Abstract A032: Dignity therapy effects by race: Chaplain and nurse implementation in pragmatic, multisite stepped-wedge randomized control trial
Authors: Wilkie Diana J. , Fitchett George , Schoppee Tasha M. , Guay Marvin O. Degado , Hauser Joshua , Kittelson Sheri M. , O-Mahony Sean , Rabow Michael W. , Quest Tammie E. , Solomon Sheldon , Yao Yingwei , Hadzo George , Chochinov Harvey Max , Emanuel Linda L. 
Published: January 2023

Abstract
Aim: As a brief psychotherapy for individuals facing mortal threat, Dignity Therapy (DT) effects on spiritual outcomes are unknown, especially as an intervention to support cancer health equity for racial minority patients. Our study aim was to compare usual outpatient palliative care and such care along with nurse-led or chaplain-led DT groups for main effects on dignity impact and the interaction of DT with race. Methods: We conducted the 4-step, stepped-wedge randomized control trial at 4 NCI designated cancer centers and 2 academic cancer centers across the United States. Half of the sites were randomized to chaplain-led DT and half to nurse-led DT. Of the 645 recruited cancer patients (age ≥ 55 years) receiving outpatient palliative care, 579 (59% female, mean age 66.4±7.4 years, 78% White, 77% Christian religion, 62% stage 4 cancer) provided data for intent-to-treat analysis. Over 6 weeks, patients completed pretest/posttest measures including the Dignity Impact Scale (DIS, primary outcome) ranging from low impact of 7 to highest impact of 35. In step 1-3, study procedures were completed in person. In step 4 (during the COVID-19 pandemic), when all sites were providing the intervention, study procedures were completed via Zoom. We used multiple imputation and regression analysis adjusting for pretest DIS, study site, and study step. Results: Of the 579 patients, 317 were in the DT group and 262 in the usual care group. The vast majority of the sample was White (n=448) along with 103 Blacks, 5 Asians, 2 Pacific Islanders, 1 Native American, 13 other races (all minorities were combined as Other Race), and 7 were missing race data. At pretest, the mean DIS score was 24.3±4.3 in the DT group and 25.9±4.3 in the usual care group. Adjusting for pretest DIS scores, study site, and study step, the chaplain-led (β=1.7, p=.02) and nurse-led (β=2.1, p=.005) groups reported significantly higher posttest DIS scores than the usual care groups. Adjusting for age, gender, race, education, and income, the effect on DIS scores remained significant for both DT groups. We then examined the interaction between race and DT with the entire sample and observed that the interaction was not significant (p=.73) and the sizes of DT effects were similar for White (β=1.9, p=.005) and the Other Race (β=1.6, p=.055) patients. Conclusions: Whether led by chaplains or nurses, DT was effective in improving dignity impact for older adult outpatient palliative care patients with cancer. DT, a patient-centered approach, has promise as an intervention to improve health equity in support of dignity for racial minorities. This rigorous trial of DT is a landmark step in gero-oncology palliative care and spiritual health services research focused on cancer health equity.
Citation Format: Diana J. Wilkie, George Fitchett, Tasha M. Schoppee, Marvin O. Degado Guay, Joshua Hauser, Sheri M. Kittelson, Sean O-Mahony, Michael W. Rabow, Tammie E. Quest, Sheldon Solomon, Yingwei Yao, George Hadzo, Harvey Max Chochinov, Linda L. Emanuel. Dignity therapy effects by race: Chaplain and nurse implementation in pragmatic, multisite stepped-wedge randomized control trial [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A032.