Randomized Clinical Trial of a Multi-Modal Palliative Care Intervention

Adults diagnosed with metastatic cancer commonly experience depression and anxiety symptoms, which can interfere with advance care planning. This randomized clinical trial evaluates a novel, piloted, primary palliative care intervention that addresses advance care planning and psychosocial needs of patients with metastatic cancer. The intervention focuses on patients with elevated anxiety and depression (anx/dep) symptoms-those with highest psychosocial needs who may be at greatest risk for advance care planning non-completion. The intervention is founded on an evidence-based intervention approach known as Acceptance and Commitment Therapy (ACT) that reduces distress and promotes behavior change through theory-driven mechanisms. In the proposed randomized trial, M-ACT will be compared to a usual care control condition. The study will also assess the association between advance care planning and anx/dep symptoms, thereby informing the critical practice question of whether anx/dep symptoms should be addressed concurrently with advance care planning. The study will enroll patients with Stage IV solid tumor cancer (N=240) within Rocky Mountain Cancer Centers, randomized 1:1 to M-ACT or usual care. The study aims to: 1) Evaluate the hypothesis that M-ACT will increase advance care planning completion (primary outcome) and sense of life meaning, and reduce anx/dep symptoms and fear of dying relative to usual care control. 2) Assess the association between anx/dep symptoms and advance care planning at baseline and over time, testing the hypothesis that decreases in anx/dep symptoms at post- intervention will be associated with increases in advance care planning at follow-up. 3) Assess M-ACT's hypothesized mechanisms to specify how the intervention works (exploratory aim). Given their advance care planning and psychosocial needs, and poor access to palliative care, rigorously investigating M-ACT has the potential to benefit community patients with metastatic cancer and to advance palliative care science by addressing gaps in novel approaches, foundational knowledge, and the scalable delivery of palliative care.

Note: Due to the coronavirus pandemic, the in-person group component of M-ACT has currently been shifted to an online group format.

This study will evaluate an innovative, multi-modal palliative care intervention that addresses the lack of advance care planning (ACP) and unmet psychosocial needs commonly experienced by patients with metastatic cancer. Up to half of adults with metastatic cancer report elevated anxiety or depression symptoms, which can cause withdrawal from daily activities and future planning and have been linked to non-adherent health behaviors in other disease populations. However, little is known about the extent to which anxiety or depression influence ACP completion in palliative care. In addition, metastatic cancer triggers patients' fear of dying and threatens their sense of meaning. The current approach aims to optimize two core palliative care outcomes - ACP and psychosocial well being - in outpatient oncology settings and to build the evidence base for primary palliative care interventions. This new multimodal intervention, which is based on extensive pilot data, uses a primary palliative care approach and focuses on patients with elevated anxiety or depression (anx/dep) symptoms.

The intervention is based on Acceptance and Commitment Therapy (ACT), an evidence-based approach to reduce distress and promote behavior change through theorized mechanisms that include cultivating acceptance of internal experience and aligning behavior with personal values. A pilot study for adults with metastatic cancer and elevated anx/dep symptoms conducted by the current research team, leveraged ACT to design and refine the multi-modal ACT intervention (M-ACT) in response to patient and provider feedback. M-ACT helps metastatic cancer patients to live meaningfully and face the future no matter what their health status, supports their engagement in ACP and addresses their psychosocial needs.

To facilitate future scalability, M-ACT uses a novel multi-modal delivery structure comprising both in-person group sessions led by existing on-site clinical social workers and self-paced, personalized online sessions completed at home, which efficiently increase intervention dose without increasing patient travel or provider demands. The current randomized controlled trial will rigorously evaluate the ability of M-ACT to increase ACP (primary outcome) and improve psychosocial outcomes (secondary). This study also will evaluate the relationship between anx/dep symptoms and ACP to inform the critical clinical question of whether anx/dep symptoms should be addressed concurrently with ACP. Finally, the study will explore mechanisms that may explain how M-ACT influences ACP and the targeted secondary outcomes.

The study will enroll patients with stage IV solid tumor cancer (N = 240), randomized in a 1:1 ratio to M-ACT or usual care for a 4-week intervention period. Outcomes will be assessed at baseline, mid-intervention (to assess mechanisms), 1-week post-intervention, and 2-month follow-up.

Note: Due to the coronavirus pandemic, the in-person group component of M-ACT has currently been shifted to an online group format.

Eligibility Criteria:
Inclusion Criteria:

1. At least 18 years of age
2. English-speaking (able to speak, read, and write well in English)
3. Diagnosed with Stage IV metastatic cancer of any solid tumor type
4. Capable at time of consent of understanding and voluntarily consenting themselves to the study, attending group sessions, and completing the online sessions at home, confirmed by an Eastern Cooperative Group Performance Status Scale of 0 to 2
5. Endorse moderate to severe anxiety or depression symptoms on the Patient Health Questionnaire-4

Exclusion Criteria:

1. Current high suicide risk
2. Psychiatric hospitalization or suicide attempt in the past 5 years
3. History of chronic, untreated trauma unrelated to their cancer