1. Goodwin, Peter M.

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CHICAGO-Patients with metastatic solid tumors being treated with chemotherapy who used an online system for reporting new or worsening symptoms to their clinical teams lived around 20 percent longer than patients randomized to a control group in a study reported at the 2017 ASCO Annual Meeting, held June 2-6 (Abstract LBA2).


"We show 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," said lead author Ethan M. Basch, MD, MSc, FASCO, from the Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, and Memorial Sloan Kettering Cancer Center, New York.


Patients in the investigational arm graded 12 symptoms associated with chemotherapy-including appetite loss, difficulty with breathing, fatigue, hot flashes, nausea, and pain-on a 5-point scale.


"These were not highly selected clinical trial patients. These were ordinary folks getting their chemotherapy-routine treatment-and we asked them to do this additional reporting as a part of their routine care, saying: This is something that your doctor and your nurse would like to have happen in their clinic. Would you be willing to partner with us to do this?"


Quality of Life

Basch said that, as well as lengthening overall survival significantly, quality of life also statistically significantly improved. "Among 31 percent of patients we saw the quality of life improve. For many, patients it didn't worsen. And this, I think, speaks to symptom control."


He postulated that patients did better because controlling symptoms over time makes them feel better and improves compliance. "Emergency room visits went down by 7 percent, and people were able to receive chemotherapy on average 2 months longer because their side effects were better controlled."


The study was conducted among 766 patients having chemotherapy for any of a range of metastatic solid tumors at Memorial Sloan Kettering Cancer Center who were randomly assigned to usual care or to use the online system to self-report symptoms by using tablet computers. Their treating physicians received symptom printouts when they saw patients, and nurses had email alerts whenever their patients reported severe or worsening symptoms.


Patients received email reminders to self-report once a week and they could report symptoms any time from home or when they came into clinic where there was a computer terminal kiosk. "Any time a patient self-reported a severe symptom, or a worsening symptoms, that triggered a real-time email alert to their nurse," said Basch.


After a median follow-up of 7 years, overall survival was compared between the two arms adjusting for age, sex, race, education level, and cancer type. Patients who self-reported their symptoms had a median overall survival 5 months longer than those in the control arm (31.2 vs. 26.0 months, p = 0.03). The hazard ratio was 0.832 (p = 0.04).


"Systematic symptom monitoring during outpatient chemotherapy using web-based patient-reported outcomes confers overall survival benefits," the authors explained.


Basch said there were good reasons why symptom control should improve disease management. "We know that patients who have advanced cancers commonly have symptoms that can be quite severe and debilitating. And as clinicians-unfortunately-we were unaware of up to half of the symptoms that patients are experiencing. This got me to thinking that this is an opportunity. Perhaps if we could monitor patients' symptoms better-particularly between their visits to the office-maybe we could improve how patients were feeling and functioning and that could translate into an improvement in the outcomes."


He noted there was a communications gap between patients and clinicians. "I think there are many reasons that we miss our patients' symptoms and I don't think the clinicians are necessarily to blame. And I don't think the patients are either. I think this is because of the structure of how health care is practiced and the dynamics between us."


When patients came into the office, time was limited, Basch explained. There were many competing topics to discuss. Doctors weren't in the practice of systematically going through lists of symptoms and often patients might have forgotten how they had been feeling 2 or 3 weeks earlier-after chemotherapy. "This problem is even worse between visits because patients may not realize the importance of contacting the office for a problem when it's just beginning.


"And the barriers to reaching the doctor, the nurse, are actually quite high," Basch said. "Patients are hesitant to pick up the phone or send an electronic message. And so the sum result of these dynamics is that we have a lack of adequate communication during and between visits about symptoms.


"Symptom management is a central part of what oncology care teams do," continued Basch, adding that the study supports broader use of online tools in routine practice to improve communication between patients and care teams. "The improvement in survival we saw may seem modest, but it is greater than the effect of many targeted cancer drugs for metastatic cancer."


Another explanation for the success of the method was that it had made it possible for care teams to take prompt action in response to symptom reports, Basch suggested. "We systematically tracked what the nurses did when they received these alerts. Where nurses received an alert, they acted almost immediately. They called the patient to give them counseling about symptom management. And in many of those cases supportive medication was changed or newly prescribed," he said.


New appointments were sometimes made. Some patients were referred to the pain clinic. Others were sent to the emergency room. Some patients went for imaging with MRIs or CAT scans. "So we know that the actions were being taken by the nurses in response to these alerts."


Study Commentary

At a press briefing the presiding ASCO Expert Harold J. Burstein, MD, PhD, FASCO, Associate Professor of Medicine at Harvard Medical School and the Dana-Farber Cancer Institute, Boston, said it was impressive that something as simple as this not only improved quality of life but had also helped patients live longer.


"This is a compelling study because it has shown that caring for patients improves patient care. It validates something that we all feel-but rarely have evidence for-that with patient-focused team-based medical care you can improve outcomes in measurable and meaningful ways," he said.


"To my mind, it is remarkable that a relatively simple intervention that allows us to meet patients where they are and to communicate to us-without the traditional barriers of having to call an office or other things that people might be discouraged to do-can improve quality-of-life and, incredibly, actually improve overall survival."


Peter M. Goodwin is a contributing writer.