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A digital symptom monitoring system that allowed patients undergoing cancer treatment to report symptoms from home led to better symptom control, physical function, and quality of life, according to new research.

The study highlights that “digital symptom monitoring with patient-reported outcomes is feasible, improves clinical outcomes, lipitor and muscle problems and is valued by patients and clinicians during routine cancer care,” said lead author Ethan Basch, MD, FASCO, from the University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill. “It catches patient symptoms early, enabling clinicians to intervene and prevent downstream complications.”

The findings were presented virtually during the inaugural session of the American Society of Clinical Oncology (ASCO) Plenary Series.

Symptoms are common among patients undergoing cancer treatment but go undetected by clinicians up to 50% of the time. There are reasons why symptom reporting remains so challenging, Basch explained.

“If we consider the usual approach to symptom monitoring — a patient may have symptoms that need to be communicated, but when coming in for an appointment, there are hurdles that include limited time, competing topics, and patients and clinicians simply forgetting to bring up symptoms,” he said. “And when patients are home, they may be reluctant to contact their care team until symptoms become severe. [All of this] prevents the information from being communicated.”

Given these hurdles, there has been growing interest in integrating electronic patient-reported outcomes (PROs) into routine oncology practice to monitor symptoms. The idea is to detect symptoms early so clinicians can intervene, alleviate suffering, and avert complications.

However, evidence demonstrating clinical benefit of electronic symptom monitoring tools has been limited. A 2017 study that Basch and colleagues conducted at a single tertiary care medical center assessed whether electronic patient-reported symptom monitoring improved overall survival for patients with metastatic cancer in comparison with usual care. Although the researchers found an overall survival benefit for the PRO group, the study was limited in scope.

The current study expands on this initial research on both the endpoint and patient population fronts. The investigators evaluated not only overall survival but also key secondary endpoints, including satisfaction with digital monitoring, effects on physical function, health-related quality of life, and symptom control. The study included 52 US-based community oncology practices, which were randomly assigned in a 1:1 ratio to digital symptom monitoring with PRO surveys or to usual-care control. The cohort included 1191 patients, with 593 patients at PRO practices and 598 patients at control practices.

Patients at the PRO practices completed a weekly survey either online or using an automated telephone system for up to 1 year. The survey included questions pertaining to nine common symptoms, performance status, and falls.

If patients reported severe or worsening symptoms, electronic alerts were triggered, and the patients were directed to care team nurses. Reports that tracked symptom data over time were available to oncologists during in-person or telehealth visits.

“A computer system can trigger reminders for patients by email or text to report their symptoms in real time,” said Basch. “This approach can enhance the connection between patients and clinicians.”

Although data regarding the primary endpoint of overall survival were “not yet mature,” Basch and colleagues found significant improvements in the secondary measures. As compared to those being treated at control practices, almost 14% more patients at PRO practices reported clinically meaningful benefits in physical function; 16% more reported better symptom control — including control of nausea/vomiting, pain, dyspnea, constipation, diarrhea, insomnia, appetite loss, fatigue; and 13.4% more reported improvements in health-related quality of life.

Patients completed over 91% of expected surveys. Of these, 34% generated alerts, most commonly for severe or worsening symptoms of pain, diarrhea, dyspnea, and/or nausea. Nurses responded to notifications related to severe or worsening symptoms 59% of the time. The responses generally involved calling the patients on the telephone to counsel them on symptom management, add medications for symptom relief, or set up new appointments.

“These results suggest a relatively simple approach to improving how we care for patients with advanced cancer receiving treatment and a range of future applications to further improve how oncologic care is delivered,” commented Robert Dreicer, MD, MACP, FASCO, deputy director of the University of Virginia Cancer Center, Charlottesville, who was not involved in the analysis.

The Right Endpoints

Commenting on the paper during the ASCO presentation, Debra A. Patt, FASCO, MD, PhD, MBA, executive vice president of Texas Oncology in Austin, noted that the main goals of cancer care aren’t just to make patients live longer but also to live better.

“Supportive care offerings can be variable and, when left untended, greatly alter quality of life for patients,” said Patt, who was not involved in the analysis. “We know that by identifying symptoms earlier, it is amenable to a more rapid intervention.”

Patt pointed out that one strength of the study is that it focused on the right endpoints — patient function, health-related quality of life, and symptom control. “One might say that we should wait for overall survival, but in my mind, the important endpoints are being discussed today,” she said. “Even if it comes to pass that there is not a survival benefit between the interventions, patients living better with chronic cancer matters.”

Patt also pointed to several open-ended questions and limitations. First, the study was conducted during the COVID pandemic, which “could muddy the waters a little bit,” she noted.

Second, Patt questioned whether digital innovations like electronic PROs will be able to close gaps in access to care, be readily implemented and optimized for patients, and be reimbursed by government payers and private insurance.

The Centers for Medicare & Medicaid Services is considering incorporating symptom-monitoring tools into regular clinical practice in an oncology payment model. But while symptom management has been a clinical priority, it doesn’t necessarily correlate with payment policy in the US.

“Failing to reimburse electronic PRO limits staffing and care delivery planning architecture to implement these solutions more broadly,” Patt said.

The study was supported by the Alliance Foundation Trials, LLC. Basch has disclosed the following: consulting or advisory role ― AstraZeneca; Carevive Systems; Navigating Cancer; SIVAN Innovation; other relationship ― American Society of Clinical Oncology; Centers for Medicare & Medicaid Services; Journal of the American Medical Association; National Cancer Institute; Patient-Centered Outcomes Research Institute. Patt has disclosed the following: consulting or advisory role ― Amgen; AstraZeneca; Pfizer; Roche; research funding ― Eisai (inst); Lilly (inst); Merck (inst); Seattle Genetics (inst).

American Society of Clinical Oncology (ASCO) Plenary Series. Abstract 349527.

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