Kudos to Sophia Smith, associate professor, Allison Applebaum (MSKCC) and their entire team for the submission of her R01 COVID-19 supplement application entitled: “Feasibility of Using a SMART Design to Optimize PTSD Symptom Management Strategies Among Cancer Caregivers During COVID-19 Pandemic." This proposal requests funding for a one-year period with a project start date of December 1, 2020.

The COVID-19 pandemic has illuminated the critical, challenging, and often burdensome role played by cancer caregivers. Specifically, caregivers of hematopoietic cell transplant (HCT) survivors - even in ordinary environments - face a unique combination of acute and chronic stressors well after cancer treatment ends. These stressors cause disruptions to caregivers’ schedules and roles and generate feelings of being “on call” 24 hours per day. As such, HCT caregivers are at a significantly higher risk for anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms than those reported by patients. Although traditional office-based cognitive behavioral therapies (CBT) are effective for treating symptoms, HCT caregivers often lack access due to cost, distance, and temporal demand (attributed to the caregiving role) barriers. Mobile Health (mHealth) programs are increasingly used to facilitate access to CBT; some are self-guided and others require individualized, more intensive videoconferenced sessions with therapists. Hence, a continuum of mHealth CBT-based (mCBT) solutions with differing intensity levels is available to support HCT caregivers with PTSD symptoms. “Right-sizing” treatment ensures optimal benefit without wasting patient time and health care costs.

This administrative supplement aims to better understand the disproportionate burden COVID-19 has placed on HCT caregivers and answer the question: Will HCT caregivers participate and find benefit in a stepped care, mHealth intervention for individuals at risk for, or suffering from, PTSD symptoms?  We propose to determine the feasibility and acceptability of an adaptive (i.e., stepped care) mHealth approach for managing symptoms of PTSD in HCT caregivers of patients who recently completed autologous or allogeneic HCT therapy. Our research team is comprised of national leaders in the area, including the investigators who have defined the problem as well as devised potential mCBT solutions. One of these solutions is Cancer Distress Coach, a mobile application developed in partnership with the National Center for PTSD, as an effective self-management tool for addressing symptoms. It will be used with more intensive mCBT therapies that require individualized sessions with therapists among 50 HCT caregivers to manage their PTSD and related symptoms. This project addresses symptom management - one of ten National Cancer Moonshort Initiative recommendations – and the underserved have the greatest opportunity for benefit. Methods include using a Sequential Multiple Assignment Randomized Trial (SMART) to establish decision rules regarding when and in what way to intensify treatment for HCT caregivers (n=50) with Cancer Distress Coach and a more intensive mCBT. Electronic data collection surveys will be used and clickstream data captured to examine mobile app usage. In addition, qualitative interviews will be conducted to describe the HCT caregiver experience with COVID-19 risk, prevention behaviors, and mental health outcomes.