A recent paper by Basch et al. 2017, found that electronic patient-reported symptom monitoring improved patient overall survival by 5 months. This finding came from a randomized clinical trial at Memorial Sloan Kettering. For patients in the arm with electronic patient-reported symptom monitoring, when “…participants reported a severe or worsening symptom, an email alert was triggered to a clinical nurse responsible for the care of that patient.” On the other hand, the usual care group discussed symptoms “during clinical encounters, and patients could contact the office by telephone between visits for concerning symptom.”
The authors claim the following potential causal pathways:
One potential mechanism of action is early responsiveness to patient symptoms preventing adverse downstream consequences. Nurses responded to symptom alerts 77% of the time with discrete clinical interventions including calls to provide symptom management counseling, supportive medications, chemotherapy dose modifications, and referrals. Another potential mechanism is that patients in the intervention group were able to tolerate continuation of chemotherapy longer than usual care (mean, 8.2 months in the PRO group vs 6.3 months in the usual care group; difference, 1.9 months [95% CI, 0.7-3.0]; P = .002).
While these findings are impressive, I am a bit skeptical of the whether the magnitude of the survival improvement can be translated into real world practice. There are four reasons behind my skepticism. First, in the clinical trial, it could be the case that nurse and doctors switched their efforts from patients in the usual care group to the electronic monitoring group since only the latter sent them electronic messages. This is the “squeaky wheel” hypothesis. Thus, providers may have provided more attention and care to patients with electronic monitoring in the trial, but if all patients received electronic monitoring, then all patients would be prioritized meaning that none would. As we say in economics, this is the difference between partial and general equilibrium. Second, the trial was relatively short. Staff may have been motivated to provide higher quality care during the trial, but in the long-run these alerts may lose their effectiveness. This is the “alert fatigue” hypothesis. Third, there likely was separate funding for this intervention. In the real world, having nurses more directly supervise patient symptom management remotely may require hiring additional staff or shifting priorities of current staff. Finally, the trial was conducted at one of the most prestigious cancer centers in the nation and it is not clear if this work environment could be replicated at other sites.
Despite these reservations, I am certainly in favor of providing more attentive care to cancer patients as well as more continuous symptom monitoring. Let us hope that my skepticism is unfounded and this new paradigm of care truly can improve outcomes for cancer patients.
Source:
- Basch E, Deal AM, Dueck AC, Scher HI, Kris MG, Hudis C, Schrag D. Overall Survival Results of a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer Treatment. JAMA. Published online June 04, 2017. doi:10.1001/jama.2017.7156
Very interesting. Thank you for sharing this, and your thoughts.
You bring up excellent “what ifs” as footnotes to their research, and I’ll add another:
As a cancer survivor,the symptoms requiring monitoring go well beyond the physiological. In fact, the physiological symptoms are manifestations of psychological symptoms working over time in a cancer patients. There are many research studies demonstrating their effects, all the way to the molecular level of the chromosome.
Given the ‘gig economy’ shift, and the growing need for ‘health coaches’ (admittedly, an undefined phrase), I foresee how LCSW’s and Survivors will become more influential partners with nurse navigators and oncol staff around these “alerts”, whatever they end up looking like. Connecting patients, on-demand, and with their mobile devices or voice activated devices, with people who can just ease their fears, help them learn ways to manage their distress and the behaviors that exacerbate [our] the pain, or suffering, will become critical as the incidence of cancer rises (to 19 million by 2022) with an aging population.