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

社会经济劣势与被诊断患有癌症的可能性更大，延迟治疗有关。 癌症诊断，接受较少的治疗，减少获得姑息治疗和临终关怀服务， 增加死亡率。虽然已经制定了干预措施，以减少癌症的发病率和延迟 在诊断那些来自社会经济上处于不利地位的背景;很少有干预措施存在，以改善 为资源最少和最需要临终关怀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， 抑郁、疼痛和疲劳也会使人衰弱。我们的团队观察到， 患有晚期癌症的弱势背景患者的抑郁、疼痛 和疲劳和较差的生活质量比那些报告较高的社会经济地位（SES）的患者。虽然 这些症状的合并症是众所周知的，没有干预措施已经开发出来，以减少这些 症状并发症基于网络的分级协作护理试点研究的成功经验 对主要来自社会经济弱势背景的癌症患者进行干预， 随机分配到干预组的患者，报告抑郁症在统计学上显著减少， 与随机接受强化常规护理的患者相比， （K07CA118576）。此外，随机分配到干预组的患者血清中 白细胞介素（IL）-1可抑制IL-6、IL-8并改善生存（R21 CA 127046）。事后分析显示， 随机分配到干预组的患者的护理人员的压力和抑郁减少， 与配偶/伴侣随机接受强化常规护理的护理者相比（K 07 CA 118576 S1）。那里 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，特别是对那些 在社会经济上处于不利地位。我们计划测试一种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在一项随机对照研究中， 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， 减轻抑郁、疼痛和疲劳症状，改善健康相关生活质量（HRQL）， 晚期癌症患者与随机分配至教育和支持组的患者相比;（2） 检查晚期癌症患者是否被随机分配到基于网络的阶梯式协作护理干预， 炎症生物标志物减少，并探索这些患者是否减缓了疾病进展 与教育和支持组患者相比， 随机分配到基于网络的阶梯式协作护理的患者的配偶或亲密伴侣 干预，减少了压力和抑郁，更好的HRQL和更少的危险因素，心血管疾病比照顾者 配偶/伴侣被随机分配到教育和支持组。 人2020“，以实现健康公平，消除差距，提高所有群体的健康， 因性别、种族或民族、教育或收入、残疾、地理位置或 性取向”这一拟议的基于网络的阶梯式协作护理干预措施的目的是改善 HRQL为那些最需要和最少获得姑息治疗。这种创新的、可扩展的基于Web的 逐步的协作护理干预有望改善患者和护理人员的HRQL， 降低死亡率。调查结果预计将导致研究的可扩展性和成本效益的 建议干预。

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.