Nick Mulcahy

June 09, 2017

CHICAGO — An experimental supportive care approach that improved survival by 5 months among patients with metastatic cancer will inevitably emerge as common practice, said an expert from the podium of the plenary session at the American Society of Clinical Oncology (ASCO) 2017 Annual Meeting here.

"We've reached the tipping point," said Monika Krzyzanowska, MD, MPH, a medical oncologist at the Princess Margaret Cancer Center in Toronto, Ontario, Canada, who acted as discussant of the landmark randomized clinical trial.

The trial, which was conducted at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City, compared web-based patient-reported outcomes for symptom monitoring vs usual care among 766 patients receiving chemotherapy. Use of the tool was associated with a significantly better median overall survival of 31.2 months, compared with 26.0 months in the usual care group (P = .03).

As many as nine other studies have shown that patient self-reporting of such symptoms as pain, nausea, and fatigue leads to a reduction in their severity. But the new trial is the first to show that it improves survival and thus tips the scales toward common use, Dr Krzyzanowska suggested.

"It's time to do something about implementing" the experimental model, which should now be a new standard of care, she told the ASCO audience.

"The study is terrific. Everyone is talking about it," said Randall Oyer, MD, medical director of the Ann Barshinger Cancer Institute at Lancaster General Health in Pennsylvania, who attended the meeting. "It's a 'treatment' that makes a person better without side effects! What's not to love?"

Harold Burstein, MD, a medical oncologist at Dana Farber Cancer Institute in Boston, Massachusetts, and an ASCO expert, believes change is imminent. "I think we'll soon see more cancer centers and practices adopting this model," he said in a meeting press statement.

But Dr Krzyzanowska, Dr Oyer, and multiple other oncologists also expressed concerns about various obstacles to getting this particular rubber to meet the road.

During a postplenary discussion, two issues repeatedly surfaced: logistics and reimbursement (ie, the lack thereof). Both threaten to untip the scales away from innovation and back in the direction of the status quo. So the question arose: Was this feasible?

There was another element to consider: A confirmatory trial is underway at 50 US community-based oncology clinics. So another question arose: Should clinicians and centers wait years for that further evidence?

Answers

The new study took place among consecutive patients initiating routine chemotherapy for metastatic solid tumors between 2007 and 2011 at MSKCC. Participants in the web-tool group provided self-reporting of 12 common symptoms via tablet computers.

The reporting took place both at and between clinic visits, explained lead  author, Ethan Basch, MD, a medical oncologist who was at MSKCC at the start of the study and is now at the University of North Carolina Lineberger Comprehensive Cancer Center in Chapel Hill.

When a patient 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 medication prescribing, chemotherapy dose modifications, and referrals.

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.

The key to the results, however, was not the digital tool, suggested experts.

"You don't need fancy technology to do this," said Dr Krzyzanowska, who has been an innovator of patient-reported symptom management at her Canadian center.

Instead, the key was having a "systematic" approach, opined multiple commentators. A system allows for more thorough and quicker symptom management, which has many benefits, such as helping patients complete chemotherapy.

Investigator Dr Basch described the systematic, supportive-care model this way: "We are just facilitating what we already do."

Lancaster General's Dr Oyer told Medscape Medical News that the study was indeed a tipping point — if the definition is the point at which a series of small changes or incidents becomes significant enough to cause a larger, more important change.

Agreed, said Virginia Sun, PhD, RN, a researcher at the City of Hope Comprehensive Cancer Center in Duarte, California, who recently published a study of a "wearable" device to monitor activity levels after cancer surgery for the purpose of identifying struggling patients.

"Tipping point is an appropriate term to describe this," Dr Sun told Medscape Medical News. "The momentum is building for leveraging technology for cancer symptom management and cancer care."

But at ASCO, practicality was a concern.

"All of us are stretched very thin in the clinic," said Dr Krzyzanowska. A systematic supportive care program to integrate patient reporting of symptoms is not an "add on," she said. It needs to be reimbursed. "Is there enough money?" she asked. "I don't know."

At the plenary discussion session, a comment from the floor was hopeful.

The emerging "value-based" oncology care model in the United States penalizes "overuse of resources," such as excessive emergency department visits for patients with cancer. The new payment approach will "incentivize" programs like the MSKCC scheme, said the clinician, whose name was inaudible.

Dr Oyer believes likewise. The approach "should save money in the soon-to-be-here bundled payment system, but may initially just add cost," he said.

Patricia Ganz, MD, a medical oncologist at the University of California, Los Angeles, wondered whether what works at one of the United States' most affluent centers will work elsewhere. "Obviously at Memorial you have a big infrastructure with nurse practitioners and other people," she said.

Dr Basch responded that their web-based tool does not require practice redesign. "You need a designated person to answer emails," he said. In the new confirmatory trial, clinics will "plug" the tool into "whatever model."

He also emphasized that, in the current study, about 25% of the patients had no computer experience yet learned how to use a tablet.

Dr Basch, other investigators, and staff of the confirmatory 50-center study will help the participating community-based clinics to get going with the web-based tool.

At ASCO, opinions were split about whether practices outside of the confirmatory study should adopt the new model now, based on the current results.

Eric Topol, MD, editor-in-chief of Medscape, suggested that the model actually has been proven twice now. In an opinion piece, he cited a 2016 study from France that showed a 7-month survival improvement among patients with lung cancer who used a smartphone app for symptom reporting, as reported by Medscape Medical News. The new study from MSKCC is, in fact, a validation of the French study, he argued.

At the plenary discussion, one voice called for the confirmatory evidence. Another did not.

The enthusiast said the new study presented by Dr Basch has a "similar" feel to the landmark study that showed a survival benefit with palliative care in patients with metastatic cancer (N Engl J Med. 2010;363:733-742), as reported by Medscape Medical News at the time.  

The commentator said that at his Wisconsin-based clinic, they didn't wait for confirmation of the palliative care model. "After the New England Journal article, it was a done deal, we moved forward with it," said the oncologist, whose name was also inaudible.

Dr Basch said, Go for it: "It would be wonderful if you did. If my national study was ruined because we all began to monitor our patients' symptoms better, I would be okay with that."

The study was funded by the Conquer Cancer Foundation of ASCO. Multiple study authors but not Dr Basch have financial ties to industry. Dr Krzyzanowska , Dr Oyer, Dr Burstein, and Dr Sun have disclosed no relevant financial relationships. Dr Ganz report s financial ties with multiple pharmaceutical companies . Dr Topol has financial ties to medical device, technology , and healthcare companies.

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

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

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

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