Tamara Somers

BACKGROUND: Women with breast cancer in medically underserved areas are particularly vulnerable to persistent pain and disability. Behavioral pain interventions reduce pain and improve outcomes. Cancer patients in medically underserved areas receive limited adjunctive cancer care, as many lack access to pain therapists trained in behavioral interventions, face travel barriers to regional medical centers, and may have low literacy and limited resources. mHealth technologies have the potential to decrease barriers but must be carefully adapted for, and efficacy-tested with, medically underserved patients. We developed an mHealth behavioral pain coping skills training intervention (mPCST-Community). We now utilize a multisite randomized controlled trial to: 1) test the extent mPCST-Community reduces breast cancer patients' pain severity (primary outcome), pain interference, fatigue, physical disability, and psychological distress; 2) examine potential mediators of intervention effects; and 3) evaluate the intervention's cost and cost-effectiveness. METHODS/DESIGN: Breast cancer patients (N = 180) will be randomized to mPCST-Community or an attention control. mPCST-Community's four-session protocol will be delivered via videoconferencing at an underserved community clinic by a remote pain therapist at a major medical center. Videoconference sessions will be supplemented with a mobile application. Participants will complete self-report measures at baseline, post-intervention, and 3- and 6-month follow-ups. CONCLUSIONS: mPCST-Community has the potential to reduce pain and disability, and decrease barriers for cancer patients in medically underserved areas. This is one of the first trials to test an mHealth behavioral cancer pain intervention developed specifically for medically underserved communities. If successful, it could lead to widespread implementation and decreased health disparities.

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.

CONTEXT: Interventions that teach patients cognitive and behavioral strategies for managing cancer pain have demonstrated effectiveness. Systematic reviews of such interventions call for research to inform their implementation in practice, including investigations into which patients are most likely to benefit. OBJECTIVES: We aimed to identify predictors of response to an evidence-based behavioral intervention for cancer pain, pain coping skills training (PCST). METHODS: We conducted an exploratory secondary analysis of a randomized noninferiority trial comparing in-person to videoconference-based PCST. Using modified Poisson regression, we estimated the adjusted associations of patient characteristics with clinically meaningful reductions (≥30%) in pain severity and pain interference. RESULTS: Of the 178 patients who were randomized, 135 completed at least one follow-up assessment and were included in this analysis. Proportions of patients experiencing reductions in pain severity and pain interference were 34% and 46%, respectively. In multivariable analysis, education level was associated with a reduction in pain severity (adjusted relative risk, some college or technical school vs. college or higher: 0.49, 95% CI: 0.26-0.93). Patients with colorectal cancer were 61% more likely to experience a reduction in pain interference than patients with breast cancer (95% CI:1.21-2.34). Marital status was also statistically significantly associated with pain interference reduction, with married patients less likely to experience a reduction in pain interference (adjusted relative risk, married vs. not: 0.69, 95% CI: 0.49-0.98). CONCLUSION: Our findings elucidate several subgroups of patients who may be especially likely to benefit from PCST, informing both targeted implementation efforts and opportunities to improve delivery for diverse patients.

BACKGROUND: We previously demonstrated that automated, Web-based pain coping skills training (PCST) can reduce osteoarthritis pain. The present secondary analyses examined whether this program also changed coping strategies participants identified for use in hypothetical pain-related situations. METHOD: People with hip/knee osteoarthritis (n = 107) were randomized to Web-based PCST or standard care control. At baseline and post-intervention, they reported their pain severity and impairment, then completed a task in which they described how they would cope with pain in four hypothetical pain-related situations, also reporting their perceived risk for pain and self-efficacy for managing it. We coded the generated coping strategies into counts of adaptive behavioral, maladaptive behavioral, adaptive cognitive, and discrete adaptive coping strategies (coping repertoire). RESULTS: Compared to the control arm, Web-based PCST decreased the number of maladaptive behavioral strategies generated (p = 0.002) while increasing the number of adaptive behavioral strategies generated (p = 0.006), likelihood of generating at least one adaptive cognitive strategy (p = 0.01), and the size of participants' coping repertoire (p = 0.009). Several of these changes were associated with changes in pain outcomes (ps = 0.01 to 0.65). Web-based PCST also reduced perceived risk for pain in the situations (p = 0.03) and increased self-efficacy for avoiding pain in similar situations (p < 0.001). CONCLUSION: Salutary changes found in this study appear to reflect intervention-concordant learning.

AIMS: To assess the impact of anxiety and depression in the risk of converting to glaucoma in a cohort of glaucoma suspects followed over time. METHODS: The study included a retrospective cohort of subjects with diagnosis of glaucoma suspect at baseline, extracted from the Duke Glaucoma Registry. The presence of anxiety and depression was defined based on electronic health records billing codes, medical history and problem list. Univariable and multivariable Cox proportional hazards models were used to obtain HRs for the risk of converting to glaucoma over time. Multivariable models were adjusted for age, gender, race, intraocular pressure measurements over time and disease severity at baseline. RESULTS: A total of 3259 glaucoma suspects followed for an average of 3.60 (2.05) years were included in our cohort, of which 911 (28%) were diagnosed with glaucoma during follow-up. Prevalence of anxiety and depression were 32% and 33%, respectively. Diagnoses of anxiety, or concomitant anxiety and depression were significantly associated with risk of converting to glaucoma over time, with adjusted HRs (95% CI) of 1.16 (1.01, 1.33) and 1.27 (1.07, 1.50), respectively. CONCLUSION: A history of anxiety or both anxiety and depression in glaucoma suspects was associated with developing glaucoma during follow-up.