When patients with metastatic cancer used a Web-based tool to self-report symptoms proactively during treatment, they lived 5 months longer than did patients assigned to usual care. In addition, they had improved quality of life and fewer emergency room visits and hospitalizations compared with those who received usual care. These results were presented by Ethan Basch, MD, MSc, as one of the four Plenary Sessions at the 2017 ASCO Annual Meeting.1 Dr. Basch is now with the University of North Carolina Lineberger Comprehensive Cancer Center in Chapel Hill. The study was conducted at Memorial Sloan Kettering Cancer Center in New York, where Dr. Basch was working at the time.
We plan to do a national study across the United States to validate these results.— Ethan Basch, MD, MSc
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“Integrating patient-reported outcomes in the care of metastatic cancer improves quality of life and overall survival. Patient-reported outcomes should be considered for inclusion in standard symptom management as a component of high-quality care,” said Dr. Basch.
“If this were a drug that had a survival advantage of this magnitude, it would be priced at $100,000, and we would ask how do we get this into our practice,” said ASCO expert Harold Burstein, MD, of the Dana-Farber Cancer Institute in Boston, at a press conference where these data were discussed. “This is an exciting and compelling study showing that patient-focused team-based care can reduce emergency room visits, improve quality of life, and, incredibly, improve overall survival.”
These study results were published online in The Journal of the American Medical Association2 to coincide with the presentation at the ASCO Meeting. The study was funded by the National Institutes of Health and the ASCO Conquer Cancer Foundation.
Many Symptoms Not Reported
Symptoms are common in patients being treated for metastatic cancer but are often undetected by the care team until they become severe and debilitating. The reasons for this are partly because patients are reluctant to report symptoms unless asked directly about them and also because of time constraints during clinic visits. Using a Web-based tool seems to overcome these barriers.
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“Up to half of symptoms are not reported to clinicians,” Dr. Basch said. “Between visits, patients are often hesitant to call the office, and even at clinic visits, symptoms are not always fully communicated. Our current approach is reactive and inhibits our ability to act quickly. We have identified a communication gap.”
Study Details
The study included 766 cancer patients receiving chemotherapy at Memorial Sloan Kettering Cancer Center for metastatic breast, lung, genitourinary, or gynecologic cancer between September 2007 and January 2011. Patients were randomized to receive the Web-based intervention or usual care. Those in the intervention group were taught to use the Web survey system from home between visits and in clinic waiting areas prior to seeing the oncologist. They received weekly e-reminders to fill out the tool, which assessed 12 common symptoms. The system automatically triggered e-alerts to nurses if any symptom worsened. Nurses printed out the reports for the oncologist to use during the patient visit.
If this were a drug that had a survival advantage of this magnitude, we would ask how do we get this into our practice?— Harold Burstein, MD
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Baseline characteristics were well balanced in both arms of the study. Median age was 61 years (range, 26–91 years), 86% were white, 58% were female, and 22% had less than a high school education.
Dr. Basch said that the instrument used in his study was an adaptation of the Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE), which is available on the National Cancer Institute’s website and can be adapted for use in any clinical practice.
Key Findings
Patients, even elderly patients, self-reported symptoms 73% of the time when prompted to do so, Dr. Basch noted. Nurses took action in response to e-alerts for symptom worsening 77% of the time by initiating counseling, referrals to emergency services, and chemotherapy dose modification.
These authors previously published results on quality of life and resource utilization with this strategy of symptom management.3 For the primary outcome of quality of life at 6 months compared with baseline, 31% more patients in the intervention group reported improved quality of life than in the standard care arm. Patients in the intervention group also had 7% fewer emergency room visits and 4% fewer hospitalizations, Dr. Basch revealed.
At 5 years, median overall survival was 31.2 months for the intervention group vs 26 months for the standard care group, representing an absolute difference of 8% favoring the intervention (P = .03). Patients randomized to the intervention also were able to receive chemotherapy 2 months longer than those in the standard care group: 8.2 months vs 6.3 months (P = .002).
Why a Survival Benefit?
Dr. Basch proposed potential drivers of this survival benefit. The intervention allowed more responsive care in real time, prompting physicians to take early action before complications worsened. Improved symptom control kept patients better able to function physically and maintain mobility, which is associated with better survival. The intervention enabled better management of chemotherapy side effects, which in turn allowed for longer administration of life-prolonging therapy.
“We are often hampered in administering life-prolonging therapy due to side effects. The intervention group was able to get chemotherapy 2 months longer,” Dr. Basch said.
“This approach should be included as part of standard symptom management. Future efforts should focus on implementing strategies to incorporate self-reporting symptoms into electronic health records,” Dr. Basch proposed. “We plan to do a national study across the United States to validate these results,” he added.
Additional Commentary
At a press conference at the ASCO Annual Meeting, Dr. Burstein also suggested potential mechanisms of action: a lower threshold for communication; more timely interventions; better support; allowing patients to refuse therapies that aren’t “good for them.”
Richard L. Schilsky, MD
“We need to figure out how to integrate this into our systems and electronic health records. This is a good problem to have! The study provides proof that patients feel better, live longer, and use fewer resources [when they self-report their symptoms],” Dr. Burstein added.
“This study validates a practice of mine in teaching medical residents,” said ASCO Chief Medical Officer Richard L. Schilsky, MD, who moderated the press conference. “When residents presented laboratory and other test evidence for me to evaluate as the attending physician, my response was always, ‘When all else fails, talk to the patient.’”
Daniel F. Hayes, MD, FACP, FASCO
ASCO President Daniel F. Hayes, MD, FACP, FASCO, pointed out the convenience of this tool for patients. “To have this technology available where patients have online access to well-trained clinical staff, such as nurses, nurse practitioners, or physician’s assistants, to help determine how to manage worsening symptoms, instead of driving 2 hours to an emergency room, is a boon for patients. I am excited about this. This study reflects ASCO’s focus not just on giving drugs to patients, but paying attention to how patients feel.” ■
DISCLOSURE: Drs. Basch, Burstein, Schilsky, and Hayes reported no conflicts of interest.
REFERENCES
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. 2017 ASCO Annual Meeting. Abstract LBA2. Presented June 4, 2017.
3. Basch E, Deal AM, Kris MG, et al: Symptom monitoring with patient-reported outcomes during routine cancer treatment. J Clin Oncol 34:557-565, 2016.
