PHILADELPHIA – Cancer patients spend a lot of time on their care. Meeting with doctors and other members of their health care team, getting labs and other tests, picking up prescriptions, and undergoing treatment all takes time. So does getting to and from each appointment, sitting in the waiting room between each appointment, and so on.
In recent years, cancer researchers have worked to quantify the level of "time toxicity" or time spent commuting to, waiting for, and receiving cancer treatment. Now, for the first time, a pilot study has shown it's possible to use digital technology to safely reduce the amount of time some patients spend receiving care. With a simple text-messaging system, patients saved more than an hour at each visit captured by the study, which was led by researchers from the Perelman School of Medicine at the University of Pennsylvania and Penn Medicine's Abramson Cancer Center , and published in NEJM Catalyst today.
"Patients with cancer spend an enormous amount of time engaging with the health care system, and for patients with advanced cancer in particular, that time is precious," said senior author Ronac Mamtani, MD , section chief of Genitourinary Cancers. "We developed a safe and effective platform that—for certain patients—could really challenge the status quo and give them quality time back."
A fast-track system
Inspired by the efficiency of the TSA pre-check line to bypass long lines at the airport, Mamtani and former Penn oncology fellow and lead author Erin M. Bange, MD, MSCE, now an assistant professor at Memorial Sloan Kettering Cancer Center, developed a text message-based platform using the Center for Health Care Transformation and Innovation's Way to Health platform to obtain patient reported-symptoms and make sure patients are ready for immunotherapy treatment. Patients receiving immunotherapy for cancer treatment are currently required to complete bloodwork and meet with their health care team in the office before every infusion to confirm they have not developed any concerning symptoms that might signal a reaction to the immunotherapy and a need to pause treatment. The pre-treatment symptom check is a necessary safety measure that many patients treated with immunotherapy pass with flying colors, given the relatively low rate of side effects for immunotherapy compared to traditional chemotherapy.
In this pilot clinical trial , patients receiving single-agent immunotherapy for solid tumor cancers at Penn Medicine's Abramson Cancer Center were enrolled and randomized to either an in-person pre-infusion symptom check in the office with their provider, or to complete a 16-question symptom check, estimated to take less than five minutes, via the text message platform. If their labs were normal and no symptoms were reported, patients were given the option to fast-track and bypass the in-person visit, proceeding directly to their immunotherapy infusion. The 16 patients who were fast-tracked saved more than 60 minutes per visit, including 30 minutes less wait time, than the 15 patients who were randomized to continue with the usual in-person visit.
More importantly, the fast-track system was safe, with no difference in post-infusion hospital visits or health-related quality of life impact compared to usual care.
"Considering that patients who consented for the study told us that saving even 45 minutes per visit would significantly impact their lives, we were excited to see that our first test of this tool surpassed expectations, giving patients even more time back each time they went in for treatment," Bange said.
While patient-reported outcomes have been used in other studies to assess various quality of life measures, the authors note that this study is the first time digital patient-reported outcomes have been used to streamline cancer care delivery.
Limitations and next steps
A total of 19 additional patients who reported their symptoms via the text message platform were eligible for fast-track, but ended up continuing with the in-person visit instead, due to patient preference, provider preference, or other care coordination issues. The study team emphasized that some patients may prefer to continue in-person visits, and the team's vision for the text message platform is to be an option for patients who want to use it, rather than a one-size-fits-all approach.
The team also conducted focus groups with health care providers to better understand any concerns about the fast-track process and potential barriers to broader implementation.
"Our goal is to ultimately test this strategy in a pragmatic trial, where it's used in a real-world setting and not the controlled setting of a traditional clinical trial, but we want to be sure that we have the best-designed tool to effectively meet both provider and patient needs, so we're taking time to assess the feedback and refine our approach before moving forward," Mamtani said. "Cancer patients are repeatedly asked to hurry up and wait while getting care. What we're trying to address is just the tip of the iceberg in terms of giving patients valuable time back to focus on living."
The study was supported by an ASCO Conquer Cancer Young Investigator Award, Marjorie and Bryan Weingarten Fellowship Grant, the Health Network Foundation, and the National Institutes of Health/National Cancer Institute (P30CA016520).
