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Online symptom reporting may help patients with cancer live longer
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CHICAGO — Patients with metastatic cancer who used a web-based tool to regularly report symptoms while receiving chemotherapy reported a higher quality of life, had fewer emergency room visits and lived a median of 5 months longer than those who did not use the tool, according to a randomized clinical trial presented during the plenary session of the ASCO Annual Meeting.
The intervention — which enables patients to report symptoms in real time and trigger alerts to clinicians — can have major benefits for patients, according to researchers.
“This is a very simple tool that is going to be familiar to many people who already are accustomed to using all kinds of online means of communication,” Ethan M. Basch, MD, MSc, FASCO, professor of medicine at Lineberger Comprehensive Cancer Center at University of North Carolina, told HemOnc Today. “This is an opportunity for us as oncologists to integrate this kind of tool — ubiquitous in other sectors — into the way we practice to better engage our patients and improve communication. And, as it turns out, it improves clinical outcomes as well.”
From 2007 to 2011, Basch and colleagues enrolled 766 patients (median age, 61 years; 86% white; 58% women; 22% with less than a high school education) with advanced solid tumors who were receiving outpatient chemotherapy. Cancer types included genitourinary (32%), gynecologic (23%), breast (19%) and lung (26%).
Researchers randomly assigned patients to an intervention group that reported symptoms via tablet computers, or to a usual-care group whose symptoms were monitored and documented by clinicians. Patients in the usual-care group discussed symptoms during visits with oncologists and were encouraged to telephone the office between visits if any concerning symptoms arose.
On a weekly basis, patients in the intervention group reported on 12 common symptoms experienced during chemotherapy — including appetite loss, difficulty breathing, fatigue, hot flashes, nausea and pain — and graded them on a 5-point scale. Researchers developed the web-based tool, Symptom Tracking and Reporting (STAR), for research purposes, and it is not commercially available.
“Symptoms such as nausea, pain and fatigue are common among patients with metastatic cancer but, unfortunately, they often go undetected by doctors and nurses until they become severe and physically debilitating,” Basch said. “This is because, between visits, patients are often hesitant to call the office until problems become severe. We hypothesized that having patients record their own symptoms using an online system, with this information conveyed to their clinicians, would prompt those clinicians to intervene earlier and improve symptom control and downstream health outcomes.”
Patients could report the symptoms remotely from home or at the doctor’s office during oncology or chemotherapy visits, using tablet computers or computer kiosks. Doctors received symptom reports during visits, and nurses received email alerts when patients reported severe or worsening symptoms.
All patients in the intervention group, including those with little prior experience using the Internet, were willing and able to regularly report their symptoms via the web throughout chemotherapy. Nurses took immediate clinical actions more than 75% of the time when patients reported severe or worsening symptoms.
Compared with patients who received usual care, patients who used the web tool to self-report symptoms had longer median OS (31.2 months vs. 26 months). In the multivariable model, these results remained statistically significant (HR = 0.83; 95% CI, 0.69-0.99).
“We know from prior research that, unfortunately, we as clinicians are unaware of up to half of our patients’ symptoms,” said Basch, who was practicing at Memorial Sloan Kettering Cancer Center when the study was conducted. “It was not initially surprising that engaging patients to self-report their symptoms and sending alerts to providers to make our teams more aware would improve symptom control and even quality of life. In fact, we saw that 31% of patients had better quality of life.
“What was more surprising was that emergency room visits were reduced by 7%, probably because we were catching things early, before they became problems, and it was surprising they were able to stay on chemotherapy an average of 2 months longer, probably because we were controlling symptoms,” Basch added. “But, ultimately, what was most surprising was the OS benefit, simply because patients were self-reporting their symptoms and we knew about it.”
Researchers’ findings are being confirmed in a larger clinical trial, which uses an updated, more user-friendly online tool that works on both personal computers and mobile devices. The study is being conducted in community practices across the United States.
“As oncologists, we all feel we could communicate better,” Basch said. “We’re nostalgic for the days of being community doctors, when we could go to patients’ homes and know their families. All of these barriers have been constructed that keep us separated from our patients, and this intervention allows us to get a little closer.” – by Chuck Gormley
References:
Basch EM, et al. Abstract LBA2. Presented at: ASCO Annual Meeting; June 2-6, 2017; Chicago.
Disclosures: The Conquer Cancer Foundation of ASCO funded this study. Researchers reported no relevant financial disclosures.
Perspective
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Harold J. Burstein, MD, PhD, FASCO
This is an exciting and compelling study because it shows that caring for patients improves patient care and validates something we all feel but rarely have evidence for, which is that patient-focused, team-based medical care can improve outcomes in measurable and meaningful ways for our patients.
On a daily basis, we all face challenges. How do we communicate with our medical team? How do we communicate with patients? Many of us still carry beepers, which were very cutting edge in the 1970s, and we have struggled to integrate some of the newer communication platforms that are widespread — how all of us communicate with friends, colleagues and family — into active medical care. This study represented an opportunity to look at what such an intervention might do and measure whether it would have an impact. In my mind, it is remarkable that a relatively simple intervention that allows us to meet patients where they are and allows them to communicate with us without the traditional barriers of having to call an office, can reduce ER visits, improve quality of life and, incredibly, actually improve OS.
If this was a new drug — if this was “Ipad-ilizumab” or “Google-itinib” — we would be asking two very powerful questions: How do we implement this into our practice, and what is the mechanism of action? This is an area we would really like to understand better. Is it because we truly have lowered the threshold that might keep people from communicating? Is it because we have more timely interventions to alleviate symptoms or prevent problems? Is it because we better supported people and allowed them to get more effective therapies, or perhaps allowed them to say no to therapies they think might not be so good for them?
These are very important questions and we need to make this more accessible and more mobile for people. If this were a drug that had a survival advantage of this magnitude, it would be retail priced at hundreds of thousands of dollars. There are very few drugs that have long-standing survival benefits. Typically, we do not have the kind of resources to invest in the electronic communication, nursing care and the other things that make this a reality on a day-to-day basis for these investigators.
A big challenge for our clinicians is going to be how we implement such systems. How do we integrate them into the electronic health record keeping we are currently using? And, how do we provide the medical team power to make this work? But that’s a good problem to have, and I know as these data have circulated, it has been immensely gratifying to the oncology community to imagine the kinds of things we really believe in — patient-focused care, paying attention to symptoms and intervening early — are helping these people have fewer ER visits and allowing them to feel better. Now we have proof that it helps them living longer.
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