A study by the Alliance for Clinical Trials in Oncology has shown that completing a simple weekly electronic symptom check-in significantly improves quality of life and may reduce health disparities among people undergoing treatment for advanced cancer.
The PRO-TECT study, which is published in JCO Oncology Practice, showed that the biggest improvements occurred among patient groups that have historically faced greater symptom burden or barriers to effective communication with their care team, including Black patients, women, younger patients, and individuals with less formal education.
“Although we know from prior work that systematic symptom monitoring improves quality-of-life outcomes in patients with advanced cancer, the current analysis extends these findings by suggesting that some groups may experience greater benefit,” said first author Allison Deal, MS, a senior biostatistician at the UNC Lineberger Comprehensive Cancer Center.
Study chair Ethan Basch, MD, who is also from the UNC Lineberger Comprehensive Cancer Center explained that the use of remote symptom monitoring using patient-reported outcomes (PROs) in cancer care in increasing across the U.S., with more than 80 health systems and large practices currently implementing this approach. However, he added that “this is still an early time for this patient-centered approach to monitoring patients, and many practices are still learning how best to implement at their own sites.”
For the PRO-TECT study, 1191 adult patients with metastatic solid tumors receiving systemic therapy were randomly assigned to complete weekly electronic symptom monitoring (n=593) or usual care (n=598) for up to one year.
The weekly surveys included questions about symptoms from the National Cancer Institute’s PRO version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) item library, oral intake, patient-reported performance status, and falls. The surveys took a few minutes to complete and patients could choose whether to complete them online (64%) or via telephone-based interactive voice response not requiring Internet access (36%).
If the answers passed a prespecified threshold (i.e., severity or worsening from previous assessment), the participant was sent a link to relevant patient-level materials for self-management of the reported symptom, and a nurse on the participant’s clinical care team was sent an automated email alert.
The researchers report that, during the study, 90% of surveys were completed and 41% of reports triggered an alert.
At three months, participants in the PRO arm had a mean 2.37-point improvement, from a baseline of 77.0 points, in the European Organisation for Research and Treatment of Cancer QLQ-C30 symptom control score, and a mean 1.54-point improvement, from a baseline of 73.9 points, in physical function score.
By comparison, participants given usual care reported a 0.20- and 0.93-point decline in symptom control and physical function, respectively.
Basch noted that the differences between the two arms were statistically significant and clinically meaningful, adding that there were also “substantial delays until symptom worsening” among people in the PRO arm relative to the usual care arm.
Deal and co-investigators also observed significant differences in outcome by race, education level, age, and sex.
Specifically, they found that the improvement in symptom control in the PRO arm was significantly larger in Black patients than in White patients, which essentially erased a baseline gap and brought symptom control among Black patients on par with that among patients by month 3. Black patients were also much more likely to report that the weekly surveys made them feel more in control of their own care and improved conversations with their care team.
Patients with a high school education or less who used the weekly surveys had significantly greater improvements in both symptom control and physical function than those with a college education. They also had higher rates of triggered alerts and reported that the weekly questions felt relevant to their daily lives.
Women and younger patients (<65 years), two groups that traditionally report higher distress and more severe side effects during cancer treatment, experienced substantial quality-of-life gains from the weekly check-ins compared with the usual care group, whereas men and older patients saw no significant improvement relative to usual care.
In addition, the weekly reporting tool was associated with significantly reduced or delayed emergency department visits for patients, which are known to cause financial and emotional stress for patients and their families.
“Our results suggest that remote monitoring may provide underserved cancer patients with a new avenue to communicate concerns that might go underrecognized in routine practice,” Basch told Inside Precision Medicine. “Broad implementation of these systems may represent an effective and highly practical strategy to advance health equity. Future studies should test technology with more general patient audiences.”
He added: “There is a follow-up initiative to this trial called OncoPRO which is supporting health systems across the country as they work to onboard these systems.”
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