Cancer patients receiving care in geographically dispersed urban and rural oncology practices who participated in a program that included telephone-based care management and home-based automated symptom monitoring had greater improvement in pain and depression compared to patients who received usual care, according to a study in the July 14 issue of JAMA.
Pain and depression are the most common physical and psychological symptoms in cancer patients. "However, despite their prevalence and associated disability, cancer-related pain and depression are frequently undetected and undertreated," according to background information in the article.
Kurt Kroenke, M.D., of the Richard Roudebush VA Medical Center, Indiana University, and Regenstrief Institute, Indianapolis, and colleagues conducted the Indiana Cancer Pain and Depression (INCPAD) trial in 16 community-based urban and rural geographically dispersed oncology practices, as a collaborative care approach to managing depression and pain. Patients entered the trial from March 2006 through August 2008, with follow-up concluding in August 2009. Participating patients had depression, cancer-related pain, or both, and were randomly assigned to receive the intervention (n = 202) or receive usual care (n = 203), and were stratified by symptom type.
Patients in the intervention group received centralized telecare management by a nurse-physician specialist team coupled with automated home-based symptom monitoring by interactive voice recording or Internet. Telephonic care management was delivered by a nurse care manager trained in assessing symptom response and medication adherence; in providing pain and depression-specific education; and in making treatment adjustments according to evidence-based guidelines. Depression and pain symptoms were assessed at the beginning of the trial and at months 1,3,6, and 12.
Of the 405 participants enrolled in the study, 131 had depression only, 96 had pain only, and 178 had both depression and pain. The researchers found that of the 274 patients with pain, 137 patients in the intervention group had greater improvements in pain severity as assessed by the Brief Pain Inventory (BPI; 30 percent or greater decrease in BPI) over the 12 months of the trial than the 137 patients in the usual-care group. Of the 309 patients with depression, the 154 patients in the intervention group had significantly greater improvement in depression severity as assessed by the Hopkins Symptom Checklist (HSCL; 50 percent or greater decrease in HSCL) than the 155 patients in the usual-care group.
Between-group differences in secondary outcomes that were not pain- or depression-specific were also assessed, and the intervention group had better outcomes for several health-related quality of life domains, including mental health, vitality, anxiety, and physical symptom burden.
"Our INCPAD trial has several important findings. First, the telecare management intervention resulted in significant improvements in both pain and depression. Second, the trial demonstrated that it is feasible to provide telephone-based centralized symptom management across multiple geographically dispersed community-based practices in both urban and rural areas by coupling human with technology-augmented patient interactions. Third, the findings did not appear to be confounded by differential rates of co-interventions or health care use," the authors write.
"The fact that INCPAD was beneficial for the most common physical and psychological symptoms in cancer patients demonstrates that a collaborative care intervention can cover several conditions, both physical and psychological."
(JAMA. 2010;304:163-171. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.