Diversity Supplement to R01-Palliative care intervention for socioeconomically disadvantaged cancer patients

社会经济劣势与被诊断为癌症的可能性更大有关，延误 癌症诊断，接受的治疗减少，获得姑息治疗和临终关怀服务的机会减少，以及 死亡率上升。尽管已经开发了干预措施来减少癌症的发生率和延误 在诊断那些来自社会经济不利背景的人时；几乎没有干预措施来改善 为拥有最少资源和最大需求的个人提供姑息治疗和临终关怀服务 这些服务。美国国立卫生研究院关于癌症相关症状的共识声明得出结论，最常见的 令人虚弱的是抑郁、疼痛和疲劳。我们的团队观察到，来自社会经济学的人 患有晚期癌症的弱势背景患者抑郁、疼痛的程度高得不成比例 与报告更高社会经济地位(SES)的患者相比，他们更容易感到疲劳，生活质量也更差。虽然 这些症状的共病是众所周知的，目前还没有开发出干预措施来减少这些 同时出现症状。我们成功开展基于网络的阶梯式协作护理试点研究的经验 对主要来自社会经济贫困背景的癌症患者的干预显示 那些被随机分配到干预组的患者，报告说抑郁症的发病率在统计学上显著降低， 与随机接受强化常规护理的患者相比，疼痛、疲劳和改善的生活质量 (K07CA118576)。此外，随机接受干预的患者降低了血清中的 IL-1、、IL-6、IL-8与生存改善(R21CA127046)。事后分析显示，家庭 当患者被随机分配到干预组时，照顾者的压力和抑郁程度都有所降低 与配偶/伴侣随机接受强化常规护理的照顾者相比(K07CA118576S1)。那里 迫切需要开发可扩展的、有效的和具有成本效益的干预措施，特别是对于那些 在社会经济上处于不利地位。我们计划测试基于网络的阶梯式协作护理干预 450例晚期癌症患者及其配偶或亲密伴侣的随机对照研究 审判。具体目标是：(1)测试基于网络的阶梯式协作护理干预的有效性 减少抑郁、疼痛和疲劳症状，提高与健康相关的生活质量(HRQL) 晚期癌症患者与随机接受教育和支持的患者相比；(2) 检查晚期癌症患者是否随机接受基于网络的阶梯式协作护理干预 减少炎症的生物标志物，并探索这些患者是否减缓了疾病的进展 与接受教育和支持的患者相比，存活率有所提高；(3)调查 患者的配偶或亲密伴侣被随机分配到基于网络的阶梯式协作护理 与照顾者相比，干预减少了压力和抑郁，改善了HRQL，减少了心血管疾病的风险因素 配偶/伴侣被随机分配到教育和支持ARM。按照健康发展的目标 实现健康公平，消除差距，改善所有群体的健康，无论 性别、种族或民族、教育或收入、残疾、地理位置或 这一建议的基于网络的阶梯式协作护理干预旨在改善 HRQL为那些最需要和最不容易获得姑息治疗的人提供。这一创新且可扩展的基于Web的 阶段性协作护理干预有望改善患者和照顾者的HRQL，并有可能 降低死亡率。预计研究结果将导致对可伸缩性和成本效益的研究 拟议的干预措施。

Socioeconomic disadvantage is associated with a greater likelihood of being diagnosed with cancer, delays in cancer diagnosis, receiving less treatment, decreased access to palliative care and hospice services, and increased mortality. Although interventions have been developed to reduce the incidence of cancer and delays in diagnosis in those from socioeconomically disadvantaged backgrounds; few interventions exist to improve access to palliative care and hospice services for individuals with the least resources and greatest needs for these services. The NIH consensus statement on cancer-related symptoms concluded that the most common and debilitating are depression, pain and fatigue. Our team has observed that people from socioeconomically disadvantaged backgrounds with advanced cancer have disproportionately higher levels of depression, pain and fatigue and poorer quality of life than patients who reported higher socioeconomic status (SES). Although the comorbidity of these symptoms is well known, no intervention has been developed to reduce these symptoms concurrently. Experience from our successful pilot study of a web-based stepped collaborative care intervention for cancer patients from predominantly socioeconomically disadvantaged backgrounds, revealed that patients randomized to the intervention arm, reported statistically significant reductions in depression, pain, and fatigue and improved quality of life when compared to patients randomized to enhanced usual care (K07CA118576). Furthermore, patients randomized to the intervention had decreased serum levels of Interleukin (IL)-1 IL-6, IL-8 and improved survival (R21CA127046). Post-hoc analyses revealed that family caregivers, of patients randomized to the intervention arm, had reductions in stress and depression, when compared to caregivers with spouses/partners randomized to enhanced usual care (K07CA118576S1). There is an urgent need to develop scalable, effective, and, cost-effective interventions, particularly for those who are socioeconomically disadvantaged. We plan to test a web-based stepped collaborative care intervention with 450 advanced cancer patients and their spousal or intimate partners in the context of a randomized controlled trial. The specific aims are: (1) to test the efficacy of a web-based stepped collaborative care intervention to reduce symptoms of depression, pain, and fatigue and improve health-related quality of life (HRQL) in advanced cancer patients when compared to patients randomized to the education and support arm; (2) to examine if advanced cancer patients randomized to the web-based stepped collaborative care intervention have reductions in biomarkers of inflammation and explore if these patients have slowed disease progression and improved survival when compared to patients in the education and support arm; (3) to investigate whether the spouses or intimate partners, of patients randomized to the web-based stepped collaborative care intervention, have reduced stress and depression, better HRQL and fewer risk factors for CVD than caregivers with spouses/partners randomized to education and support arm. In accordance with the goals of Healthy People 2020 "to achieve health equity, eliminate disparities, and improve the health of all groups, regardless of differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation” this proposed web-based stepped collaborative care intervention was designed to improve HRQL for those in greatest need and least access to palliative care. This innovative and scalable web-based stepped collaborative care intervention is expected to improve patients’ and caregivers’ HRQL and potentially reduce mortality. Findings are expected to lead to studies examining scalability and cost-effectiveness of the proposed intervention.