'Time Has Come' for Electronic Reporting of Cancer Symptoms

Medical Culture Is Final Barrier

Nick Mulcahy

March 04, 2011

March 4, 2011 — The "time has come" for electronic patient interfaces that allow cancer symptom self-reporting to be "part of standard clinical cancer care," according to an editorial that accompanies 2 new studies of such technologies published online January 31 in the Journal of Clinical Oncology.

To win physician support, these approaches must be "relatively easy to use, with clear and immediate value," write editorialists Ethan Basch, MD, from Memorial Sloan-Kettering Cancer Center in New York City, and Amy P. Abernethy, MD, from Duke University School of Medicine in Durham, North Carolina.

Each technology used in the studies appears to approach those criteria, suggest the editorialists.

Interestingly, each technology has a "red-flag" feature that calls attention to outstanding symptoms, in effect triaging the flow of self-reported information.

Automated Phone System

In the first study, an automated telephone system allowed 79 patients to self-report symptoms for 4 weeks after lung cancer surgery at the University of Texas M.D. Anderson Cancer Center in Houston.

These surgical patients were randomized into 2 groups. One group used the telephone phone system, which prompts callers to answer questions about symptoms. The other group used the same system but with an extra service: when they reported moderate or severe symptoms over the phone, an automated email alert was sent to their clinician.

The email group experienced a greater reduction in severe symptom events than did the group without email alerts (19% vs 8%), and a more rapid decline in severe symptom events, reported the study authors, led by Charles S. Cleeland, MD, from M.D. Anderson.

The email group also reported being "significantly more comfortable" with the interactive telephone system, "possibly reflecting their knowledge that their symptoms were being monitored," write the authors.

Most of the alerts (84%) from the email group were acknowledged by treating clinicians within 24 hours, and 60% of the alerts resulted in a call to patients.

"There are 2 important implications of this study," write the editorialists. "Clinicians will integrate automated symptom alerts into their existing clinical workflows, and doing so adds value by yielding better symptom control."

However, the editorialists admit that there was no way of knowing if the participating clinicians "valued the approach" or wished to continue it after the research period. Still, "the high rate of use by clinicians suggests enthusiasm," write Drs. Basch and Abernathy.

The editorialists issue a challenge to oncologists to make use of electronic patient-reported information. "Logistic barriers" are the big reason that patient-reported symptom information has not been routinely collected in the past, they say. "Most of these issues have been worked out. The principal remaining barrier is cultural," they note, suggesting that clinicians are part of the problem.

Patient-reported data drive many types of clinical choices, say the editorialists. Some clinician decisions based on patient reports include "a treatment change (e.g., reduction of chemotherapy dose for fatigue), beginning a supportive therapy (e.g., providing an antiemetic for nausea), triaging for additional medical services (e.g., psychosocial care), [and] additional evaluation of a complaint (e.g., imaging a patient with abdominal pain postoperatively)."

Waiting Room Software

The second study involved computer software that allows for patient self-reporting of symptoms and quality-of-life issues (SQLIs) on an electronic questionnaire, according to the study authors, led by Donna L. Berry, PhD, RN, from Harvard Medical School in Boston, Massachusetts.

The software was installed on touchscreen notebook computers, which were available to patients in the waiting rooms at the participating institutions — Seattle Cancer Care Alliance and the University of Washington Medical Center.

In the controlled trial, 660 patients with various cancer diagnoses and stages were randomized into 2 groups. In the intervention group, patient-reported SQLIs were automatically displayed on a graphic summary and provided to the clinical team before an on-treatment visit (n = 327); in the control group, no summary was provided (n = 333).

The participants had a clinic visit before their cancer treatment and a second visit 4 to 6 weeks later, when "treatment-related SQLIs were expected." The electronic questionnaire was completed at each visit.

To obtain the study's primary outcome measure — the discussion of SQLIs by clinicians and patients during the second visit — the investigators audio recorded all communication between clinicians, patients, and accompanying friends or family members during those visits.

The study found that clinicians were more likely to discuss SQLIs that were flagged as "problematic" by the software. The investigators also found that the clinic visit duration did not differ between the 2 groups, suggesting that the process did not lengthen visits.

The computer software, known as Electronic Self-Report Assessment–Cancer (ESRA-C) — "is the first electronic self-report application to increase discussion of SQLIs in a . . . randomized trial" conducted in the United States, according to the authors.

The study has a variety of limitations, including the fact that the participants were "predominantly white," and most had computer experience. The group also had a mean age of only 54 years, which is younger than the average cancer patient, who might therefore be less computer savvy.

Dr. Abernathy reports receiving research funding from Pfizer, Bristol-Myers Squibb, KangLaiTe, and Helsinn.

J Clin Oncol. Published online January 31, 2011. Abstract, Abstract, Abstract


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