If This Were a Drug, the Price Would Be $100,000

Oncology Nurses Do Heavy Lifting

Nick Mulcahy

June 04, 2017

CHICAGO — Use of a web-based tool that allowed patients with metastatic cancer to self-report symptoms to their care team at all hours of the day was associated with a 5-month improvement in overall survival compared with usual care, according to new randomized clinical trial results.

The study, which took place at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City, was featured in the plenary session here today at the American Society of Clinical Oncology (ASCO) 2017 Annual Meeting.

Median overall survival was 31.2 months in the web tool users group (n = 441) and 26.0 months in the usual care group (n = 325; P = .03), said lead study author, Ethan Basch, MD, a medical oncologist who was at MSKCC at the start of the study.

Median follow-up was 7 years, said Dr Basch, who spoke at a meeting press conference.

"If this were a drug that had a survival advantage of this magnitude, it would be retail priced at $100,000s," said Harold Burstein, MD, PhD, from Dana Farber Cancer Institute in Boston, Massachusetts, and an ASCO expert, who commented during the press event.

But the mechanism of action of the survival-extending intervention is uncertain.

The benefit may have resulted from clinicians' "early responsiveness" to reported symptoms, such as pain, nausea, and fatigue, and the prevention of problems worsening, the authors say in a research letter simultaneously published online today in JAMA.

Or perhaps the mechanism of action is that the web-tool users stayed on chemotherapy longer than the usual care patients (mean, 8.2 vs 6.3 months; P = .002). The symptom-reporting web tool may have enabled patients to tolerate chemotherapy longer, the authors speculated.

The web-tool users also had superior overall physical functioning, which "is known to be associated with better survival," said Dr Basch, who is now at the University of North Carolina Lineberger Comprehensive Cancer Center in Chapel Hill.

He explained that in 2016 the team had reported the study's primary outcome, which was quality of life — including physical functioning — at 6 months vs at enrollment. The new overall survival findings are from a post hoc analysis.

Another expert, Dawn Hershman, MD, a medical oncologist at the Herbert Irving Comprehensive Cancer Center, Columbia University, New York City, advised that clinicians should not focus too much on the technology.

"It is less about the tool that was used and more about the use of patient-reported outcomes to identify symptoms or toxicities," she told Medscape Medical News.

Dr Hershman, who was not part of the study, believes the key is acting on symptoms early.

Unfortunately, patients with cancer often try to tough it out, said Betty Ferrell, PhD, director of Nursing Research at City of Hope National Medical Center in Los Angeles, California.

"It is very well established that patients are often hesitant to report symptoms and tend to endure symptoms rather than to see them as influencing their survival," she said in an email to Medscape Medical News.

It is very well established that patients are often hesitant to report symptoms. Betty Ferrell

 The new study "adds to the growing body of evidence that unrelieved symptoms impact not only quality of life but survival," Dr Ferrell added.  

Richard Schilsky, MD, chief medical officer of ASCO, summarized the study results by repeating advice he used to give to residents: "When all else fails, talk to the patient."

National Trials Underway

Oncology nurses played a big part in the study results.

When the web-tool group participants reported a severe or worsening symptom, an email alert was sent to a clinical nurse responsible for that patient.

Those alerts frequently prompted action; nurses responded to symptom alerts 77% of the time with clinical interventions. These included symptom management counseling, supportive medications prescribing, chemotherapy dose modifications, and referrals.

The study took place among consecutive MSKCC patients initiating routine chemotherapy for metastatic solid tumors between 2007 and 2011. Participants in the web-tool group provided self-reporting of 12 common symptoms. The reporting took place both at and between clinic visits via a web-based questionnaire platform.

The participants in the usual care group discussed symptoms during scheduled clinical encounters and could contact the office by telephone between visits for concerning symptoms.

Participation was continuous until cessation of cancer treatment, voluntary withdrawal from the trial, transition to hospice care, or death.

Overall survival was assessed in June 2016 after 517 of 766 participants (67%) had died. In a multivariable analysis, the results remained statistically significant, with a hazard ratio of 0.83 (95% confidence interval, 0.70 - 0.99; P = .04).

Dr Hershman discussed the ways in which acting on symptoms can influence survival outcomes in patients with cancer.

"Acting early can prevent toxicities from worsening to the point that the cancer medication has to be discontinued or withheld," she said. The end result can improve adherence to effective treatment.

Acting early can prevent toxicities from worsening. Dawn Hershman

 

She also said that symptom management can prevent serious adverse events and hospitalizations and "possibly reduce the risk of dying from a complication." Additionally, addressing symptoms sooner rather than later can allow patients to discontinue ineffective treatments earlier.

The median age of participants was 61 years; 86% of patients were white, 58% were women, and 22% had less than a high school education. Notably, nearly 30% were computer inexperienced.

Dr Basch said the trial has spawned national studies, with a new next-generation reporting system.

Dr Burstein acknowledged that the practice of medicine has been behind the curve in technology adoption.

"Many of us still carry beepers, which were very cutting edge in the 1970s, and we've struggled to integrate some of the newer communication platforms that are widespread," he said.

But change is coming, Dr Burstein predicted in a meeting press statement: "I think we'll soon see more cancer centers and practices adopting this model."

Dr Basch and multiple coauthors have ties to the pharmaceutical industry. Dr Schilsky also has ties to several pharmaceutical companies. Dr Burstein, Dr Hershman, and Dr Ferrell have disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 2017 Annual Meeting. Abstract LBA2. Presented June 4, 2017.

JAMA. Published online June 4, 2017. Abstract

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

For more from Medscape Oncology, follow us on Twitter: @MedscapeOnc

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