Remote management during chemotherapy fails to reduce ED visits, hospitalization

A remote, proactive, and telephone-based management of toxicities in outpatients during adjuvant or neoadjuvant chemotherapy for early-stage breast cancer does not lead to fewer visits to the emergency department (ED) or hospital admissions, a study has shown.

“With the rapid rise in remote care because of the COVID-19 pandemic, identifying scalable strategies for remote management of patients during cancer treatment is relevant,” the researchers said.

All patients starting chemotherapy at 20 cancer centres in Ontario, Canada, were randomized either to remote management of toxicities or routine care. Twenty-five patients from each centre completed the patient-reported outcome questionnaires. The proactive, standardized, nurse-led telephone management of common toxicities was done at two time points after each chemotherapy cycle.

Baseline characteristics of participants were similar in the intervention (n=944) and control arms (n=1,214), with about one in five (22 percent) patients aged >65 years. Penetration, or the percentage of patients receiving the intervention at each centre, was 50–80 percent. [BMJ 2021;375:e066588]

The mean number of visits to the ED or admissions to hospital per patient was comparable between the intervention and control arms (0.91 vs 0.94; p=0.94). Of the 2,158 patients, 1,014 (47 percent) had at least one ED visit or hospital admission during chemotherapy.

Among 580 participants who completed the patient-reported outcome questionnaire, 134 (48 percent) in the intervention arm and 163 (58 percent) in the control arm reported at least one grade 3 toxicity. There were no between-group differences seen in self-efficacy, anxiety, or depression.

In addition, the functional assessment of cancer therapy trial outcome index decreased by 6.1 points in the intervention arm and 9.0 points in the control arm relative to baseline.

“Our intervention was associated with a lower proportion of patients with grade 3 toxicities (p=0.05), especially fatigue (p=0.009), aching joints (p=0.003), and aching muscles (p=0.004), and significant findings for quality of life outcomes that did not fully meet the criteria for a clinically important difference,” the researchers said. [J Clin Epidemiol 2017;89:188-198]

These findings supported those of previous studies, which showed the association of proactive remote monitoring of symptoms during cancer treatment with a positive effect on symptoms and quality of life and indicated that the effect on symptom burden might be scalable beyond individually randomized trials. [Comput Inform Nurs 2017;35:520-529; J Clin Oncol 2021;39:734-747; Support Care Cancer 2009;17:437-444]

On the other hand, the intervention did not result in improvement in other outcomes, such as self-efficacy, anxiety, or depression. The lack of effect on self-efficacy could be due to a focus on managing symptoms rather than teaching self-management behaviours, while that on anxiety or depression could be explained by the content of the calls, which focused on physical rather than emotional symptoms.

“Given the high level of acceptability of the intervention by patients and providers, and with a growing body of evidence from other studies showing the benefits of remote monitoring during chemotherapy, future studies of proactive remote management should focus on pragmatic large-scale implementation in routine care settings,” the researchers said.