Daily remote outcome assessments may improve symptom management during cancer treatment
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Daily electronic patient-reported outcome assessments may provide valuable insight into symptom management among patients with cancer undergoing antineoplastic treatment, according to a study published in JAMA Network Open.
Additionally, symptom alerts the assessments generated appeared associated with risk for acute care.
“The optimal cadence or ‘dosage’ of ePROs [electronic patient-reported outcomes] is an open question in cancer care. However, the cadence will likely vary based on the cohort of patients and where they are in their treatment trajectory,” Bobby Daly, MD, MBA, assistant attending medical oncologist in the department of medicine, thoracic oncology service, at Memorial Sloan Kettering Cancer Center, told Healio. “[These results indicate] there is potential value in a daily ePRO in identifying rapidly developing symptoms that require prompt management.”
Background and methodology
Researchers have grappled with the question of optimal cadence as they seek to apply ePROs to different populations of patients with cancer, Daly said. In the current study, they evaluated daily cadence of ePRO symptom assessments among a high-risk cohort of patients initiating IV antineoplastic therapy, using ePROs developed to manage cancer therapy-related symptoms.
“From a clinical perspective, we hypothesized that a daily cadence would allow us to provide better care for this patient cohort given their high symptom burden and risk for requiring acute care,” Daly said.
The analysis included ePRO data of 217 adults (median age, 66 years; range, 31-92; 52.5% men) submitted between Oct. 16, 2018, and Feb. 29, 2020, from a single regional site within the Memorial Sloan Kettering Cancer network. The most common malignant neoplasms among patients included thoracic (27.2%), head and neck (22.1%) and gastrointestinal (19.8%).
Patience response rate, symptom alert frequency and analysis of clinical value of daily ePROs served as the primary outcomes.
Key findings
Daly and colleagues monitored patients for a median of 91 days (range, 2-369).
Of the 14,603 unique symptom assessments completed, 7,349 (50.3%) generated red (severe) or yellow (moderate) symptom alerts to clinicians. Symptoms commonly generating alerts included pain (665 assessments; 23%) and functional status (465 assessments; 16.1%).
Additionally, researchers reported that patients completed most assessments (8,438 assessments; 57.8%) at home during regular clinic hours (9 a.m. to 5 p.m.), with higher response rates on weekdays (58.4%; 95% CI, 57.5-59.5) vs. weekend days (51.3%; 95% CI, 49.5-53.1).
Daly said it was “thought provoking” that 284 of 630 unique red alerts (45.1%) emerged without a prior yellow alert for the same symptom during the previous 7 days. Symptom severity fluctuated over the course of a week, and symptom assessments that produced red alerts led to acute care visits within 7 days more often that assessments that did not produce red alerts (8.7% vs. 2.9%).
“This would lead me to want to better understand how we could use data from ePROs in predictive analytics to better understand at-risk periods for patients, how to optimally notify clinical teams of these at-risk periods, and the interventions that could be employed to help keep them at home and out of the acute care setting,” Daly said.
Implications
Kevin Nicholas, MPA, data scientist in the strategy and innovation department at Memorial Sloan Kettering Cancer Center and a co-author of the study, noted that the robust ePRO submission rates over a long period — including among a subset of patients who remained enrolled after a year — surprised researchers.
“We expected patients and their caregivers to be motivated to complete the assessments,” Nicholas told Healio. “However, completion of the ePROs was strictly voluntary, so it was a pleasant surprise to see that patients were actively surfacing information to the care team and, for the most part, doing so consistently throughout their entire enrollment period.”
Daly said he is interested in better understanding how such remote monitoring programs affect other outcomes, such as ED visits, inpatient admissions and resource utilization. He is also interested in further research into how biometric devices (such as smart watches and pulse oximeters) can be paired with ePROs to improve at-home monitoring of patients with cancer and their outcomes.
“How do we best incorporate remote monitoring into clinical workflows, and how can this type of monitoring be supported by current health care policy?” Daly said.
Future directions
In an accompanying editorial, Gabrielle B. Rocque, MD, MSPH, associate professor of medicine in the divisions of hematology and oncology and gerontology, geriatrics and palliative care at The University of Alabama at Birmingham, said the study “scratches the surface of what will be needed scientifically for broad uptake of ePRO.”
“This evidence-based intervention is uniquely poised for rigorous evaluation using the principles of implementation science, given the complexity and multilevel nature of the intervention,” Rocque wrote. “Hopefully, future analysis of the program assessed by Daly and colleagues, and others will allow the oncology community to collectively learn, avoiding duplication of unsuccessful implementation strategies, to ultimately unlock the potential of home-based symptom monitoring.”
References:
Daly B, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.1078.
Rocque GB. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.1090.
For more information:
Bobby Daly, MD, MBA, can be reached at Memorial Sloan Kettering Cancer Center, 530 E. 74th St., New York, NY 10021; email: dalyr1@mskcc.org.
Kevin Nicholas, MPA, can be reached at Memorial Sloan Kettering Cancer Center, Strategy and Innovation Department, 530 E. 74th St., New York, NY 10021; email: nicholak@mskcc.org.
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