Harnessing digital health and equity informed multi-level implementation strategies to promote uptake of depression treatment in cancer settings: iCan DepCare

Cancer patients with elevated depressive symptoms have higher rates of cancer mortality, recurrence, diminished quality of life (QoL), healthcare expenditure, and chemotherapy nonadherence. Depression also partially drives racial/ethnic cancer disparities. As such, several advisory groups recommend depression screening and evidence-based treatment across the cancer continuum. However, only one in four depressed cancer patients receives evidence-based treatment for depression due to: (1) suboptimal oncologist referral/prescribing/training compounded by complex algorithms in treatment guidelines; (2) low patient uptake due to knowledge gaps, cancer-related physical symptoms, stigma; and (3) organizational factors like clinic culture, resources, and leadership support all resulting in poor patient-provider communication, one-size-fits all SW referrals, high no show rates and little actual delivery of evidence-based treatment. Despite several systematic reviews/meta-analyses supporting the effectiveness of several treatments for depression in cancer patients, few if any theory and equity-informed, multi-level implementation trials exist. There is an urgent need for hybrid III effectiveness-implementation psycho-oncology trials. We propose to test a strategy for efficiently and sustainably delivering complex treatment algorithms/ guidelines, facilitating efficient communication/triage/referral processes for oncology teams within existing mental health infrastructures, and increasing the proportion of patients who receive evidence-based treatment. Informed by the Consolidated Framework for Implementation Research (CFIR) 2.0, implementation mapping and user-centered design principles we arrived at iCan DepCare centered around a digital psychoeducation- activation tool (completed in clinic, infusion sites or home) with treatment selection support (e.g., urgency/ severity/preference based recommendations for SW/financial counseling, individual/group therapy, medication, exercise OR watchful waiting with linkage to adjunctive pain/mood/exercise apps/resources) and technical assistance with education/feedback of tool results for oncology/mental health teams to address contextual barriers to treatment uptake and move clinics along the behavioral integration continuum. Feasibility is supported by usability testing and a pilot RCT of a prototype; focus groups with racial/ethnic minority cancer patients/oncology teams; a feasibility study; and vast experience delivering TA, all demonstrating a signal for usability, effectiveness, and integration into clinical workflows (e.g., leveraging existing screening/treatment). We propose to use conjoint analyses to refine our strategy before conducting a clinic-level cluster randomized trial, informed by the equity and sustainability enhanced REAIM framework, to test the effect of iCan DepCare (vs. usual care) on treatment optimization, implementation indices, and costs in 18 prostate, lung, gastrointestinal and breast cancer clinics in community and academic settings serving socioeconomically diverse patients (n=1900 patients with moderate-severe depressive symptoms).