Kudos to Sophia Smith and her entire team for the submission of her Department of Defense (DOD) application entitled "Integrating Technological Approaches for Cancer Pain Management."  This proposal requests funding for a two-year period with a start date of Feb. 1, 2019.

Scientific Objective and Rationale: Cancer is a disease that is caused by an uncontrolled division of abnormal cells; it can occur in many parts of the body, including the blood. Veterans are more likely to have blood cancer, in large part because they were exposed to chemicals such as Agent Orange; about 3,000,000 Veterans served in the armed forces during the course of the Vietnam War when these agents were used. Blood cancers such as leukemia, lymphoma, and multiple myeloma often go along with pain resulting from the disease (e.g., lymph node swelling), radiation treatments (e.g.. dry skin), and chemotherapy (e.g., numbness or weakness in the nerves) that lasts for many years and impacts quality of life. Factors that affect the mind, such as posttraumatic stress disorder (PTSD), are also common in blood cancer survivors; our team found that more than 1 in 3 lymphoma survivors have PTSD symptoms that last or get worse over several years. PTSD was found to co-exist with pain symptoms in lymphoma survivors. Prescription drugs address pain but can be abused.
There is a critical need to find new ways to reduce pain and PTSD symptoms in Veterans with a blood cancer. Mobile health technology offers non-drug treatments that are cost-effective, accessible, and reduce barriers to care. First, neurofeedback, a type of biofeedback that can train people to gain more control over brain states and increase relaxation, has been used successfully to treat chronic pain and PTSD. Second, cognitive behavioral therapy (CBT), a type of psychotherapy that reframes negative thinking patterns into positive thoughts, has been shown to lower pain intensity and PTSD. After a small amount of training, individuals can use neurofeedback and CBT on their own using mobile technology, which can reduce clinic visits, lower reliance on prescription drugs, minimize stigma (shame), and allow Veterans to work actively on their own treatment.

Types of Patients to be Helped: This project will address pain and PTSD symptoms in Veterans with a blood cancer, in a way that can be easier for them to access than other types of treatments. When it comes to traditional treatments, Veterans report barriers including travel to clinics, stigma, and believing they have to work out problems on their own. These barriers have been linked to low use of traditional treatments.

Clinical Applications, Benefits, and Risks: Neurofeedback and CBT show promise as transportable, low-cost interventions for reducing pain in Veterans with blood cancer. In this proposal, we aim to develop and test the usability and acceptability of a mobile app, Integrated Pain Management (IPM), for managing pain and PTSD symptoms among Veteran blood cancer patients. We will: 1) combine a mobile neurofeedback app and Cancer Distress Coach (a CBT-based app), to create IPM; and, 2) conduct testing of the IPM app with 50 Veterans with a blood cancer to enhance its usability by applying software revisions. Following software development, we will interview Veterans with a blood cancer and: 1) observe patients interacting with the tablet and headset using “think aloud” procedures while taking extensive notes; and, 2) gather Veteran feedback immediately following their use of the IPM app. Usability feedback will include ease of learning, efficiency, memorability, error frequency and severity, and subjective satisfaction. We hypothesize that, with technical support, Veterans can use the IPM app to manage their pain and PTSD symptoms.

Projected Time to Achieve Clinically Relevant Outcome: This project will be completed within two years.

Contributions of the Study to Advancing Cancer Research and Patient Care: This project will be the first to test the usability of such pain management approaches in a population of cancer patients reporting chronic pain and PTSD. And, it advances the field by investigating a highly innovative, portable, mobile app (IPM) that could fundamentally shift future approaches to managing pain and PTSD in clinical oncology practice.

FY18 PRCRP Military Relevance Focus Area: Gaps in treatment and survivorship.

Military Relevance: If successful, we will identify a low-cost, transportable, user-friendly, and effective approach for military Veterans and Service members with blood cancer to manage pain and PTSD. Providing neurofeedback and CBT through mobile devices would reduce reliance on drug treatments and overcome barriers of traditional non-pharmaceutical treatments because they can be self-administered at home. We expect that lower pain and PTSD symptoms from this treatment would enhance quality of life of individuals with a blood cancer. Because pain and PTSD are linked to negative outcomes, IPM may lower odds of some of the most tragic outcomes of military Veterans and Service members, including violence, drug use, and suicidal behavior.