Web-Based Patient Reporting of Symptoms Shown to Improve Survival in Patients With Metastatic Solid Tumors

PATIENTS RECEIVING ROUTINE

outpatient chemotherapy for metastatic solid tumors who self-reported 12 common symptoms via tablet computers experienced an overall survival (OS) benefit over those who received usual care. This outcome was reported at a plenary session at the 2017 American Society of Clinical Oncology (ASCO) Annual Meeting.¹

In 2016, Ethan Basch, MD, and his team at Memorial Sloan Kettering Cancer Center reported significant benefits in quality of life, patient satisfaction, and emergency department (ED) use outcomes in their large single-center randomized controlled comparison of Web-based symptom monitoring with patient-reported outcomes (PROs) vs usual care in patients receiving chemotherapy for metastatic solid tumors.² Basch’s research group, now at the Lineberger Comprehensive Cancer Center of the University of North Carolina, presented OS results of this trial at ASCO.

Patients were randomized to self-report 12 common symptoms including appetite loss, difficulty breathing, fatigue, hot flashes, nausea, and pain. Patients graded them on a 5-point scale. The web-based tool, Symptom Tracking And Reporting (STAR), was developed for research purposes and is not commercially available.

Patients reported symptoms remotely from home or at the doctor’s office during oncology or chemotherapy visits, using tablet computers or computer kiosks. The intervention group included patients with little prior experience using the internet.

Treating physicians received symptom printouts at visits and nurses received e-mail alerts when participants reported severe or worsening symptoms. OS was tabulated based on medical records and Social Security Death Index data, estimated using the Kaplan-Meier method, and compared using a log-rank test and Cox proportional hazards regression that adjusted for age, sex, race, educational level, and cancer type.

Between 2007 and 2011, 766 patients with a median age of 61 (range 26-91 years) years were randomized—86% were white, 58% female, and 22% had less than a high school education. Cancer types included genitourinary (32%), gynecologic (23%), breast (19%), and lung cancer (26%).

Fewer participants in the STAR arm visited the ER than those who received usual care (34% vs 41% after 1 year; P = .02). The 2016 analysis concluded that in adults receiving outpatient chemotherapy for advanced cancer at a large specialty cancer center, Web-based symptom reporting with automated clinician e-mail alerts resulted in better health-related QOL, fewer ED visits, fewer hospitalizations, a longer duration of palliative chemotherapy, and superior quality-adjusted survival.²

Survival results were assessed in 2016 after a median follow-up of 7 years. A total of 517 of 766 (67%) participants had died. Median OS in the intervention arm was 5 months longer than in the control arm (31.2 vs 26.0 months, P = .03). In the multivariable model, results remained statistically significant with a hazard ratio of 0.832 (P = .04; 95% CI, 0.696-0.995).

The investigators concluded that systematic symptom monitoring during outpatient chemotherapy using web-based PROs confers OS benefits.

These single-center results are being evaluated further in a national multicenter implementation trial. The national trial 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.

“We showed that using a web-based symptom reporting system that alerts the care team about problems leads to actions that alleviate suffering and improve patient outcomes,” Bach said in a statement. “The improvement in survival we saw may seem modest, but it is greater than the effect of many targeted cancer drugs for metastatic cancer. Symptom management is a central part of what oncology care teams do.”³

ASCO Expert Harold J. Burstein, MD, PhD, FASCO, commented, “Online technologies have transformed communications in practically every aspect of our lives, and now we’re seeing they’re also allowing patients to take an active role in their care and get immediate access to their care provider. It is impressive that something as simple as this not only improves quality of life, but in this case, helps patients live longer. I think we will soon see more cancer centers and practices adopting this model.”³REFERENCES

1. 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; abst LBA2).

2. Basch E, Deal AM, Kris MG, et al. Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized clinical trial. J Clin Oncol. 2016;34(6):557-565. doi: 10.1200/JCO.2015.63.0830.

3. Web-based system for self-reporting symptoms helps patients live longer [press release]. Chicago, IL: ASCO; June 4, 2017.asco.org/about-asco/press-center/news-releases/web-based-system-self-reporting-symptoms-helps-patients-live. Accessed June 30, 2017.

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