Development and pilot testing of an mHealth behavioral cancer pain protocol for medically underserved communities

Interactive digital tools to support empowerment of people with cancer: a systematic literature review

PURPOSE

To identify and synthesise interactive digital tools used to support the empowerment of people with cancer and the outcomes of these tools.

METHODS

A systematic literature review was conducted using PubMed, CINAHL, Web of Science, Cochrane, Eric, Scopus, and PsycINFO databases in May 2023. Inclusion criteria were patient empowerment as an outcome supported by interactive digital tools expressed in study goal, methods or results, peer-reviewed studies published since 2010 in cancer care. Narrative synthesis was applied, and the quality of the studies was assessed following Joanna Briggs Institute checklists.

RESULTS

Out of 1571 records screened, 39 studies published in 2011-2022 with RCT (17), single-arm trial (15), quasi-experimental (1), and qualitative designs (6) were included. A total of 30 interactive digital tools were identified to support empowerment (4) and related aspects, such as self-management (2), coping (4), patient activation (9), and self-efficacy (19). Significant positive effects were found on empowerment (1), self-management (1), coping (1), patient activation (2), and self-efficacy (10). Patient experiences were positive. Interactivity occurred with the tool itself (22), peers (7), or nurses (7), physicians (2), psychologists, (2) or social workers (1).

CONCLUSION

Interactive digital tools have been developed extensively in recent years, varying in terms of content and methodology, favouring feasibility and pilot designs. In all of the tools, people with cancer are either active or recipients of information. The research evidence indicates positive outcomes for patient empowerment through interactive digital tools. Thus, even though promising, there still is need for further testing of the tools.

Development and pre-pilot testing of STAMP + CBT: an mHealth app combining pain cognitive behavioral therapy and opioid support for patients with advanced cancer and pain

PURPOSE

We developed and piloted a mobile health app to deliver cognitive behavioral therapy for pain (pain-CBT), remote symptom monitoring, and pharmacologic support for patients with pain from advanced cancer.

METHODS

Using an iterative process of patient review and feedback, we developed the STAMP + CBT app. The app delivers brief daily lessons from pain-CBT and pain psychoeducation, adapted for advanced cancer. Daily surveys assess physical symptoms, psychological symptoms, opioid utilization and relief. Just-in-time adaptive interventions generate tailored psychoeducation in response. We then conducted a single-arm pilot feasibility study at two cancer centers. Patients with advanced cancer and chronic pain used the app for 2 or 4 weeks, rated its acceptability and provided feedback in semi-structured interviews. Feasibility and acceptability were defined as ≥ 70% of participants completing ≥ 50% of daily surveys, and ≥ 80% of acceptability items rated ≥ 4/5.

RESULTS

Fifteen participants (female = 9; mean age = 50.3) tested the app. We exceeded our feasibility and accessibility benchmarks: 73% of patients completed ≥ 50% of daily surveys; 87% of acceptability items were rated ≥ 4/5. Participants valued the app's brevity, clarity, and salience, and found education on stress and pain to be most helpful. The app helped participants learn pain management strategies and decrease maladaptive thoughts. However, participants disliked the notification structure (single prompt with one snooze), which led to missed content.

CONCLUSION

The STAMP + CBT app was an acceptable and feasible method to deliver psychological/behavioral treatment with pharmacologic support for cancer pain. The app is being refined and will be tested in a larger randomized pilot study. TRN: NCT05403801 (05/06/2022).

Meaning-centered pain coping skills training for patients with metastatic cancer: Protocol for a randomized controlled efficacy trial

BACKGROUND

Many patients with advanced cancer describe pain as a debilitating symptom that greatly interferes with daily activities and enjoyment of life. Psychosocial interventions can improve cancer-related pain but rarely address spiritual concerns (e.g., loss of meaning, peace), which can influence the pain experience for those facing life-threatening illness. To address these needs, we systematically developed and pilot tested a novel psychosocial intervention called Meaning-Centered Pain Coping Skills Training (MCPC). In this randomized controlled trial, we aim to determine MCPC's efficacy for reducing pain interference (primary outcome) and improving secondary outcomes. We will also estimate MCPC's cost-effectiveness.

METHOD/DESIGN

Patients (target N = 210) with advanced solid tumor malignancies (Stage IV) and clinically-elevated pain interference will be enrolled and block randomized with equal allocation to MCPC + enhanced usual care or enhanced usual care alone. MCPC's four, videoconferenced, 45-60 min weekly sessions will be individually delivered by trained study therapists. Primary (pain interference) and secondary (pain severity, anxiety and depressive symptoms, pain self-efficacy, social support, spiritual well-being) patient-reported outcomes will be assessed at baseline, and 8-weeks (primary endpoint) and 12-weeks after baseline.

CONCLUSION

Our MCPC intervention is the first to systematically address the biopsychosocial-spiritual aspects of pain in patients with advanced cancer. If MCPC demonstrates efficacy, next steps will involve hybrid efficacy-effectiveness and implementation work to broaden access to this brief, manualized, remotely-delivered intervention, with the goal of reducing suffering in patients with life-threatening illness.

Digital Health for Migrants, Ethnic and Cultural Minorities and the Role of Participatory Development: A Scoping Review

Digital health interventions (DHIs) are increasingly used to address the health of migrants and ethnic minorities, some of whom have reduced access to health services and worse health outcomes than majority populations. This study aims to give an overview of digital health interventions developed for ethnic or cultural minority and migrant populations, the health problems they address, their effectiveness at the individual level and the degree of participation of target populations during development. We used the methodological approach of the scoping review outlined by Tricco. We found a total of 2248 studies, of which 57 were included, mostly using mobile health technologies, followed by websites, informational videos, text messages and telehealth. Most interventions focused on illness self-management, mental health and wellbeing, followed by pregnancy and overall lifestyle habits. About half did not involve the target population in development and only a minority involved them consistently. The studies we found indicate that the increased involvement of the target population in the development of digital health tools leads to a greater acceptance of their use.

Cost-Effectiveness Analysis Evaluating Delivery Strategies for Pain Coping Skills Training in Women With Breast Cancer

Pain coping skills training (PCST) is efficacious in patients with cancer, but clinical access is limited. To inform implementation, as a secondary outcome, we estimated the cost-effectiveness of 8 dosing strategies of PCST evaluated in a sequential multiple assignment randomized trial among women with breast cancer and pain (N = 327). Women were randomized to initial doses and re-randomized to subsequent doses based on their initial response (ie, ≥30% pain reduction). A decision-analytic model was designed to incorporate costs and benefits associated with 8 different PCST dosing strategies. In the primary analysis, costs were limited to resources required to deliver PCST. Quality-adjusted life-years (QALYs) were modeled based on utility weights measured with the EuroQol-5 dimension 5-level at 4 assessments over 10 months. A probabilistic sensitivity analysis was performed to account for parameter uncertainty. Implementation of PCST initiated with the 5-session protocol was more costly ($693-853) than strategies initiated with the 1-session protocol ($288-496). QALYs for strategies beginning with the 5-session protocol were greater than for strategies beginning with the 1-session protocol. With the goal of implementing PCST as part of comprehensive cancer treatment and with willingness-to-pay thresholds ranging beyond $20,000 per QALY, the strategy most likely to provide the greatest number of QALYs at an acceptable cost was a 1-session PCST protocol followed by either 5 maintenance telephone calls for responders or 5 sessions of PCST for nonresponders. A PCST program with 1 initial session and subsequent dosing based on response provides good value and improved outcomes. PERSPECTIVE: This article presents the results of a cost analysis of the delivery of PCST, a nonpharmacological intervention, to women with breast cancer and pain. Results could potentially provide important cost-related information to health care providers and systems on the use of an efficacious and accessible nonmedication strategy for pain management. TRIALS REGISTRATION: ClinicalTrials.gov: NCT02791646, registered 6/2/2016.

Behavioral cancer pain intervention dosing: results of a Sequential Multiple Assignment Randomized Trial

ABSTRACT

Behavioral pain management interventions are efficacious for reducing pain in patients with cancer. However, optimal dosing of behavioral pain interventions for pain reduction is unknown, and this hinders routine clinical use. A Sequential Multiple Assignment Randomized Trial (SMART) was used to evaluate whether varying doses of Pain Coping Skills Training (PCST) and response-based dose adaptation can improve pain management in women with breast cancer. Participants (N = 327) had stage I-IIIC breast cancer and a worst pain score of > 5/10. Pain severity (a priori primary outcome) was assessed before initial randomization (1:1 allocation) to PCST-Full (5 sessions) or PCST-Brief (1 session) and 5 to 8 weeks later. Responders ( > 30% pain reduction) were rerandomized to a maintenance dose or no dose and nonresponders (<30% pain reduction) to an increased or maintenance dose. Pain severity was assessed again 5 to 8 weeks later (assessment 3) and 6 months later (assessment 4). As hypothesized, PCST-Full resulted in greater mean percent pain reduction than PCST-Brief (M [SD] = -28.5% [39.6%] vs M [SD]= -14.8% [71.8%]; P = 0.041). At assessment 3 after second dosing, all intervention sequences evidenced pain reduction from assessment 1 with no differences between sequences. At assessment 4, all sequences evidenced pain reduction from assessment 1 with differences between sequences ( P = 0.027). Participants initially receiving PCST-Full had greater pain reduction at assessment 4 ( P = 0.056). Varying PCST doses led to pain reduction over time. Intervention sequences demonstrating the most durable decreases in pain reduction included PCST-Full. Pain Coping Skills Training with intervention adjustment based on response can produce sustainable pain reduction.

mHealth Coping Skills Training for Symptom Management (mCOPE) for colorectal Cancer patients in early to mid-adulthood: Study protocol for a randomized controlled trial

Background

Colorectal cancer (CRC) patients in early to mid-adulthood (≤50 years) are challenged by high symptom burden (i.e., pain, fatigue, distress) and age-related stressors (e.g., managing family, work). Cognitive behavioral theory (CBT)-based coping skills training interventions reduce symptoms and improve quality of life in cancer patients. However, traditional CBT-based interventions are not accessible to these patients (e.g., in-person sessions, during work day), nor designed to address symptoms within the context of this stage of life. We developed a mobile health (mHealth) coping skills training program for pain, fatigue and distress (mCOPE) for CRC patients in early to mid-adulthood. We utilize a randomized controlled trial to test the extent to which mCOPE reduces pain, fatigue and distress (multiple primary outcomes) and improves quality of life and symptom self-efficacy (secondary outcomes).

Methods/Design

Patients (N = 160) ≤50 years with CRC endorsing pain, fatigue and/or distress are randomized 1:1 to mCOPE or standard care. mCOPE is a five-session CBT-based coping skills training program (e.g., relaxation, activity pacing, cognitive restructuring) that was adapted for CRC patients in early to mid-adulthood. mCOPE utilizes mHealth technology (e.g., videoconference, mobile app) to deliver coping skills training, capture symptom and skills use data, and provide personalized support and feedback. Self-report assessments are completed at baseline, post-treatment (5-8 weeks post-baseline; primary endpoint), and 3- and 6-months later.

Conclusions

mCOPE is innovative and potentially impactful for CRC patients in early to mid-adulthood. Hypothesis confirmation would demonstrate initial efficacy of a mHealth cognitive behavioral intervention to reduce symptom burden in younger CRC patients.

Role of self-efficacy for pain management and pain catastrophizing in the relationship between pain severity and depressive symptoms in women with breast cancer and pain

PURPOSE

This study evaluated the relationship between pain and depressive symptoms through pain self-efficacy and pain catastrophizing in breast cancer patients with pain.

DESIGN

Secondary analysis of a randomized trial investigating a cognitive-behavioral pain management protocol.

SAMPLE

Females (N = 327) with stage I-III breast cancer and report of at least moderate pain.

METHODS

Pain severity, pain self-efficacy, pain catastrophizing, and depressive symptoms were measured. The proposed model was assessed using structural equation modeling.

RESULTS

Higher pain severity was significantly related to lower pain self-efficacy and higher pain catastrophizing. Lower pain self-efficacy and higher pain catastrophizing were significantly related to more depressive symptoms. Higher pain severity was significantly associated with more depressive symptoms through lower pain self-efficacy and higher pain catastrophizing. The association between pain severity and depressive symptoms was not significant when specified as a direct effect.

CONCLUSION

Pain severity related to depressive symptoms in breast cancer patients via pain self-efficacy and pain catastrophizing.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

Measurement of pain self-efficacy and pain catastrophizing should be incorporated into comprehensive pain assessments for women with breast cancer, as these variables may be relevant therapeutic targets. Psychosocial symptom management interventions should include strategies that increase pain self-efficacy and decrease pain catastrophizing because these pain-related cognitive variables appear to drive the relationship between pain severity and depressive symptoms.

Understanding pain related to adjuvant endocrine therapy after breast cancer: A qualitative report

OBJECTIVES

Most patients report pain while taking adjuvant endocrine therapy (AET) for the treatment of breast cancer. While studies have examined patients' experiences with side effects, none solely capture patients' experiences with AET-related pain, a troubling symptom that reduces quality of life and impairs treatment adherence. This study explored themes of AET-related pain to inform future intervention development.

METHODS

Between November 2017 and November 2018, female patients (n = 30) with early-stage breast cancer enrolled between 3 and 36 months post-initiation of AET. Purposeful sampling was stratified by adherence level, age, distress level and time taking AET. Study staff conducted, transcribed and coded semi-structured interviews via inductive thematic coding to identify pain-related themes and achieved high inter-coded reliability (Kappa = 0.96).

RESULTS

Several pain-related themes were observed. Attitudes around pain are generally negative, and management needs are largely unmet. Patients reported preferences for non-pharmacological management strategies and cited AET pain as a reason for medication breaks but not discontinuation. Patients within 19 months of starting AET and low adherers reported more intense and disruptive pain.

CONCLUSIONS

Patients' experiences varied by patient attributes and revealed modifiable factors that may be targeted through behavioural interventions. AET-related pain is a complex side effect for which psychosocial support may be beneficial.

Improving well-being for individuals with persistent pain after surgery for breast cancer, lobular carcinoma in situ, or ductal carcinoma in situ: A randomized clinical trial

>276,000 Americans will be diagnosed with invasive breast cancer, lobular carcinoma in situ, or ductal carcinoma in situ this year and most will undergo breast surgery as part of their care. Although prognosis is excellent, many patients experience persistent post-surgical pain (PSP), which has no satisfactory pharmacological treatment. The causal contributions of pain-associated psychological factors (e.g., catastrophic thoughts about pain, psychological flexibility, self-efficacy) to the continuing burden of PSP have not yet been determined and may be opportune intervention targets. The randomized trial described here will compare the benefits of three manualized behavioral interventions for individuals with PSP. Participants will receive either: 1) self-guided health education (SGHE); 2) interventionist-guided health education (IGHE); or 3) interventionist-guided pain coping skills training with elements of acceptance and commitment therapy that specially target catastrophic thoughts about pain, self-efficacy, and psychological flexibility (CST-PSP). Participants will prospectively complete validated assessments of primary outcomes (PSP severity and interference) at baseline (pre-intervention) and 3-, 6-, and 12-months later. Validated measures of emotional distress and cancer-specific distress will be assessed as secondary outcomes. To test their roles as drivers of PSP, catastrophic thoughts about pain, self-efficacy, and psychological flexibility, will be assessed and statistically analyzed as mediators of hypothesized beneficial effects. The interventions' impacts on pain sensitivity and central sensitization will be investigated to test these physiological pathways as proximal drivers of PSP. To better characterize the patient experience, additional validated measures will be explored for associations with PSP, along with demographic and clinical factors. Trial registration: https://clinicaltrials.gov/ct2/show/NCT04225585, registered January 13, 2020.

Linking physical activity to personal values: feasibility and acceptability randomized pilot of a behavioral intervention for older adults with osteoarthritis pain

BACKGROUND

Osteoarthritis (OA) pain is common and leads to functional impairment for many older adults. Physical activity can improve OA outcomes for older adults, but few are appropriately active. Behavioral interventions can reduce physical activity barriers. We developed and tested a brief, novel behavioral intervention (i.e., Engage-PA) for older adults combining values to enhance motivation and strategic activity pacing to improve arthritis-related pain and functioning and increase physical activity.

METHODS

A randomized feasibility and acceptability pilot trial compared Engage-PA to treatment-as-usual plus fitness tracker (TAU+) in N = 40 adults age 65+ with OA pain in the knee or hip. Engage-PA involved two 60-min telephone sessions. All participants wore a fitness tracker to collect daily steps throughout the study and completed baseline and post-treatment assessments of secondary outcomes (arthritis-related pain and physical functioning, physical activity, psychological distress, psychological flexibility, and valued living). The impact of COVID-19 on general well-being and physical activity was also assessed. Descriptive statistics were conducted for feasibility and acceptability outcomes. Indicators of improvement in secondary outcomes were examined via change scores from baseline to post-treatment and performing independent samples t-tests to assess for between-group differences.

RESULTS

Feasibility was high; 100% accrual, low (5%) attrition, and 100% completion of study sessions. Acceptability was high, with 89% finding the intervention "mostly" or "very" helpful. Engage-PA participants demonstrated improvements in arthritis pain severity (M_diff = 1.68, p = 0.044, 95% CI [- 0.26, 3.62]) and self-reported activity (M_diff = 0.875, p = 0.038, 95% CI [- 1.85, 0.98]) from baseline to post-treatment as compared to TAU+. Due to pandemic-related challenges, there was a high level of missing data (43%) for daily steps, but available data showed no significant change in steps over time or between the groups. COVID-19 added an additional burden to participants, such that 50% were exercising less, 68% were more sedentary, and 72% lost access to spaces and social support to be active.

CONCLUSIONS

Engage-PA is a promising brief, novel behavioral intervention with the potential to support older adults in improving arthritis-related pain and functioning and increasing physical activity. The feasibility and acceptability of Engage-PA are particularly notable as most participants reported COVID-19 added more barriers to physical activity.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04490395 . Registered on July 29, 2020.

Pain, depressive symptoms, and self-efficacy for pain management: examination in African-American women with breast cancer

PURPOSE

African-American women with breast cancer face significant disparities, including high levels of pain. Depressive symptoms and self-efficacy for pain management impact how women with breast cancer manage pain, yet little is known about how these variables relate to pain specifically for African-American women with breast cancer.

METHODS

Baseline linear regression analyses were conducted using a sample of women (n = 98) with stage I-III breast cancer identifying as Black or African-American who were part of a larger intervention trial. Linear regressions explored the effect of depressive symptoms on pain (i.e., severity and interference), and the effect of self-efficacy for pain management on pain. Covariates were age (M = 57.22, SD = 10.76), cancer stage (50% = stage 1), and education level (36% = some college).

RESULTS

Participants reported moderate levels of pain severity and interference. Higher depressive symptoms were related to both higher pain severity and interference; (B = 0.06, p < 0.01, 95% CI [0.02,0.09]) and (B = 0.13, p < 0.001, 95% CI [0.09, 0.17]) respectively. Likewise, lower self-efficacy for pain management was also related to both higher pain severity and interference; (B =  - 0.04, p < 0.001, 95% CI [- 0.05, - 0.02]) and (B =  - 0.06, p < 0.001, 95% CI [- 0.08, - 0.04]) respectively. Women reporting less than a high school diploma endorsed significantly higher pain severity and interference than women reporting some college. Age and cancer stage were not significantly related to pain.

CONCLUSION

Pain for African-American women with breast cancer may be influenced by depressive symptoms and self-efficacy for pain management, in addition to other important variables. Attending to better assessment and treatment of depressive symptoms and self-efficacy for pain management may improve outcomes.

Breast Cancer Disparities and the Digital Divide

Purpose of Review

Socioeconomically disadvantaged populations and minority groups suffer from high breast cancer mortality, a disparity caused by decreased access to specialty care, lower treatment adherence, co-morbidities, and genetic predisposition for biologically aggressive breast tumor subtypes. Telehealth has the potential to mitigate breast cancer disparities by increasing access to specialty care and health information. However, unequal access to high-speed/broadband internet service and telehealth itself magnifies breast cancer disparities in vulnerable populations. This review evaluates the impact of the digital divide on breast cancer outcomes, as well as strategies for leveraging telehealth to reduce breast cancer disparities.

Recent Findings

There is a paucity of research specific to employing telehealth to address breast cancer disparities. Previous studies provide examples of telehealth utilization for increasing screening mammography, in addition to improving access to breast cancer care, including breast cancer specialist, nurse navigators, and clinical trials. Telehealth can also be used as an approach to risk reduction, with strategies to support weight management and genetic testing.

Summary

Eliminating the digital divide holds enormous potential for mitigating breast cancer disparities through an intentional focus on improving access to telehealth. With increased accessibility, resource allocation, and improved digital infrastructure, telehealth can be used to address disparities in early detection, quality of breast cancer care, treatment adherence, and risk assessment. Further research is essential to elucidate best practices in breast cancer telehealth approaches in underserved communities.

Meaning-Centered Pain Coping Skills Training: A Pilot Feasibility Trial of a Psychosocial Pain Management Intervention for Patients with Advanced Cancer

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.

Leveraging mobile health technology and research methodology to optimize patient education and self-management support for advanced cancer pain

PURPOSE

Patient education is critical for management of advanced cancer pain, yet the benefits of psychoeducational interventions have been modest. We used mobile health (mHealth) technology to better meet patients' needs.

METHODS

Using the Agile and mHealth Development and Evaluation Frameworks, a multidisciplinary team of clinicians, researchers, patients, and design specialists followed a four-phase iterative process to develop comprehensive, tailored, multimedia cancer pain education for a patient-facing smartphone application. The target population reviewed the content and provided feedback.

RESULTS

The resulting application provides comprehensive cancer pain education spanning pharmacologic and behavioral aspects of self-management. Custom graphics, animated videos, quizzes, and audio-recorded relaxations complemented written content. Computable algorithms based upon daily symptom surveys were used to deliver brief, tailored motivational messages that linked to more comprehensive teaching. Patients found the combination of pharmacologic and behavioral support to be engaging and helpful.

CONCLUSION

Digital technology can be used to provide cancer pain education that is engaging and tailored to individual needs. A replicable interdisciplinary and patient-centered approach to intervention development was advantageous. mHealth interventions may be a scalable approach to improve cancer pain. Frameworks that merge software and research methodology can be useful in developing interventions.

Predictors of Response to an Evidence-Based Behavioral Cancer Pain Management Intervention: An Exploratory Analysis From a Clinical Trial

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.

Enhancing meaning in the face of advanced cancer and pain: Qualitative evaluation of a meaning-centered psychosocial pain management intervention

OBJECTIVES

The objectives of this study were to obtain patient evaluations of the content, structure, and delivery modality of Meaning-Centered Pain Coping Skills Training (MCPC), a novel psychosocial intervention for patients with advanced cancer and pain. MCPC aims to help patients connect with valued sources of meaning in their lives (e.g., family relationships), while providing training in evidence-based cognitive and behavioral skills (e.g., guided imagery) to reduce pain.

METHODS

Semi-structured interviews were conducted with 12 patients with stage IV solid tumor cancers and persistent pain. Transcripts were analyzed using methods from applied thematic analysis.

RESULTS

When evaluating MCPC's educational information and skills training descriptions, participants described ways in which this content resonated with their experience. Many coped with their pain and poor prognosis by relying on frameworks that provided them with a sense of meaning, often involving their personally held religious or spiritual beliefs. They also expressed a need for learning ways to cope with pain in addition to taking medication. A few participants offered helpful suggestions for refining MCPC's content, such as addressing common co-occurring symptoms of sleep disturbance and fatigue. Concerning MCPC's structure and delivery modality, most participants preferred that sessions include their family caregiver and described remote delivery (i.e., telephone or videoconference) as being more feasible than attending in-person sessions.

SIGNIFICANCE OF RESULTS

Participants were interested in an intervention that concurrently focuses on learning pain coping skills and enhancing a sense of meaning. Using remote delivery modalities may reduce access barriers (e.g., travel) that would otherwise prevent many patients from utilizing psychosocial services.

Behavioral cancer pain intervention using videoconferencing and a mobile application for medically underserved patients: Rationale, design, and methods of a prospective multisite randomized controlled trial

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.

Predictors of Intervention Session Completion in a Randomized Clinical Trial of a Behavioral Cancer Pain Intervention

CONTEXT

Some patients with cancer are able to complete psychosocial pain management intervention sessions, and others find it difficult to do so.

OBJECTIVES

Conduct a secondary analysis of a randomized clinical trial (N = 178) that compared delivery formats (in-person vs. videoconference) of a pain coping skills training (PCST) intervention for patients with cancer to examine if intervention session completion predicts postintervention outcomes of pain severity and interference, psychological distress, physical well-being, and pain self-efficacy; and identify predictors (i.e., demographics, medical characteristics, baseline outcome scores) of session completion.

METHODS

Session completion (i.e., completing all four sessions vs. missing at least one session) was tested as a predictor of postintervention outcomes. Predictors of session completion were then examined.

RESULTS

In both study conditions combined, PCST session completion predicted improvement from baseline to postintervention in pain severity (β = -0.27; P = 0.03), pain interference (β = -0.25; P = 0.048), and pain self-efficacy (β = 0.23; P = 0.07). Participants in the videoconference condition were significantly more likely than those in the in-person condition to complete all sessions (83% vs. 65%; P = 0.006). Participants with at least some college education (odds ratio [OR] 4.36; P = 0.04), a diagnosis of breast cancer (OR 6.73; P = 0.04), and higher levels of pain self-efficacy (OR 2.32; P = 0.02) were more likely to complete videoconference sessions. Participants who lived closer to the medical center (OR 0.64; P = 0.07), had early stage cancer (OR 3.82; P = 0.07), and fewer medical comorbidities (OR 0.59; P = 0.04) were more likely to complete in-person sessions.

CONCLUSION

Completing PCST sessions is important for improving pain outcomes. Efforts to increase session completion (e.g., videoconference delivery) should be considered.

Can-Pain-a digital intervention to optimise cancer pain control in the community: development and feasibility testing

Purpose

To develop a novel digital intervention to optimise cancer pain control in the community. This paper describes intervention development, content/rationale and initial feasibility testing.

Methods

Determinants of suboptimal cancer pain management were characterised through two systematic reviews; patient, caregiver and healthcare professional (HCP) interviews (n = 39); and two HCP focus groups (n = 12). Intervention mapping was used to translate results into theory-based content, creating the app “Can-Pain”. Patients with/without a linked caregiver, their general practitioners and community palliative care nurses were recruited to feasibility test Can-Pain over 4 weeks.

Results

Patients on strong opioids described challenges balancing pain levels with opioid intake, side effects and activities and communicating about pain management problems with HCPs. Can-Pain addresses these challenges through educational resources, contemporaneous short-acting opioid tracking and weekly patient-reported outcome monitoring. Novel aspects of Can-Pain include the use of contemporaneous breakthrough analgesic reports as a surrogate measure of pain control and measuring the level at which pain becomes bothersome to the individual.

Patients were unwell due to advanced cancer, making recruitment to feasibility testing difficult. Two patients and one caregiver used Can-Pain for 4 weeks, sharing weekly reports with four HCPs. Can-Pain highlighted unrecognised problems, promoted shared understanding about symptoms between patients and HCPs and supported shared decision-making.

Conclusions

Preliminary testing suggests that Can-Pain is feasible and could promote patient-centred pain management. We will conduct further small-scale evaluations to inform a future randomised, stepped-wedge trial.

Trial registration

Qualitative research: ClinicalTrials.gov, reference NCT02341846

Feasibility study: NIHR CPMS database ID 34172

Electronic supplementary material

The online version of this article (10.1007/s00520-020-05510-0) contains supplementary material, which is available to authorized users.

Benefits of Mobile Apps for Cancer Pain Management: Systematic Review

Background

Pain ratings reported by patients with cancer continue to increase, and numerous computer and phone apps for managing cancer-related pain have been developed recently; however, whether these apps effectively alleviate patients’ pain remains unknown.

Objective

This study aimed to comprehensively evaluate the role of mobile apps in the management of cancer pain.

Methods

Literature on the use of apps for cancer pain management and interventions, published before August 2019, was retrieved from the following databases: MEDLINE, Embase, Cochrane, CINAHL, Scopus, and PsycINFO. The effects of apps on cancer pain were evaluated using RevMan5.3 software, and the rates of adverse drug reactions were analyzed using the R Statistical Software Package 3.5.3.

Results

A total of 13 studies were selected for the analysis: 5 randomized controlled trials (RCTs), 4 before-after studies, 2 single-arm trials, 1 prospective cohort study, and 1 prospective descriptive study. The 5 RCTs reported data for 487 patients (240 patients in the intervention group and 247 patients in the control group), and the remaining studies reported data for 428 patients. We conducted a meta-analysis of the RCTs. According to the meta-analysis, apps can significantly reduce pain scores (mean difference [MD]=–0.50, 95% CI –0.94 to –0.07, I²=62%, P=.02). We then used apps that have an instant messaging module for subgroup analysis; these apps significantly reduced patients’ pain scores (MD=–0.67, 95% CI –1.06 to –0.28, I²=57%, P<.01). Patients using apps without an instant messaging module did not see a reduction in the pain score (MD=0.30, 95% CI –1.31 to 1.92, I²=70%, P=.71). Overall, patients were highly satisfied with using apps. Other outcomes, such as pain catastrophizing or quality of life, demonstrated greater improvement in patients using apps with instant messaging modules compared with patients not using an app.

Conclusions

The use of apps with instant messaging modules is associated with reduced pain scores in patients with cancer-related pain, and patient acceptance of these apps is high. Apps without instant messaging modules are associated with relatively higher pain scores. The presence of an instant messaging module may be a key factor affecting the effect of an app on cancer pain.