Ethan M. Basch, MD, MSc, FASCO
Patients receiving treatment for metastatic cancer who used a web-based tool to report their symptoms either while at home or during clinic visits lived on average 5 months longer than their counterparts who had standard symptom monitoring, according to findings of a randomized trial reported at the 2017 ASCO Annual Meeting and published simultaneously online in JAMA
Those who used the tool also were able to stay on their chemotherapy longer, had fewer visits to the emergency department (ED), and experienced better quality of life and physical function, reported lead author Ethan M. Basch, MD, MSc, FASCO, at an ASCO press conference June 4.
“Compared to standard care, patients who self-reported symptoms experienced multiple, statistically significant, clinical benefits,” said Basch, MD, MSc, FASCO, professor of medicine at the Lineberger Comprehensive Cancer Center of the University of North Carolina, who was practicing at Memorial Sloan Kettering Cancer Center (MSK) when the study was conducted.
Providing a rationale for the study, Basch said that between visits, patients are often hesitant to call the office, until problems become severe. Even at clinic visits, with many competing topics and limited time, symptoms are often not fully communicated between patients and their doctors and nurses.
“We hypothesized that having patients report their own symptoms—using an online system with the information conveyed to their clinicians—would prompt clinicians to intervene earlier, therefore, improving symptom control and downstream outcomes.”
The trial enrolled 766 patients between September 2007 and January 2011 who were being treated with chemotherapy for metastatic solid tumors (breast, lung, genitourinary, or gynecologic) at MSK. Patients in the intervention arm reported on 12 common symptoms, including appetite loss, dyspnea, fatigue, hot flashes, nausea, and pain, and were asked to grade each on a 5-point grading scale based on the Common Terminology Criteria for Adverse Events. Each symptom could be reported either as “none,” or graded from 1 (mild) to 4 (disabling). Short descriptions were included alongside each of the choices to help patients accurately rate their symptoms.
Participants in the self-report intervention arm (n = 441) completed online questionnaires in 1 of 2 ways. They could respond at home between visits, which generated an automated e-mail alert to nurses any time a severe or worsening symptom was reported by the patient; weekly e-mails were sent to participants reminding them to complete the questionnaire. Patients also could complete the symptom survey at terminals in the waiting room before their clinic visit for immediate dispatch to their oncology team prior to the appointment.
Usual care control participants (n = 325) discussed symptoms during clinic visits and were encouraged to telephone the office between visits if any worrying symptoms arose.
Thirty-one percent of patients who self-reported their symptoms using the web tool had better quality of life and physical function compared with those receiving standard care. Basch noted that, interestingly, patients who were not especially computer-savvy experienced the greatest quality-of-life benefit with this approach. Additionally, investigators reported a 7% reduction in ED visits, and patients were able to remain on potentially life-prolonging chemotherapy for an average of 2 months longer.
Among the most notable study findings, however, according to Basch, is the 5-month increase in median overall survival (OS). Median OS for patients in the self-reporting arm was 31.2 months versus 26.0 months in the standard care cohort (P = .03), which, he said, equated to an almost 20% increase in survival time for these patients. Looking at this finding in the context of 5-year survival, he added, “At 5 years, 8% more patients were alive in the self-reporting group,” (41% vs 33%, respectively).
Basch posited 3 potential drivers to explain the success of the intervention. One obvious benefit is that the system enables better management of chemotherapy adverse effects, which allows patients to stay on their treatment longer. The system also yielded more responsive care, he said, “by alerting clinicians in real time about symptoms as they emerged, prompting them to take early action and manage problems before they became complications.”
Finally, Basch said, “By controlling symptoms better, this system kept patients more physically functional and kept them from becoming deconditioned or immobile, which we know from multiple prior studies has a strong association with better survival.”
The findings are being confirmed in a larger clinical trial being conducted in community practices across the United States, using an updated, more user-friendly online tool that works on both personal computers and mobile devices to make it even easier for patients to communicate with their care team. Basch said the focus now is on how best to integrate these tools into oncology practice and that researchers are building similar ones to enhance understanding of symptoms of patients participating in drug development trials.
ASCO expert Harold J. Burstein, MD, PhD, FASCO, remarked on the significance of the trial, which was chosen to be part of an ASCO plenary session because of its strong potential to influence and improve patient care: “If this were a drug that had a survival advantage of this magnitude, it would be retail priced at hundreds of thousands of dollars.”
“We don’t have the kind of resources typically to invest in this kind of electronic communication, nursing care, and other things that made this a reality for these investigators,” Burstein continued. “A big challenge for our clinicians is going to be: How do we implement such systems, how do we integrate them into electronic health recordkeeping we are currently using, and how do we provide the medical team power in the way of doctors, nurses, and other supportive providers to make this work?”
Still, he said, “That’s a good challenge and a good problem to have. I know that as these data have been circulated, it has been immensely gratifying to the oncology community to see that the kind of things we really believe in—patient-focused care, paying attention to their symptoms, and intervening early—is really helping these patients to consume fewer healthcare resources in terms of ER visits, feel better, and now—we have proof—helping them to live longer.”
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- Basch EM, Deal AM, Dueck AC, et al. Overall survival results of a randomized trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. J Clin Oncol. 2017;35(suppl; abstr LBA2).
- Basch EM, Deal AM, Dueck AC, et al. Overall survival results of a randomized trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment [published online first June 4, 2017]. JAMA. doi:10.1001/jama.2017.7156.