Cancer Clinical Trial
Official title:
Reducing Disparities in Rural Advanced Cancer Patients and Caregivers
The Purpose of this project is to implement ENABLE (Educate, Nurture, Advise, Before Life Ends) at four community cancer practices that have a high percentage of rural and/or medically-underserved patients diagnosed with advanced cancer and their family caregivers. The ENABLE principal investigator (PI) and the Coordinating Center team are located at the University of Alabama at Birmingham (UAB). Site teams are - Spartanburg SC/Gibbs Cancer Center, Birmingham VA Medical Center, University of South Alabama/Mitchell Cancer Institute, UAB Division of Gynecologic Oncology and UAB Department of Hematology Oncology.
ENABLE is an evidence-based concurrent oncology palliative care model that is ready for
implementation. It can overcome the barriers created by rural geography and addresses the
often unrecognized and unmet needs of the family caregivers. The EIT is an emerging
conceptual model for translating evidence into practice. The central core is the linkage
between evidence and stakeholders. Successful implementation results from the interaction of
Intervention Program/Policy (ENABLE), Implementation Processes (community-based participatory
research methods[CBPR] within a learning collaborative) and the Practical Progress Measures
(RE-AIM). On-going consideration of the Multi-level Context is pivotal to successful
implementation. This approach has the potential to have a high impact on reducing disparities
resulting from the gap between ASCO recommendations and current oncology and palliative care
practices in rural patients and families.
The Urgent Need to Improve Rural Palliative and End-of-life Care for Patients and Caregivers
According to the 2010 US Census data, nearly 60 million citizens live in rural or
non-metropolitan areas; however, less than 10% of the 833 US palliative care programs are
located in rural areas (data provided by the Center to Advance Palliative Care Registry).
Rural advanced cancer patients are vulnerable and at high risk of experiencing social
isolation and disparities in palliative care due to long distances from treatment centers,
low population density, and limited clinical expertise (because rural primary care clinicians
and hospices programs have relatively few terminally-ill patients.) Rural location is related
to less and later hospice use. Hence, most rural cancer patients are unlikely to have access
to interdisciplinary team-based palliative and hospice care recommended by ASCO2 and National
Comprehensive Cancer Network guidelines. These patients will lack this expertise or be
transferred to a distant site for palliation.6 Patients transferred to distant tertiary care
settings are at high risk of spending their last days or weeks of life far from home and
loved ones. Conversely, rural patients may suffer during their last weeks or days of life
without the benefit of state-of-art treatments of pain or other causes of distress. A US
palliative care report card identified rural location as high risk for little access to
palliative care. By definition, palliative care includes family caregiver support. An
estimated million Americans are informal caregivers defined as an unpaid individual who
assist someone with functional impairment with activities of their daily living to some
degree. Informal caregiving can have deleterious effects on the caregivers' physical and
emotional health; a phenomenon referred to as caregiver burden. A recent meta- analysis
showed that cancer caregivers in particular, compared to non-caregiver controls, exhibited
higher levels of stress and depression, and lower subjective well-being and physical health.
ENABLE includes the evidence-based, caregiver-specific COPE (Creativity, Optimism, Planning,
Expert information) intervention, developed by McMillan and colleagues. COPE, based in
problem-solving education theory, is designed to improve caregivers' creative
problem-solving, realistic optimism, reasonable goal-setting, and knowledge/utilization of
relevant resources. Compared to usual care, two weeks post-intervention, caregivers in COPE
showed improvements in caregiver burden and overall QOL. COPE is the basis of the ACS
caregiving guide and has been adapted for caregivers in other diseases.
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