Project Summary/Abstract Individuals with cancer who live in rural settings experience worse outcomes as compared to those in urban settings. Individuals in rural regions have difficulty accessing supportive care services due to travel challenges, cost of services, and overall lack of available supportive care resources. The latter issue likely contributes greatly to the urban/rural survival differences, given that multiple studies document that regularly addressing patient symptoms has a survival benefit in the setting of advanced cancer. Technology may provide solutions to overcome issues of rurality, however, little work has been done to specifically leverage technology- based solutions to deliver high quality supportive care in rural settings. Our team has developed and pilot tested a tablet-based symptom assessment and supportive care intervention called Nurse AMIE (Addressing Metastatic Individuals Everyday) that was well received by patients with metastatic cancer, including a subset of rural patients living in non-metropolitan counties (Rural Urban Continuum Code (RUCC) counties of 4 or higher). Patients were provided a tablet and cellular data plan to allow them to answer symptom questions daily, and an embedded personalized decision tree then offered evidence based self-care interventions to address the self-reported symptom with a goal of improving overall health and well-being. A pedometer and resistance band were also provided, given evidence that physical activity can assist with all four of the symptoms addressed in Nurse AMIE (fatigue, sleep, distress, and pain). These four symptoms form the basis of the psychoneurological symptom cluster that has been noted to be associated with quality of life and survival in oncology patients. Nurse AMIE can conduct symptom assessment, track data, and provide interventions offline if internet access is unavailable. Our preliminary evidence demonstrates acceptability and feasibility of the tablet-based approach as our patients logged on 57% of intervention days. Furthermore, patients using Nurse AMIE reported high patient satisfaction with the self-care system. Based on findings from the pilot, we propose to add a weekly survey similar to that from prior research by Basch et al. and Denis et al. to expand the symptom assessment aspect of the platform. We propose that this distance based supportive care intervention (Nurse AMIE) will have significant effects on rural patients overall survival (primary outcome), cancer treatment-related symptoms, function, and health related quality of life. We will focus our efforts on N=344 underserved or low-income adult men and women living in non-metropolitan counties (RUCC codes 4- 9) that have low access to supportive care. This work will be carried out with the help of a strong community advisory board, and guided by the PA and WV State Offices of Rural Health. We will enroll and randomize patients to receive the Nurse AMIE supportive care intervention or usual care. Enrollment will occur at regularly scheduled medical visits and the intervention will extend for the length of follow-up (2 years). We will also examine the cost effectiveness of Nurse AMIE.

Nurse AMIE Project Narrative Rural patients with metastatic cancer are less likely to have access to high quality supportive care. This may have a negative effect on survival and well-being. We will conduct a randomized controlled trial to assess the survival benefits of a high quality technology based supportive care platform among 344 underserved, low income patients with metastatic cancer living in rural Pennsylvania or West Virginia.