Tamara Somers

BACKGROUND/AIMS: Many cancer survivors who received intensive treatment such as hematopoietic stem cell transplantation (HCT) experience posttraumatic stress disorder (PTSD) symptoms. PTSD is associated with lower quality of life and other symptoms that require clinical treatment. The iterative treatment decisions that happen in clinical practice are not adequately represented in traditional randomized controlled trials (RCT) of PTSD treatments. The proposed stepped-care SMART design allows for evaluation of initial response to the Cancer Distress Coach mobile app; adaptive stepped-care interventions; and precision treatment strategies that tailor treatment selection to patient characteristics. METHODS/DESIGN: HCT survivors (N = 400) reporting PTSD symptoms are being recruited at two cancer centers and randomly assigned to: 1) Cancer Distress Coach app or 2) Usual Care. The app includes educational and cognitive behavioral therapy (CBT)-based activities. Four weeks post-randomization, participants re-rate their PTSD symptoms and, based on intervention response, non-responders are re-randomized to receive video-conferenced sessions with a therapist: 3) coaching sessions in using the mobile app; or 4) CBT specific to HCT survivors. Participants complete outcome measures of PTSD, depression, and anxiety after Months 1, 3, and 6. Participant characteristics moderating intervention responses will be examined. CONCLUSIONS: This novel adaptive trial design will afford evidence that furthers knowledge about optimizing PTSD interventions for HCT survivors. To our knowledge, this study is the first SMART design evaluating PTSD symptom management in cancer survivors. If successful, it could be used to optimize treatment among a range of cancer and other trauma survivors.

Background: Pain from advanced cancer can greatly reduce patients' physical, emotional, and spiritual well-being. Objective: To examine the feasibility and acceptability of a behavioral pain management intervention, Meaning-Centered Pain Coping Skills Training (MCPC). Design: This trial used a single-arm feasibility design. Setting/Subjects: Thirty participants with stage IV solid tumor cancer, moderate-to-severe pain, and clinically elevated distress were enrolled from a tertiary cancer center in the United States. The manualized protocol was delivered across four 45- to 60-minute videoconference sessions. Measurements: Feasibility and acceptability were assessed through accrual, session/assessment completion, intervention satisfaction, and coping skills usage. Participants completed validated measures of primary outcomes (i.e., pain severity, pain interference, and spiritual well-being) and secondary outcomes at baseline, post-intervention, and four-week follow-up. Results: Eighty-eight percent (38/43) of patients who completed screening met inclusion criteria, and 79% (30/38) consented and completed baseline assessment. Sixty-seven percent (20/30) of participants were female (mean age = 57). Most participants were White/Caucasian (77%; 23/30) or Black/African American (17%; 5/30) with at least some college education (90%; 27/30). Completion rates for intervention sessions and both post-intervention assessments were 90% (27/30), 87% (26/30), and 77% (23/30), respectively. At the post-intervention assessment, participants reported a high degree of intervention satisfaction (mean = 3.53/4.00; SD = 0.46), and 81% (21/26) reported weekly use of coping skills that they learned. Participants also showed improvement from baseline on all primary outcomes and nearly all secondary outcomes at both post-intervention assessments. Conclusions: MCPC demonstrated strong feasibility and acceptability. Findings warrant further evaluation of MCPC in a randomized controlled trial. ClinicalTrials.gov Identifier: NCT03207360.

<h4>Purpose</h4>Fatigue is one of the most common and distressing symptoms experienced by cancer survivors. Understanding fatigue trajectories from pre- to post-diagnosis could inform fatigue prevention and management strategies.<h4>Methods</h4>We used the Surveillance, Epidemiology and End Results Medicare Health Outcomes Survey (SEER-MHOS) linked data resource to characterize fatigue trajectories and their predictors 1214 older adult survivors of breast, colorectal, or prostate cancer. Fatigue was measured prior to the cancer diagnosis (T0) and at two timepoints after diagnosis (T1: mean = 20 months and T2: mean = 39 months post-diagnosis). Latent growth curve modeling and mixed effects models for repeated measurements were used to investigate fatigue experiences before and after a cancer diagnosis.<h4>Results</h4>Overall, mean fatigue T-scores declined (T0 = 50, T1 = 46, and T2 = 45) indicating worsening fatigue over time. Four latent trajectory subgroups were identified: severe fatigue worsening over time (8.2% of sample), severe fatigue persisting over time (14.4%), no fatigue pre-diagnosis and mild fatigue post-diagnosis (44.4%), and not fatigued (33%). Age, cancer stage, comorbidities, and depressed mood predicted membership in the two trajectory groups experiencing severe fatigue that persisted or that worsened post-diagnosis. Older age, advanced cancer stage at diagnosis, and depressed mood were significantly associated with worsening fatigue from T1 to T2 (all p < 0.0001).<h4>Conclusions</h4>Evaluating cancer patients for depressive symptoms and considering prior fatigue levels, age, comorbid conditions, and cancer stage may help providers anticipate fatigue trajectories and implement pre-emptive strategies to lessen fatigue impact.

African Americans are more likely than members of other racial groups to report perceived discrimination in health care settings, and discrimination is linked to depression. Using data from a randomized controlled trial of pain coping skills training (PCST) for African Americans with osteoarthritis (N=164), we evaluated the interaction between discrimination experiences and experimental condition (PCST or control group) in linear regression models predicting depressive symptoms. There was a significant interaction between personal discrimination and experimental condition on depressive symptoms (interaction term coefficient: b=-3.2, 95% CI [- 6.4, - .02], p=.05). Discrimination was associated with depressive symptoms among those in the control group but not among those who received PCST. Participation in a PCST intervention may have reduced the association between discrimination experiences and depressive symptoms among participants in this sample. Future research should explore whether interventions aimed at teaching coping skills may be effective in ameliorating the harmful mental health effects of perceived discrimination.

BACKGROUND: Osteoarthritis (OA) disproportionately impacts African Americans compared to Caucasians, including greater pain severity. The Pain Coping Skills Training for African Americans with Osteoarthritis (STAART) study examined a culturally enhanced Pain Coping Skills Training (CST) program among African Americans with OA. This mixed methods study evaluated the acceptability of the Pain CST program among STAART participants. METHODS: STAART was a randomized controlled trial evaluating the effectiveness of an 11-session, telephone-based pain CST program, compared to a usual care control group. Participants were from the University of North Carolina and Durham Veterans Affairs Healthcare Systems. The present analyses included 93 participants in the CST group who completed a questionnaire about experiences with the program. Descriptive statistics of the questionnaire responses were calculated using SAS software. Thematic analysis was applied to open-response data using Dedoose software. RESULTS: Participants' mean rating of overall helpfulness of the pain CST program for managing arthritis symptoms was 8.0 (SD = 2.2) on a scale of 0-10. A majority of participants reported the program made a positive difference in their experience with arthritis (83.1%). Mean ratings of helpfulness of the specific skills ranged from 7.7 to 8.8 (all scales 0-10). Qualitative analysis of the open-response data identified four prominent themes: Improved Pain Coping, Mood and Emotional Benefits, Improved Physical Functioning, and experiences related to Intervention Delivery. CONCLUSIONS: The high ratings of helpfulness demonstrate acceptability of this culturally enhanced pain CST program by African Americans with OA. Increasing access to cognitive-behavioral therapy-based programs may be a promising strategy to address racial disparities in OA-related pain and associated outcomes. TRIAL REGISTRATION: NCT02560922 , registered September 25, 2015.