statista. 2018. Number of apps available in leading app stores as of 3rd quarter URL: https://www.statista.com/statistics/
276623/number-of-apps-available-in-leading-app-stores/[WebCite Cache ID 73OPIihnk]
Marlynn W. Psychology Today. 2017. What mindfulness app is right for you? URL: https://www.psychologytoday.com/
us/blog/urban-survival/201508/what-mindfulness-app-is-right-you [accessed 2018-10-23] [WebCite Cache ID 73OPbPIwJ]
Fischer K. Healthline. 2018. Best Meditation Apps of 2018 URL: https://www.healthline.com/health/mental-health/
top-meditation-iphone-android-apps [accessed 2018-10-23] [WebCite Cache ID 73OQpuk1M]
Rabin C, Bock B. Desired features of smartphone applications promoting physical activity. Telemed J E Health 2011
Dec;17(10):801-803. [doi: 10.1089/tmj.2011.0055] [Medline: 22010977]
Dennison L, Morrison L, Conway G, Yardley L. Opportunities and challenges for smartphone applications in supporting
health behavior change: qualitative study. J Med Internet Res 2013;15(4):e86 [FREE Full text] [doi: 10.2196/jmir.2583][Medline: 23598614]
Bowen DJ, Kreuter M, Spring B, Cofta-Woerpel L, Linnan L, Weiner D, et al. How we design feasibility studies. Am J
Prev Med 2009 May;36(5):452-457 [FREE Full text] [doi: 10.1016/j.amepre.2009.02.002] [Medline: 19362699]
de Bruin EI, van der Zwan JE, Bögels SM. A RCT comparing daily mindfulness meditations, biofeedback exercises, anddaily physical exercise on attention control, executive functioning, mindful awareness, self-compassion, and worrying instressed young adults. Mindfulness (N Y) 2016;7(5):1182-1192 [FREE Full text] [doi: 10.1007/s12671-016-0561-5][Medline: 27642375]
Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis.
J Psychosom Res 2004 Jul;57(1):35-43. [doi: 10.1016/S0022-3999(03)00573-7] [Medline: 15256293]
Moore AW, Gruber T, Derose J, Malinowski P. Regular, brief mindfulness meditation practice improves electrophysiologicalmarkers of attentional control. Front Hum Neurosci 2012;6:18 [FREE Full text] [doi: 10.3389/fnhum.2012.00018] [Medline:
22363278]
McDonald K. How to Meditate: A Practical Guide. Somerville, MA: Wisdom Publications; 2005.
Chittaro L, Vianello A. Evaluation of a mobile mindfulness app distributed through on-line stores: a 4-week study. Int J
Hum Comput Stud 2016 Feb;86:63-80. [doi: 10.1016/j.ijhcs.2015.09.004]
Huberty J, Matthews J, Leiferman J, Cacciatore J, Gold K. A study protocol of a three-group randomized feasibility trialof an online yoga intervention for mothers after stillbirth (The Mindful Health Study). Pilot Feasibility Stud 2018;4(1):12.
[doi: 10.1186/s40814-017-0162-7] [Medline: 28694991]
Cohen J. Statistical Power Analysis for the Behavioral Sciences. United Kingdom: Routledge; 1988.
Economides M, Martman J, Bell MJ, Sanderson B. Improvements in stress, affect, and irritability following brief use of amindfulness-based smartphone app: a randomized controlled trial. Mindfulness (N Y) 2018;9(5):1584-1593 [FREE Fulltext] [doi: 10.1007/s12671-018-0905-4] [Medline: 30294390]
Bostock S, Crosswell AD, Prather AA, Steptoe A. Mindfulness on-the-go: Effects of a mindfulness meditation app on workstress and well-being. J Occup Health Psychol 2019 Feb;24(1):127-138. [doi: 10.1037/ocp0000118] [Medline: 29723001]
Huberty J, Eckert R, Larkey L, Mesa R. Myeloproliferative neoplasm patients experience of using a consumer-based mobile
meditation app to improve fatigue: informing future directions. J Med Internet Res 2019 (forthcoming)(forthcoming).

http://formative.jmir.org/2019/2/e12662/

XSL• FO
RenderX

Huberty et al

JMIR Form Res 2019 | vol. 3 | iss. 2 | e12662 | p. 10(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
41.

42.

43.

44.
45.
46.
47.

48.

49.

50.
51.

52.

Huberty et al

Bakker D, Kazantzis N, Rickwood D, Rickard N. Mental health smartphone apps: review and evidence-based
recommendations for future developments. JMIR Ment Health 2016;3(1):e7 [FREE Full text] [doi: 10.2196/mental.4984][Medline: 26932350]
Newman M, Lauterbach D, Munson S, Resnick P, Morris M. It's not that i don't have problems, i'm just not putting themon facebook: Challenges and opportunities in using online social networks for health. In: Proceedings of the ACM 2011conference on Computer supported cooperative work. 2011 Presented at: Conference on Computer Supported Cooperative
Work; March 19-23, 2011; China p. 341-350. [doi: 10.1145/1958824.1958876]
Richardson CR, Buis LR, Janney AW, Goodrich DE, Sen A, Hess ML, et al. An online community improves adherence in
an internet-mediated walking program. Part 1: results of a randomized controlled trial. J Med Internet Res 2010;12(4):e71[FREE Full text] [doi: 10.2196/jmir.1338] [Medline: 21169160]
Ledesma D, Kumano H. Mindfulness-based stress reduction and cancer: a meta-analysis. Psychooncology 2009
Jun;18(6):571-579. [doi: 10.1002/pon.1400] [Medline: 19023879]
Carlson LE. Mindfulness-based interventions for coping with cancer. Ann N Y Acad Sci 2016 Jun;1373(1):5-12. [doi:10.1111/nyas.13029] [Medline: 26963792]
Ross A, Thomas S. The health benefits of yoga and exercise: a review of comparison studies. J Altern Complement Med
2010 Jan;16(1):3-12. [doi: 10.1089/acm.2009.0044] [Medline: 20105062]
Schellekens MP, Tamagawa R, Labelle LE, Speca M, Stephen J, Drysdale E, et al. Mindfulness-Based Cancer Recovery(MBCR) versus Supportive Expressive Group Therapy (SET) for distressed breast cancer survivors: evaluating mindfulness
and social support as mediators. J Behav Med 2017 Jun;40(3):414-422 [FREE Full text] [doi: 10.1007/s10865-016-9799-6][Medline: 27722908]
Speca M, Carlson L, Mackenzie M. Mindfulness-based cancer recovery: An adaptation of Mindfulness-Based Stress
Reduction (MBSR) for cancer patients. In: Baer R, editor. Mindfulness-Based Treatment Approaches. 2nd Edition. San
Diego, CA: Elsevier; 2014:293-316.
Price GL, Davis KL, Karve S, Pohl G, Walgren RA. Survival patterns in United States (US) medicare enrollees with
non-CML myeloproliferative neoplasms (MPN). PLoS One 2014;9(3):e90299 [FREE Full text] [doi:10.1371/journal.pone.0090299] [Medline: 24618579]
Hui D, Zhukovsky D, Bruera E. Which treatment is better? Ascertaining patient preferences with crossover randomized
controlled trials. J Pain Symptom Manage 2015;49(3):625-631. [Medline: 25555446]
Raghunathan NJ, Korenstein D, Li QS, Tonorezos ES, Mao JJ. Determinants of mobile technology use and smartphone
application interest in cancer patients. Cancer Med 2018 Nov;7(11):5812-5819 [FREE Full text] [doi: 10.1002/cam4.1660][Medline: 30280495]
Girault A, Ferrua M, Lalloué B, Sicotte C, Fourcade A, Yatim F, et al. Internet-based technologies to improve cancer carecoordination: current use and attitudes among cancer patients. Eur J Cancer 2015 Mar;51(4):551-557. [doi:10.1016/j.ejca.2014.12.001] [Medline: 25661828]

Abbreviations
MPN: myeloproliferative neoplasm
MPN-SAF: Myeloproliferative Neoplasm Symptom Assessment FormNIH PROMIS: National Institutes of Health Patient Reported Outcomes Measurement Information System
RCT: randomized controlled trial

Edited by G Eysenbach; submitted 31.10.18; peer-reviewed by Y Zhang, L Morrison, W van Harten, U Subnis, C Jacob; comments
to author 27.12.18; revised version received 11.02.19; accepted 24.03.19; published 29.04.19
Please cite as:
Huberty J, Eckert R, Larkey L, Kurka J, Rodríguez De Jesús SA, Yoo W, Mesa R
Smartphone-Based Meditation for Myeloproliferative Neoplasm Patients: Feasibility Study to Inform Future Trials
JMIR Form Res 2019;3(2):e12662
URL: http://formative.jmir.org/2019/2/e12662/
doi: 10.2196/12662
PMID: 31033443©Jennifer Huberty, Ryan Eckert, Linda Larkey, Jonathan Kurka, Sue A Rodríguez De Jesús, Wonsuk Yoo, Ruben Mesa. Originallypublished in JMIR Formative Research (http://formative.jmir.org), 29.04.2019. This is an open-access article distributed under
the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is
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