Culturally adapted mobile treatment of chronic pain in adolescent survivors of pediatric bone sarcoma

摘要 超过70%的儿童和青少年被诊断患有骨肉瘤，现在生存至少五年后， 诊断.不幸的是，治愈性治疗会导致毒性，使许多幸存者患有严重的 不利的身心健康后果的负担，包括慢性疼痛。高达59%的长期存活者 报告疼痛，骨肉瘤幸存者报告疼痛的可能性是日常干预的4倍， 其他幸存者和增加阿片类药物的使用和滥用的标记。与此相关的应用程序，黑色和 西班牙裔幸存者在生存期间不成比例地经历疼痛。我们怀疑这种差异可能是 部分原因是健康的社会决定因素（SDOH），这也导致了总体上的差异。 人口尽管黑人和西班牙裔儿童癌症的患病率和疼痛负担很高， 对于幸存者，缺乏针对这一人群的非药物干预措施。认知行为疗法 (CBT)是一种针对慢性疼痛的既定非药物治疗方法， 与疼痛相关的想法和行为，以及与经颅直流电刺激（tDCS）相结合时 负责疼痛的认知和情感处理的大脑区域可能会增强慢性疼痛控制， 癌症幸存者移动的CBT程序和远程交付tDCS的最新发展减少了 获得护理的障碍。然而，这些方案尚未进行调整， 服务不足的人群，从而限制了它们的覆盖范围、效用和吸收。我们建议在文化上定制一个 为黑人和西班牙裔青少年幸存者建立的以证据为基础的慢性疼痛移动的CBT计划。 一旦程序完全适应，我们建议将文化适应的移动的CBT与远程交付的CBT配对， 在非西班牙裔白色、非西班牙裔黑人和西班牙裔青少年的种族/民族多样性样本中的tDCS 小儿骨肉瘤的幸存者此外，我们建议检查患者报告的合并症的影响 (e.g.,抑郁、焦虑、睡眠）和SDOH（例如，区域剥夺指数，父母社经地位 结果。重要的是，在青春期和早期生存期进行的非药物干预 对于改变慢性疼痛的轨迹和成年后的负面结果至关重要。积极的结果，从这个 研究将用于未来的第3阶段实施试验，以证明 所有患有慢性疼痛的儿童癌症幸存者的大规模和地理上多样化的人群。

ABSTRACT More than 70% of children and adolescents diagnosed with a bone sarcoma now survive at least five years post- diagnosis. Unfortunately, curative treatments result in toxicities that leave many survivors with a substantial burden of adverse physical and mental health outcomes, including chronic pain. Up to 59% of long-term survivors report pain, and bone sarcoma survivors are 4 times as likely to report pain with daily interference compared to other survivors and have increased opioid use and markers for misuse. Relevant to this application, Black and Hispanic survivors disproportionately experience pain during survivorship. We suspect this disparity may be explained, in part, by social determinants of health (SDOH), which also contribute to disparities in the general population. Despite the high prevalence and burden of pain among Black and Hispanic childhood cancer survivors, non-pharmacologic interventions tailored for this population are lacking. Cognitive behavioral therapy (CBT) is an established non-pharmacologic treatment for chronic pain that focuses on addressing maladaptive thoughts and behaviors related to pain, and when combined with transcranial direct current stimulation (tDCS) of brain regions responsible for cognitive and affective processing of pain may enhance chronic pain control in cancer survivors. The recent development of mobile CBT programs and remote delivery of tDCS has reduced barriers to access care. However, these programs have not been adapted to be culturally responsive to underserved populations thus limiting their reach, utility, and uptake. We propose to culturally tailor an established, evidence-based mobile CBT program for chronic pain to Black and Hispanic adolescent survivors. Once the program is fully adapted, we propose to pair the culturally adapted mobile CBT with remotely delivered tDCS in a racially/ethnically diverse sample of non-Hispanic White, non-Hispanic Black, and Hispanic adolescent survivors of pediatric bone sarcoma. Further, we propose to examine the impact of patient-reported comorbidities (e.g., depression, anxiety, sleep) and SDOHs (e.g., area deprivation index, parent SES) on intervention outcomes. Importantly, non-pharmacological interventions delivered during adolescence and early survivorship are critical to modify a trajectory of chronic pain and negative outcomes into adulthood. Positive results from this study will be used for a future Phase 3 implementation trial to demonstrate generalizability and scalability to the large and geographically diverse population of all childhood cancer survivors with chronic pain.