Dialing It In

Pain and depression are two of the most common symptoms experienced by cancer patients, but they are not always recognized and treated properly. However, a recent study suggests that oncology practices can detect and alleviate these often-undetected symptoms and improve patient quality of life by using simple technology.

A large percentage of cancer patients suffer from pain or depression, and up to 40 percent experience both, according to Kurt Kroenke, MD, lead investigator of the study and professor of medicine at the Indiana University School of Medicine. Such knowledge led to the year-long Indiana Cancer Pain and Depression (INCPAD) trial.

“While they are among the most common and disabling cancer-related symptoms, pain and depression are also among the most undertreated symptoms,” says Kroenke, “so we decided to do a study to improve their care.”

The INCPAD trial used telephone care management, which combined automated survey calls and follow-up calls by a nurse care manager, to diagnose and mitigate the symptoms of pain and depression. Patients continued to visit their oncologist for their primary cancer care. The trial included 405 patients from 16 different oncology practices in Indiana. Researchers did not select for a specific tumor type, cancer stage, or whether they were in active treatment or a survivor.

“What they had in common was they all had cancer,” says Kroenke. “What we were treating was not their cancer, but their pain and depression.”

While they are among the most common and disabling cancer-related symptoms, pain and depression are also among the most undertreated symptoms.

Participants in the study had to have had at least moderately severe depression (131 patients), moderately severe pain (96 patients), or both (178 patients). Patients were randomly assigned to either a usual care group or a telecare management group, with an even distribution of pain and depression in both groups.

Those in the usual care group received standard treatment from their oncologists with no special attention to pain or depression other than what would normally occur. The intervention group received automated symptom-monitoring surveys twice a week at the beginning of the trial, then in decreasing frequency for those showing symptom improvement as the trial progressed. Patients chose to receive the surveys either by an automated telephone call scheduled at their convenience or via Internet. Survey items included brief scales for pain and depression and questions about medication use, side effects, overall improvement, and desire for additional medical attention—usually resulting in a follow-up call from a nurse.

The survey results were sent to a nurse care manager who tracked each patient’s responses as the study progressed. If a patient showed signs of increased or unchanging pain or depression, the nurse would then contact the patient by phone to discuss the results and treatment. The nurse care manager met weekly with a pain and depression specialist who offered treatment recommendations for patients with persistent symptoms. These recommendations, often for prescription medications, were then sent to the patient’s primary oncologist to be considered.

With these positive results, the INCPAD trial shows that both physical and psychological symptoms can be alleviated with telephone-based care, potentially reducing unnecessary visits to their oncologists’ office.

After one year, pain and depression were assessed in both groups. Pain was evaluated using a system called the Brief Pain Inventory (BPI) while depression was evaluated by the Hopkins Symptom Checklist. The researchers found that of the patients with pain, patients in the intervention group had greater improvements, with more having at least a 30 percent decrease in BPI score. Depression improved in the intervention group as well, with more having at least a 50 percent decrease in depression severity.

With these positive results, the INCPAD trial shows that both physical and psychological symptoms can be alleviated with telephone-based care, potentially reducing unnecessary visits to their oncologists’ office, notes Kroenke.

Becky Sanders, RN, BSN, the nurse care manger for the study, mentioned that telecare extends beyond the relief of pain and depression. She not only compiled survey results and called patients about symptoms but also helped with details such as questions about medications and transportation issues.

“It was often that I could so easily fix something for a patient by just a simple answer to a question that would keep them from needling to call back into the clinic,” she says. “I think that the practices do a really good job of educating patients, but I equally think patients are just overwhelmed.”

According to Kroenke, many patients said they could feel more comfortable bringing up details about their symptoms than if they were in a doctor’s office with the pressures of a limited appointment time because they were in a comfortable place and had time to think about the survey questions. The next step in telecare management, he says, is to cover a broader range of symptoms, including fatigue, nausea, anxiety, and insomnia.

“If you could figure out what parts of clinical care we deliver that could be best done by phone and what things really need the patient to come in physically, then I think we can come up with a more patient-centered approach,” says Kroenke.

You can read the full results of the study in the July 14, 2010 issue of the

http://jama.ama-assn.org/cgi/content/full/304/2/163.

Journal of the American Medical Association. To read the study online, go to