Ethan Basch presenting at the 2017 annual meeting of the American Society of Clinical Oncology. Photo: © ASCO/Rodney White 2017
People receiving chemotherapy for metastatic solid tumors survived longer when they used a web-based tool to document their symptoms, according to results from a large, randomized study conducted at Memorial Sloan Kettering. The findings were presented by Ethan Basch at the annual meeting of the American Society of Clinical Oncology in Chicago and were simultaneously published in the Journal of the American Medical Association.
Among the 766 individuals analyzed in the trial, median overall survival was five months longer for those who had the self-reporting tool integrated into their care.
“National studies have shown that doctors and nurses miss many of the symptoms that people experience,” says Dr. Basch, who led this work at MSK and is now Director of Cancer Outcomes Research at the University of North Carolina at Chapel Hill. “We designed this tool and conducted this study to improve upon that.”
An Initial, and More Modest, Goal
“Symptom management is a cornerstone of high-quality cancer care,” Dr. Basch says. Unfortunately, though, it is an imperfect science. “There is a substantial discrepancy between what people experience and what we pick up and act on.”
The traditional method to collect information about a person’s well-being is for a doctor or nurse to talk with the patient during a clinic visit. But a new health issue that occurs between appointments and goes unreported or isn’t acted upon early enough can easily disrupt a person’s cancer treatment plan.
So Dr. Basch and his team set out to create a more efficient way to gather symptom data and, ultimately, to improve health-related quality of life.
Study participants were asked to use an online interface called Symptom Tracking and Reporting (STAR). They answered questions about 12 side effects from chemotherapy: appetite loss, constipation, cough, diarrhea, difficulty breathing, difficulty urinating, fatigue, hot flashes, nausea, neuropathy, pain, and vomiting. Individuals graded each of their conditions on a scale of zero (not present) to four (disabling). The STAR system also sent two email alerts: Participants received a weekly reminder to complete an assessment, and nurses received a notification when any symptom grade reached three or increased by two points or more from the previous report.
A previous analysis of the same study, published in the Journal of Clinical Oncology in early 2016, showed that the protocol was effective. Health-related quality of life improved more in people who used the tool compared with those who received standard care. Those in the online-reporting group also remained on their treatment longer and were less frequently hospitalized or admitted to the emergency room.
“The benefit to quality of life was substantial compared with the usual care,” Dr. Basch says. “We were catching symptoms early, and people weren’t getting really sick to the point that they could not tolerate treatment.”
Floored by the Findings
Dr. Basch and his team then embarked on a full analysis of survival, which was a secondary endpoint in the 2016 trial.
“When I started this study, I was interested in improving how we collect data on symptoms and how we could enhance communication,” Dr. Basch says. “Evaluating overall survival was not the direction I was going in.”
Part of the initial plan or not, the overall survival data “floored” him, Dr. Basch says. The analysis showed that those who used the web-based tool survived a median of 31.2 months, compared with 26.0 months for those who received the usual care. In other words, people who self-reported their symptoms lived significantly longer than those who did not.
Even further, nurses responded to email alerts 77% of the time. They helped manage health problems through counseling, providing referrals and supportive medications, and modifying chemotherapy doses.
Looking Ahead
One of the next crucial steps is to use the tool to assess quality of care, Dr. Basch says.
“For example, as oncologists and nurses, a goal of ours is to control nausea after chemotherapy. This tool helps quantify that symptom’s presence and severity,” Dr. Basch says. “Hard data can help us answer some important questions: How good of a job are we really doing at managing symptoms? Where is there room for improvement?”
The second vital aspect of this research concerns implementation. Dr. Basch notes that is a complicated task, as it requires technology, engaging with and monitoring patients, and changing the workload of nurses.
Today, there are two large national studies integrating this self-reporting side-effect-monitoring tool into community oncology practices. Dr. Basch and his team are interviewing practice leaders and nurses to work out the kinks.
“Like many things in healthcare, it’s one thing to show that something has benefit; it’s another thing to actually roll it out into practice,” he says.
