Integrated Psychosocial Care Plan for Comorbid Depression in Breast Cancer Patients in Low Resources Settings

Background and Research Question Worldwide breast cancer the leading cause of death in females and affects 2.1 women annually. Annual mortality rates are double within south Asian women compared to high-income countries. Co-morbid depression and anxiety is reported in more than one third of breast-cancer survivors and predict higher recurrence and poorer survival among these women. Pakistan has one of the highest rates of breast cancer within South Asia. There is a significant delay in first contact with health professionals due poor health literacy, stigma, taboos in seeking care for breast health and denial among women and families. Global Breast Cancer Initiative calls for an integrated psychosocial and physical care plan within health systems especially within low resource settings. There is equipoise as to which integrated psychological interventions are most effective and scalable for breast cancer survivors in low-income settings to address co-morbid mental health conditions among this population. Aim & Objectives: We develop and evaluate the effectiveness and implementation of culturally adapted integrated psychosocial care for depressed breast-cancer survivors across low-resource settings. Methods and timeline: Research plan consist of seven overlapping workstreams (WS). Using a three-phase Sequential, Multiple Assignment, Randomized Trial (SMART) cluster randomised trial in Pakistan based across health facilities, we evaluate both the clinical and cost-effectiveness of an integrated psychosocial care plan delivering a suite of scalable interventions non-specialist delivered interventions. These being a low intensity guided self-help, a cognitive behaviour-based Moving on ABC Plus, and moving on ABC Plus with adjuvant antidepressants. Primary outcome will be depression remission at 48 weeks, measured by Hamilton Depression Rating Scale. Outcomes assessed at baseline, weeks 6,18,30, and 48 post enrolment (0-60 months) Embedded alongside will be the development of an implementation plan for future scale-up of the evidence-based approach (0-60 months). Prevention and early identification of breast cancer will be achieved using community and social media campaigns ( 0-60 months). In order to inform policy and practice, working with policy makers and other stakeholders for policy implementation (0-60 months). To build research and clinical capacity in Pakistan and other South Asian countries: Six PhD and10 MPhil students along with training for large number of early career researchers will be trained in implementation research and , psychosocial care planning for depression and breast cancer (4-60 months) Develop a breast cancer registry, based on WHO guidance, for Sind province (0-60 months). Anticipated Impact and Dissemination The clinical, policy, and scholarly outputs will support the expansion and upscaling of breast cancer care and training programmes across Pakistan and partner countries. The collaborative workshops with key stakeholders in each partner country (WS5) will lead to the development of low-cost interventions (available as patient and carer manuals, in booklet and digital format) and a train-the-trainer programme for healthcare professionals, strengthening research and clinical expertise. A significant reduction in depression associated with breast cancer is aimed along with wide dissemination of findings via key international conferences, and publishing in high impact peer-reviewed journals.