The Lynx Group

Patient-Reported Outcomes Should Be Used Routinely in Cancer Care

October 2016, Vol 7, No 9

San Francisco, CA—Although symptom management is the cornerstone of high-quality cancer care, clinicians often miss the patients’ symptoms or underestimate their magnitude. Patient-reported outcomes (PROs), about their symptoms, physical functioning, or health state, can remedy this situation, but PROs have not been instituted as a standard approach for symptom monitoring, said Ethan M. Basch, MD, MSc, Director of Cancer Outcomes Research, University of North Carolina at Chapel Hill at the 2016 Palliative Care in Oncology Symposium.

“Patient self-reporting improves clinical outcomes,” Dr Basch said. “There is a scientific rationale for integrating patient-reported outcomes into routine oncology care. In the future, electronic health record systems need to better integrate patient-reported outcomes for both data collection and data visualization for clinicians, and standardization is needed for outcomes, metrics, and implementation approaches.”

PROs have been the gold standard for measuring symptoms in cancer clinical research. In clinical trials, patients often report their pain using questionnaires that are collected electronically, and a number of published studies have demonstrated that “integrating PROs into routine oncology practice improves communication between patient and providers, patient satisfaction, and health-related quality of life,” he said.

Despite the mounting evidence, this approach has not been widely adopted, although a growing interest in PROs has yielded several initiatives from a number of national stakeholder organizations. For example, PROs have been implemented in the Oncology Care Model instituted by the Centers for Medicare & Medicaid Services.

Monitoring Symptoms with PROs: A Randomized Controlled Trial

Dr Basch reviewed results from a randomized controlled trial of 766 patients who received palliative chemotherapy for incurable or metastatic cancer and were randomized to a PROs group or to standard of care (Basch E, et al. J Clin Oncol. 2016;34:557-565). The PROs arm included 12 common symptoms that patients could report online. In addition, whenever a patient reported a severe or a new symptom, an automated e-mail alert was sent to the nurse involved in that patient’s care.

The feasibility results showed durability of self-reporting over time, said Dr Basch. On average, 80% of patients who were eligible to self-report did so at any given time, and this lasted for up to 40 clinic visits or 3 years.

The automated alerts were also successful. Nurses responded with clinical actions to more than 75% of the automated alerts they received. These actions consisted of telephone calls to patients for general advice about symptom management, as well as referrals to the emergency department and to other providers. In very rare cases, said Dr Basch, there was a chemotherapy dose modification or hold that resulted from these alerts.

Patients in the PROs intervention compared with standard of care had a significant and substantial improvement in quality of life from baseline to 6 months (34% vs 18%, respectively). In addition, a 41% reduction in emergency department admissions over a 1-year period was seen in the PROs group compared with 34% in patients receiving standard of care.

The duration of time patients received chemotherapy also differed between the arms “presumably due to superior symptom management,” Dr Basch said. Patients engaged in self-reporting of their systems received chemotherapy for 8.2 months versus only 6.3 months for standard of care.

Finally, patients in the PRO arm had a longer median survival than patients receiving standard of care (P = .03).

For providers interested in incorporating this approach in their practice today, Dr Basch recommends downloading the User’s Guide to Implementing Patient-Reported Outcomes Assessment in Clinical Practice (www.isoqol.org).

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