Ethan Basch, MD, MSc from the Lineberger Comprehensive Cancer Center, University of North Carolina speaks about the Benefits of Digital Symptom Monitoring With Patient-Reported Outcomes During Adjuvant Cancer Treatment.
Link to Article:
https://ascopubs.org/doi/full/10.1200/JCO.20.03375
In prospective randomized trials and population studies, digital symptom tracking through electronic patient-reported outcomes (PROs) has been shown to improve outcomes for adults with metastatic cancer undergoing systemic care, including symptom management, quality of life, emergency department visits, time on treatment, and survival. 1–8 This technique allows care teams to intervene early and avoid preventable downstream complications by detecting symptoms early. 9 It is well known that up to half of a patient’s symptoms go unnoticed by clinicians, and digital surveillance helps to close this gap. 10-12
Best practices for digital monitoring include loading a short questionnaire of common actionable symptoms (ie, 10-15 items) into software and allowing patients to self-report through a variety of modes, such as the Web, mobile, or automated telephone interface. The software may be used in combination with an electronic medical record platform or on its own. With the inclusion of personalized items unique to a cancer type or treatment, a physical function item (ie, performance status), and an open-ended free-text box, a core group of crosscutting symptoms reflecting common cancer symptoms and adverse treatment sequelae13 may be included. 14
Patients can complete questionnaires at clinic visits using computer kiosks or tablets, or at home using their own devices between visits (prompted by regularly scheduled text, e-mail, or phone reminders). If patients fail to complete a scheduled self-report, an electronic alert may be sent to them, preferably accompanied by a phone call from clinic staff. When a patient has a worsening or serious symptom, an electronic warning is sent to the care team (usually a nurse or care coordinator) to alert them to possible action, and self-care advice may be sent to the patient immediately. Patients’ full descriptions of symptoms should be accepted or checked by the care team during appointments so that they understand that their self-reported information is an important aspect of their care. Patients and clinic workers must be qualified and coached in order to achieve appropriate commitment and compliance when adhering to quality assurance and implementation science concepts.
To date, the majority of evidence of the effects of digital symptom tracking has come from patients undergoing treatment for metastatic cancer. There has been no research on the effect of adjuvant therapy on patients with curable diseases. Patients who undergo adjuvant therapy differ from those who have metastatic cancer in that they usually have a low disease burden and few baseline cancer symptoms, and they have not previously undergone toxic cancer treatment. As a result, they begin with a higher level of performance and reserve than those with metastatic cancer. Furthermore, adjuvant therapy is time-limited, while metastatic cancer care is often limitless. As a result, it’s unclear if digital monitoring will be as effective in the adjuvant setting as it is in the metastatic setting.
Absolom et al15 address this evidence discrepancy in the article that follows this editorial, making a substantial contribution to the digital monitoring literature. The authors randomly allocated 508 patients to receive either standard care or automated symptom monitoring, with the majority of patients (69.4%) receiving adjuvant treatment with the goal of cure. Patients that used remote monitoring saw advantages as compared to normal care; statistically relevant quality-of-life benefits (specifically, physical well-being) were seen at 6 and 12 weeks, but not at the primary end point of 18 weeks.
Given the large number of trial participants who received time-limited adjuvant treatment, this trend of quality-of-life results is not unexpected. Patients undergoing adjuvant therapy with the intention of curing their cancer experience side effects during treatment, which subside until supportive measures are in place or therapy is done. As a result, this study backs up the idea that digital symptom tracking is beneficial during the active phase of adjuvant therapy.
Patients in the symptom tracking community of this trial used a framework that included several best practice elements, such as weekly reminders through e-mail or text to log in from home and notifications to the care team for serious symptoms. It’s unclear if patients and clinic employees were supervised and coached on a regular basis to maintain commitment and compliance. On average, 64.6 percent of patients checked in at the scheduled times, but by week 18, that number had fallen to 58.1 percent. Because of the low patient compliance, it’s possible that there wasn’t enough patient commitment to enable self-reporting. Patients undergoing adjuvant therapy may also be less likely to self-report as their care progresses. A alert electronic prompt within 24 hours for nonreporting, accompanied by a telephone call reminder by clinic staff 24 hours later, is a best practice technique for encouraging patient enforcement that should be included in future reviews of this method.
In this study, extreme patient-reported symptom magnitude or multiple mild symptoms caused e-mail alerts to the care team. It’s also a good idea to provide warnings for worsening symptoms, as research shows that worsening rather than absolute thresholds are the most actionable concerns. A warning algorithm that does not take this approach, for example, will miss potentially actionable worsening of symptoms from none to moderate.
Unlike previous research, no decrease in hospital admissions was observed. This result is most likely due to the large number of participants in this trial who received adjuvant therapy. While avoidable hospitalizations are common in patients with metastatic cancer, they are less common in adjuvant patients.
In conclusion, the authors should be commended for undertaking this study, which contributes to the growing body of evidence demonstrating the clinical benefits of digital symptom tracking in oncology. Many of the foundational published research incorporating PROs into standard cancer treatment has come from their research community. There is now evidence that those undergoing adjuvant therapy benefit from digital monitoring, at least during the active phase of treatment. Long-term periodic surveillance in this population can be useful for detecting late toxicities, which requires further investigation. Digital tracking with PROs is an important tool for constantly engaging and assuring patients’ wellbeing, and it should become a pillar of oncology community health management.