Palliative care intervention for socioeconomically disadvantaged cancer patients

 描述（由申请人提供）：社会经济劣势与被诊断患有癌症的可能性更大、癌症诊断延迟、接受治疗较少、获得姑息治疗和临终关怀服务的机会减少以及死亡率增加有关。虽然已经制定了干预措施，以减少来自社会经济不利背景的人的癌症发病率和诊断延误;很少有干预措施，以改善资源最少和最需要这些服务的个人获得姑息治疗和临终关怀服务。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，最常见和最令人衰弱的是抑郁，疼痛和疲劳。我们的团队观察到，来自社会经济弱势背景的晚期癌症患者的抑郁，疼痛和疲劳水平不成比例地高于那些报告较高社会经济地位（SES）的患者。虽然这些症状的合并症是众所周知的，但尚未开发出同时减少这些症状的干预措施。我们对主要来自社会经济弱势背景的癌症患者进行的基于网络的阶梯式协作护理干预的成功试点研究的经验显示，与随机分配至加强常规护理的患者相比，随机分配至干预组的患者报告抑郁、疼痛和疲劳统计学显著性降低，生活质量改善（K 07 CA 118576）。此外，随机分配至干预组的患者血清白细胞介素（IL）-1β、IL-6、IL-8水平降低，生存期改善（R21 CA 127046）。事后分析显示，与配偶/伴侣随机接受强化常规护理的护理者相比，随机接受干预组的患者的家庭护理者的压力和抑郁减轻（K 07 CA 118576 S1）。迫切需要制定可扩展的、有效的和具有成本效益的干预措施，特别是针对那些在社会经济上处于不利地位的人。我们计划在一项随机对照试验的背景下，对450名晚期癌症患者及其配偶或亲密伴侣进行基于网络的阶梯式协作护理干预。具体目标是：（1）与随机分配至教育和支持组的患者相比，测试基于网络的阶梯式协作护理干预在减轻晚期癌症患者的抑郁、疼痛和疲劳症状以及改善健康相关生活质量（HRQL）方面的功效;（2）检查随机分配到网络的晚期癌症患者是否-基于阶梯式协作护理干预的患者炎症生物标志物减少，并探索与教育和支持组患者相比，这些患者是否减缓了疾病进展并提高了生存率;（3）调查被随机分配到基于网络的阶梯式协作护理干预组的患者的配偶或亲密伴侣是否比被随机分配到教育和支持组的配偶/伴侣的照顾者具有更低的压力和抑郁、更好的HRQL和更少的心血管疾病危险因素。并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、地理位置或性取向是否存在差异”，这项基于网络的分步协作护理干预措施旨在改善那些最需要和最不容易获得姑息治疗的人的HRQL。这种创新的、可扩展的基于网络的阶梯式协作护理干预有望改善患者和护理人员的HRQL，并可能降低死亡率。预计调查结果将导致研究检查拟议的干预措施的可扩展性和成本效益。

 DESCRIPTION (provided by applicant): 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 an 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)-1β, 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.