Text message system could reduce ‘time toxicity’ of cancer care
Key takeaways:
- Patients with normal labs and no treatment-related symptoms could bypass an in-patient visit and proceed to immunotherapy.
- Patients who used the text-based system saved more than 60 minutes per visit.
A text message-based electronic triage system showed efficacy for collecting patient-reported treatment outcomes and minimizing the time burden of cancer care, according to results of a pilot study.
The intervention — based on TSA PreCheck, which offers expedited airport security to prescreened travelers — reduced total time per ambulatory encounter by more than an hour and shortened wait time by 30 minutes.
The issue of “time toxicity” — defined as time spent traveling to, waiting for and receiving cancer care — has gained increased attention in oncology.
“Time toxicity is relevant across all settings in medicine, but it’s particularly relevant in patients with advanced cancer because they have limited life expectancy,” Ronac Mamtani, MD, MSCE, senior author and section chief of genitourinary cancers at Penn Medicine, told Healio.
‘Skip the doc’
Mamtani developed the text message-based platform with lead author Erin M. Bange, MD, MCSE, a former Penn oncology fellow now on the faculty at Memorial Sloan Kettering Cancer Center, and other researchers at University of Pennsylvania.
“This is an example of an innovative approach that provides one small way to give a patient choice over how their health care delivery might look,” Bange said. “We hope this will inspire ongoing research into these types of interventions.”
They were inspired by Bange’s previous research.
“Dr. Bange’s study found that among patients with pancreatic cancer, 10% of their remaining time alive was spent engaging with the health care system and having physical days in contact with the clinic,” Mamtani said. “That’s 10% of their precious time, and that really struck us.”
When traveling to a conference, Bange and Mamtani noticed the efficiency and time-saving benefits of TSA PreCheck.
“The entire success behind TSA PreCheck is its focus on prescreening passengers,” Mamtani said. “We thought, ‘Why couldn’t we do the same thing?’ We could screen patients for symptoms of treatment-related side effects and leverage that information to triage them. If symptoms are present, they go to their doctors. If symptoms are absent, they can skip the line — or in this case, skip the doc.”
Methods
Mamtani and colleagues conducted an unblinded randomized trial to assess the effectiveness and implementation of the platform vs. usual care among adults with solid tumors treated with single-agent immune checkpoint inhibitors.
They enrolled 40 patients (median age, 67.5 years; interquartile range, 59.5-71.5 years; 80% men; 84.6% white) at Penn Medicine’s Abramson Cancer Center.
The researchers randomly assigned 21 patients to an in-person preinfusion symptom assessment with their provider. Investigators assigned the remaining 19 patients to the text message-based platform, consisting of a 16-question symptom check along with routine laboratory testing.
Patients in the intervention group with normal bloodwork and no reported symptoms were given a “fast-track” option to skip the in-person visit and proceed directly to immunotherapy infusion.
Follow-up continued for 3 months or three visits.
Total time per ambulatory encounter served as the primary endpoint. Secondary endpoints included wait time, emergency department or hospital visits, quality of life and patient satisfaction.
Results
The analysis included 31 patients (intervention, n = 16; usual care, n = 15).
Patients in the e-triage group spent an average of 66 minutes (95% CI, –123.7 to –8.08) less total time per encounter and 30.1 minutes (95% CI, –60.9 to 1.1) less waiting than those in the usual care group. Other outcomes were similar between groups.
“Prior to the study, we interviewed patients and asked them what would be important to them in an intervention like this,” Mamtani told Healio. “They said if they could decrease their time by 45 minutes, that would positively impact their quality of life.
“This exceeded our expectations, and we also found it was safe — it didn’t increase the proportion of patients admitted to the hospital or emergency department. It also didn’t impact health-related quality of life, so we were thrilled.”
In a sequential mixed-methods study assessing the implementation readiness of the system, 17 surveyed oncologists reported that it was acceptable, appropriate and feasible. However, they specified perceived barriers to uptake, including challenges in patient identification and the potential for underreporting of drug toxicity.
“They were concerned about overlooking symptoms that the text message system couldn’t capture, and they were worried about impacts on reimbursement,” Mamtani said. “They all said they would’ve loved to have actually been more involved in identifying the appropriate patients for the triage system.”
‘The human touch can be irreplaceable’
Mamtani said his team plans to continue to assess how this intervention could be optimized to meet the needs of all patients with cancer. They ultimately plan to evaluate the approach in a real-world, pragmatic trial rather than a conventional clinical trial.
He also emphasized that, for some patients, time with their physicians is valuable and not something they necessarily want to bypass.
“At the end of the day, the human touch can be irreplaceable, so some patients wanted to see their doctor, and some physicians wanted to see their patient,” Mamtani said. “We have to figure out how to find the right patients for this protocol. I believe once we do that, we’ll be ready for prime time.”
For more information:
Ronac Mamtani, MD, MSCE, can be reached at ronac.mamtani@pennmedicine.upenn.edu.
Collapse
