Going beyond (electronic) patient-reported outcomes: harnessing the benefits of smart technology and ecological momentary assessment in cancer survivorship research

The feasibility and acceptability of delivering and evaluating a physical activity intervention (ACCEPTANCE) for cervical cancer survivors

BACKGROUND

Cervical cancer treatment can be associated with long-term physical, psychological and emotional issues leading to compromised quality of life (QOL). Physical activity (PA) may improve QOL in cervical cancer survivors.

METHODS

A one-arm pre/post-feasibility study with parallel process evaluation was conducted to test the feasibility and acceptability of a 12-week PA intervention (ACCEPTANCE). Feasibility was determined by using pre-established criteria relating to inclusion criteria, recruitment and retention, compliance with intervention components and compliance with evaluation measures. The 12-week intervention consisted of (1) an online education session on the benefits of PA and a barrier identification and problem-solving session; (2) a Fitbit monitor; (3) daily and weekly diary entries; (4) brief fortnightly online health coaching sessions; and (5) organising and participating in group walks; (6) online social interaction via a messaging group. Measures included accelerometer assessed PA and sleep, quality-of-life and PA behaviour change questionnaires distributed at 4-time points (baseline, week 6, week 12, and week 24). Process evaluation measures were questionnaires on the acceptance of intervention components and semi-structured interviews with participants after completion.

RESULTS

Thirty participants were recruited with a retention rate of 77% at week 24. The education session, health coaching and Fitbit PA monitor were deemed to be feasible based on compliance rates whilst the online messaging group, diary and group walking compliance suggested that modifications would be needed for these components. Accelerometer and questionnaires were deemed to be feasible evaluation measures based on compliance rates. Process evaluation results suggest that the Fitbit and health coaching sessions were perceived to be the most beneficial aspects of the programme as they enabled self-monitoring of behaviour and goal setting. Unexpected mechanisms of behaviour change were the integration of a small change approach and formation of habits to facilitate PA, whilst barriers to behaviour change included the online, virtual nature of the programme, poor mental health, and environmental challenges. PA levels were higher after the intervention, whilst global QOL was seen to worsen throughout the study, and depression and anxiety symptoms improved.

CONCLUSIONS

The ACCEPTANCE study is deemed to be feasible based on criteria established a priori, and only minor modifications would needed to implement in a definitive randomised control trial. The intervention showed potential to increase PA, through hypothesised mechanisms of self-monitoring behaviour and problem solving and unexpected mechanisms such as habit formation.

TRIAL REGISTRATION

ISRCTN16349793, Registered 30 September 2020.

Feasibility and psychometric quality of smartphone administered cognitive ecological momentary assessments in women with metastatic breast cancer

Objective

Metastatic breast cancer (MBC) is associated with burdensome side effects, including cognitive changes that require ongoing monitoring. Cognitive ecological momentary assessments (EMAs) allow for assessment of individual cognitive functioning in natural environments and can be administered via smartphones. Accordingly, we sought to establish the feasibility, reliability, and validity of a commercially available cognitive EMA platform.

Methods

Using a prospective design, clinical cognitive and psychosocial assessments (cognitive batteries; patient reported outcomes) were collected at baseline, followed by a 28-day daily EMA protocol that included self-ratings for symptoms and mobile cognitive tests (memory, executive functioning, working memory, processing speed). Satisfaction and feedback questions were included in follow-up data collection. Feasibility data were analyzed using mixed descriptive methods. Test-retest reliability was examined using intraclass correlation coefficients (ICCs) for each EMA, and Pearson's correlation were used to evaluate convergent validity between cognitive EMAs and baseline clinical cognitive and psychosocial variables.

Results

Fifty-one women with MBC (n = 51) completed this EMA study. High satisfaction (median 90%), low burden (median 19%), high adherence rates (mean 94%), and 100% retention rate were observed. ICCs for cognitive tests of working memory, executive function, and processing speed were robust (>0.90) and ICC for memory tests acceptable (>0.66). Other correlational findings indicated strong convergent validity for all cognitive and psychosocial EMAs.

Conclusion

Cognitive EMA monitoring for 28 days is feasible and acceptable in women with MBC, with specific cognitive EMAs (mobile cognitive tests; cognitive function self-ratings) demonstrating strong reliability and validity.

Uncovering the Daily Experiences of People Living With Advanced Cancer Using an Experience Sampling Method Questionnaire: Development, Content Validation, and Optimization Study

BACKGROUND

The experience sampling method (ESM), a self-report method that typically uses multiple assessments per day, can provide detailed knowledge of the daily experiences of people with cancer, potentially informing oncological care. The use of the ESM among people with advanced cancer is limited, and no validated ESM questionnaires have been developed specifically for oncology.

OBJECTIVE

This study aims to develop, content validate, and optimize the digital Experience Sampling Method for People Living With Advanced Cancer (ESM-AC) questionnaire, covering multidimensional domains and contextual factors.

METHODS

A 3-round mixed methods study was designed in accordance with the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) and the European Organization for Research and Treatment of Cancer guidelines. The study included semistructured interviews with 43 people with stage IV breast cancer or stage III to IV lung cancer and 8 health care professionals. Round 1 assessed the appropriateness, relative importance, relevance, and comprehensiveness of an initial set of ESM items that were developed based on the existing questionnaires. Round 2 tested the comprehensibility of ESM items. Round 3 tested the usability of the digital ESM-AC questionnaire using the m-Path app. Analyses included descriptive statistics and qualitative content analysis.

RESULTS

Following the first round, we developed an initial core set of 68 items (to be used with all patients) and a supplementary set (optional; patients select items), both covering physical, psychological, social, spiritual-existential, and global well-being domains and concurrent contexts in which experiences occur. We categorized items to be assessed multiple times per day as momentary items (eg, "At this moment, I feel tired"), once a day in the morning as morning items (eg, "Last night, I slept well"), or once a day in the evening as evening items (eg, "Today, I felt hopeful"). We used participants' evaluations to optimize the questionnaire items, the digital app, and its onboarding manual. This resulted in the ESM-AC questionnaire, which comprised a digital core questionnaire containing 31 momentary items, 2 morning items, and 7 evening items and a supplementary set containing 39 items. Participants largely rated the digital questionnaire as "easy to use," with an average score of 4.5 (SD 0.5) on a scale from 1 ("completely disagree") to 5 ("completely agree").

CONCLUSIONS

We developed the ESM-AC questionnaire, a content-validated digital questionnaire for people with advanced breast or lung cancer. It showed good usability when administered on smartphone devices. Future research should evaluate the potential of this ESM tool to uncover daily experiences of people with advanced breast or lung cancer, explore its clinical utility, and extend its validation to other populations with advanced diseases.

Symptomatic and functional recovery after transurethral resection of bladder tumor: Data from ecological momentary symptom assessment

OBJECTIVES

To quantitatively describe the nature, severity, and duration of symptoms and functional impairment during recovery from transurethral resection of bladder tumors.

MATERIALS AND METHODS

All patients scheduled for transurethral resection were approached for enrollment in a text-message based ecological momentary symptom assessment platform. Nine patients reported outcomes were measured 7 days before surgery and on postoperative days 1, 2, 3, 5, 7, 10, and 14 using a 5-point Likert scale. Self-reported degree of hematuria was collected using a visual scale. Clinical data was collected via retrospective chart review.

RESULTS

A total of 159 patients were analyzed. Postoperative symptoms were overall mild, with the largest differences from baseline to postoperative day 1 seen in dysuria (median 0/5 vs. 3/5) and ability to work (median 5/5 vs. 4/5). Recovery was generally rapid, with 76% of patients reporting ≥4/5 agreement with the statement "I feel recovered from surgery" by postoperative day 2, although 15% of patients reported persistently lower levels of agreement on postoperative day 10 or 14. Patients undergoing larger resections (≥2cm) did take longer to return to baseline in multiple symptom domains, but the difference of medians vs. those undergoing smaller resections was less than 1 day across all domains. Multivariable analysis suggested that receiving perioperative intravesical chemotherapy was associated with longer time to recovery. 84% of patients reported clear yellow urine by postoperative day 3.

CONCLUSION

In this population, hematuria and negative effects on quality of life resulting from transurethral resection of bladder tumors were generally mild and short-lived, although a small number of patients experienced longer recoveries.

Testing the feasibility of mobile ecological momentary assessment for symptom burden and management among metastatic cancer patients

Background

Individuals who have metastatic cancer experience substantial physical and psychological distress (e.g., pain, depression, anxiety) from their disease and its treatment compared to patients with less advanced disease. As the burden of symptoms varies over time, ecological momentary assessment (EMA) may be used to better understand patients' symptom trajectories, complimenting traditional longitudinal data collection methods. However, few have used EMA in patients with metastatic disease. The current study adds to the existing literature by exploring interrelated, common cancer-related symptoms of pain, anxiety, and depression and use of cannabis-based products, opioid medications, other (nonopioid) pain medications, and medications for anxiety or depression.

Methods

An eight-day prospective observational feasibility study was conducted among 50 patients with metastatic cancer recruited from seven solid cancer clinics at The Ohio State University Comprehensive Cancer Center. Participants completed a week of interval-contingent mobile EMA, administered daily at 9 a.m., 3 p.m., and 8 p.m., and a comprehensive interviewer-administered questionnaire on Day 8. Participants were queried on their symptom burden and management strategies (i.e., use of medications and cannabis). We considered EMA to be feasible if a priori retention (80%) and adherence goals (75%) were met.

Results

Seventy-nine percent of eligible patients contacted enrolled in the study (n = 50 of 63). Among those enrolled, 92% were retained through Day 8 and 80% completed >90% of EMAs, exceeding a priori objectives. Participants' average pain, anxiety, and depressive symptoms across the week of EMA ranged from 1.7 to 1.8 (1 to 5 scale). Symptoms varied little by day or time of administration. On Day 8, significant proportions of participants reported past-week use of medications and cannabis for symptom management.

Conclusions

Participants exceeded a priori adherence and retention objectives, indicating that mobile EMA is feasible among metastatic cancer patients, addressing a gap in the existing literature and informing future research. Restricting eligibility to participants with a minimum cutoff of symptom burden may be warranted to increase observations of symptom variability and provide opportunities for future health interventions. Future research is needed to test the acceptability and quality of data over a longer study period in this patient population.

Current Landscape of Ecological Momentary Assessment (Real-Time Data) Methodology in Cancer Research: A Systematic Review

OBJECTIVE

To critically synthesize and describe the use and methods of ecological momentary assessment (EMA) in cancer research.

DATA SOURCES

A systematic review was conducted and has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Guideline. Electronic databases (APA PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, and Web of Science Core Collection) were searched using a variety of keywords and subject headings by an expert systematic review librarian. All publications were double screened by two reviewers using predetermined exclusion and inclusion criteria throughout the full review process. The review used Covidence Systematic Review Software. Methodological quality assessment and data extraction were performed. A narrative synthesis was conducted to examine the aim for EMA, the characteristics of the study samples, the EMA sampling procedures, EMA completion rates, outcome measures, and any implications of findings for survivorship care.

CONCLUSION

A total of 42 EMA studies in cancer were included. Most studies used an electronic mobile device to capture EMA data apart from several that used paper diaries. Existing studies were found to have significant heterogeneity in methods and widely varying approaches to design and self-report measurements. While EMA in cancer research holds significant promise to advance cancer care research into the future by increasing ecological validity and reducing retrospective bias and can capture the unique idiographic within-person change over time, in real-time, further research is needed to develop standardized EMA self-report questionnaires.

IMPLICATIONS FOR NURSING PRACTICE

This is the first comprehensive systematic review to describe the use and methods of EMA in cancer research. There is significant heterogeneity in methods and widely varying approaches to design and self-report measurements in EMA cancer research. People affected by cancer found taking part in EMA studies reported benefit from the experience. However, researchers must engage with cancer survivors in the development and co-design of future EMA questionnaires to ensure relevant and acceptability of EMA data collection protocols.

Assessing Patient-Reported Outcomes in Routine Cancer Clinical Care Using Electronic Administration and Telehealth Technologies: Realist Synthesis of Potential Mechanisms for Improving Health Outcomes

BACKGROUND

The routine measurement of patient-reported outcomes in cancer clinical care using electronic patient-reported outcome measures (ePROMs) is gaining momentum worldwide. However, a deep understanding of the mechanisms underpinning ePROM interventions that could inform their optimal design to improve health outcomes is needed.

OBJECTIVE

This study aims to identify the implicit mechanisms that underpin the effectiveness of ePROM interventions and develop program theories about how and when ePROM interventions improve health outcomes.

METHODS

A realist synthesis of the literature about ePROM interventions in cancer clinical care was performed. A conceptual framework of ePROM interventions was constructed to define the scope of the review and frame the initial program theories. Literature searches of Ovid MEDLINE, Ovid Embase, Scopus, and CINAHL, supplemented by citation tracking, were performed to identify relevant literature to develop, refine, and test program theories. Quality appraisal of relevant studies was performed using the Mixed Methods Appraisal Tool.

RESULTS

Overall, 61 studies were included in the realist synthesis: 15 (25%) mixed methods studies, 9 (15%) qualitative studies, 13 (21%) descriptive studies, 21 (34%) randomized controlled trials, and 3 (5%) quasi-experimental studies. In total, 3 initial program theories were developed regarding the salient components of ePROM interventions-remote self-reporting, real-time feedback to clinicians, and clinician-patient telecommunication. The refined theories posit that remote self-reporting enables patients to recognize and report symptoms accurately and empowers them to communicate these to clinicians, real-time feedback prompts clinicians to manage symptoms proactively, and clinician-patient telephone interactions and e-interactions between clinic encounters improve symptom management by reshaping how clinicians and patients communicate. However, the intervention may not achieve the intended benefit if ePROMs become a reminder to patients of their illness and are not meaningful to them and when real-time feedback to clinicians lacks relevance and increases the workload.

CONCLUSIONS

The key to improving health outcomes through ePROM interventions is enabling better symptom reporting and communication through remote symptom self-reporting, promoting proactive management of symptoms through real-time clinician feedback, and facilitating clinician-patient interactions. Patient engagement with self-reporting and clinician engagement in responding to feedback are vital and may reinforce each other in improving outcomes. Effective ePROM interventions might fundamentally alter how clinicians and patients interact between clinic encounters.

Neuroimaging based biotypes for precision diagnosis and prognosis in cancer-related cognitive impairment

Cancer related cognitive impairment (CRCI) is commonly associated with cancer and its treatments, yet the present binary diagnostic approach fails to capture the full spectrum of this syndrome. Cognitive function is highly complex and exists on a continuum that is poorly characterized by dichotomous categories. Advanced statistical methodologies applied to symptom assessments have demonstrated that there are multiple subclasses of CRCI. However, studies suggest that relying on symptom assessments alone may fail to account for significant differences in the neural mechanisms that underlie a specific cognitive phenotype. Treatment plans that address the specific physiologic mechanisms involved in an individual patient's condition is the heart of precision medicine. In this narrative review, we discuss how biotyping, a precision medicine framework being utilized in other mental disorders, could be applied to CRCI. Specifically, we discuss how neuroimaging can be used to determine biotypes of CRCI, which allow for increased precision in prediction and diagnosis of CRCI via biologic mechanistic data. Biotypes may also provide more precise clinical endpoints for intervention trials. Biotyping could be made more feasible with proxy imaging technologies or liquid biomarkers. Large cross-sectional phenotyping studies are needed in addition to evaluation of longitudinal trajectories, and data sharing/pooling is highly feasible with currently available digital infrastructures.

Efficacy of the PRO-CTCAE mobile application for improving patient participation in symptom management during cancer treatment: a randomized controlled trial

PURPOSE

Although mobile-based symptom monitoring is expected to improve patient participation in symptom management during anticancer therapy, previous trials have not evaluated its effectiveness. Therefore, this study aims to evaluate the impact of a symptom monitoring mobile application on improving patient participation in symptom management during anticancer therapy.

METHODS

We conducted a single-center, open-label, randomized controlled trial that enrolled patients with breast, lung, head and neck, esophageal, or gynecologic cancer who were scheduled to receive anticancer therapy (oral or intravenous) between October 2020 and March 2021. We excluded patients with physical or psychological problems. The intervention group received a symptom monitoring application for 8 weeks, and the control group received the usual clinical practice. At 8 weeks, the improvement in patient participation in symptom management was assessed, and additionally quality of life and unplanned clinical visits were assessed.

RESULTS

A total of 222 patients were included in the analysis, of whom 142 were randomly assigned to the intervention group and 71 to the control group. The intervention group reported better outcome in patient participation in symptom management than the control group at 8 weeks (mean scores of 8.5 vs. 8.0; P = 0.01). There were no significant differences between the groups in Quality of life (P = 0.88) and unplanned clinical visits (P = 0.39-0.76).

CONCLUSIONS

This study is meaningful in figuring out that the mobile-based symptom monitoring made them more engaged in their management. Future research should continue to evaluate the effects of patient participation as mediators of clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04568278.

Effects of a Geriatric Assessment Intervention on Patient-Reported Symptomatic Toxicity in Older Adults With Advanced Cancer

PURPOSE

Providing a geriatric assessment (GA) summary with management recommendations to oncologists reduces clinician-rated toxicity in older patients with advanced cancer receiving treatment. This secondary analysis of a national cluster randomized clinical trial (ClinicalTrials.gov identifier: NCT02054741) aims to assess the effects of a GA intervention on symptomatic toxicity measured by Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (PRO-CTCAE).

METHODS

From 2014 to 2019, the study enrolled patients age ≥ 70 years, with advanced solid tumors or lymphoma and ≥ 1 GA domain impairment, who were initiating a regimen with high prevalence of toxicity. Patients completed PRO-CTCAEs, including the severity of 24 symptoms (11 classified as core symptoms) at enrollment, 4-6 weeks, 3 months, and 6 months. Symptoms were scored as grade ≥ 2 (at least moderate) and grade ≥ 3 (severe/very severe). Symptomatic toxicity was determined by an increase in severity during treatment. A generalized estimating equation model was used to assess the effects of the GA intervention on symptomatic toxicity.

RESULTS

Mean age was 77 years (range, 70-96 years), 43% were female, and 88% were White, 59% had GI or lung cancers, and 27% received prior chemotherapy. In 706 patients who provided PRO-CTCAEs at baseline, 86.1% reported at least one moderate symptom and 49.7% reported severe/very severe symptoms at regimen initiation. In 623 patients with follow-up PRO-CTCAE data, compared with usual care, fewer patients in the GA intervention arm reported grade ≥ 2 symptomatic toxicity (overall: 88.9% v 94.8%, P = .035; core symptoms: 83.4% v 91.7%, P = .001). The results for grade ≥ 3 toxicity were comparable but not significant (P > .05).

CONCLUSION

In the presence of a high baseline symptom burden, a GA intervention for older patients with advanced cancer reduces patient-reported symptomatic toxicity.

Assessing cancer-related cognitive function in the context of everyday life using ecological mobile cognitive testing: A protocol for a prospective quantitative study

Objective

Millions of cancer survivors are at risk for cancer-related cognitive impairment (CRCI), yet accurate and accessible assessments of cognitive functioning remain limited. Ecological mobile cognitive testing (EMCT) could offer a solution. This paper presents the protocol for a study that aims to (1) establish the reliability and validity of EMCT to assess CRCI in breast cancer survivors, and (2) prospectively evaluate within-person processes (and interactions) among context, mood, and behavior that explain cognitive variability, everyday functioning, and quality of life of cancer survivors.

Methods

Participants will include breast cancer survivors (>21 years old) who are within 5 years of completing chemotherapy treatment. Participants will complete two virtual visits (baseline, follow-up) 2 months apart to assess self-reported cognitive symptoms and cognitive performance, sociodemographic characteristics, clinical history, everyday functioning, and quality of life. Between virtual visits, EMCT will be used to sample cognitive functioning every other day (28 times total). We will use linear mixed-effect regressions and single-level multiple regression models to analyze the data.

Results

We anticipate a minimum of 124 breast cancer survivors enrolling and completing data collection. Study results will be published in peer-reviewed scientific journals.

Conclusions

Our findings will have broad implications for assessing CRCI in an ecologically valid and person-centered way using EMCT. We aim to provide this protocol to aid researchers who would like to apply this approach to their studies.

The Effects of Multimodal Prehabilitation Interventions in Men Affected by Prostate Cancer on Physical, Clinical and Patient Reported Outcome Measures: A Systematic Review

OBJECTIVES

To synthesize existing evidence on the effects of multimodal prehabilitation interventions in men affected by prostate cancer on physical, clinical, and patient-reported outcome measures.

DATA SOURCES

A systematic review was conducted according to the PRISMA 2020 Statement Guidelines. Electronic databases (ie, Medline, Embase, CINAHL and Cochrane CENTRAL, and clinicaltrials.gov) were searched using key search terms. Articles were assessed according to prespecified eligibility criteria. Data extraction and quality appraisal was conducted. The findings were integrated in a narrative synthesis.

CONCLUSION

Of the 5863 publications screened, 118 articles were assessed in full text and 17 studies met the prescreening eligibility criteria. There were a range of study designs that included randomized controlled clinical trials (n = 11), quasi experimental (n = 4), cohort (n = 1), and case series (n = 1), covering a total of 1739 participants. The prehabilitation interventions included physical activity, peer support, pelvic floor muscle training, diet, nurse-led prehabilitation, psychological, and prehabilitation administration of phosphodiesterase-5 inhibitors.

IMPLICATIONS FOR NURSING PRACTICE

Significant heterogeneity existed in the prehabilitation intervention programs for men affected by prostate cancer in terms of the composition, duration, method of administration, and the outcomes measured to quantify their impact. This systematic review has identified that multimodal prehabilitation interventions are an emerging area for practice and research among men affected by prostate cancer. Importantly, there has been a lack of focus on the inclusion of partners as critical companions during this distressing phase of the cancer care continuum. For the moment, all members of the multidisciplinary team caring for people affected by prostate cancer are encouraged to use the findings in this review to inform holistic models of care.

Emotion Regulation Flexibility and Electronic Patient-Reported Outcomes: A Framework for Understanding Symptoms and Affect Dynamics in Pediatric Psycho-Oncology

Simple Summary

The individual’s ability to conceive and regulate the broad spectrum of their human emotions is closely linked to their mental health. The implications of a serious disease such as cancer represent an extraordinary burden to these internal coping mechanisms, especially in the case of young patients. Regarding their well-being and support, it is therefore of particular interest for caregivers to be able to follow the dynamics of the patient’s emotional world and perceptions. Technical progress enables new possibilities for data collection through tools for digital patient self-reports while simultaneously creating new challenges. Within the scope of this article, we provide an overview of the literature on this topic, outlining the current strengths and weaknesses and possible perspectives on digital aids, especially in terms of capturing the flexibility, fluctuations and early detection of symptom changes.

Abstract

Emotion dysregulation is regarded as a driving mechanism for the development of mental health problems and psychopathology. The role of emotion regulation (ER) in the management of cancer distress and quality of life (QoL) has recently been recognized in psycho-oncology. The latest technological advances afford ways to assess ER, affective experiences and QoL in child, adolescent and young adult (CAYA) cancer patients through electronic patient-reported outcomes (ePRO) in their daily environment in real-time. Such tools facilitate ways to study the dynamics of affect and the flexibility of ER. However, technological advancement is not risk-free. We critically review the literature on ePRO in cancer existing models of ER in pediatric psycho-oncology and analyze strength, weaknesses, opportunities and threats of ePRO with a focus on CAYA cancer research and care. Supported by personal study-based experiences, this narrative review serves as a foundation to propose a novel methodological and metatheoretical framework based on: (a) an extended notion of ER, which includes its dynamic, adaptive and flexible nature and focuses on processes and conditions rather than fixed categorical strategies; (b) ePRO as a means to measure emotion regulation flexibility and affect dynamics; (c) identifying early warning signals for symptom change via ePRO and building forecasting models using dynamical systems theory.

Smartphone-based Ecological Momentary Assessment to study "scanxiety" among Adolescent and Young Adult survivors of childhood cancer: A feasibility study

OBJECTIVE

Scan-related anxiety ("scanxiety") refers to the fear, stress, and anxiety in anticipation of tests and scans in follow-up cancer care. This study assessed the feasibility of Ecological Momentary Assessment (EMA) for real-world, real-time capture of scanxiety using patients' personal smartphone.

METHODS

Adolescent and Young Adult survivors of childhood cancer were prompted to complete EMA surveys on a smartphone app three times per day for 11 days (33 surveys total) around their routine surveillance scans. Participants provided structured feedback on the EMA protocol.

RESULTS

Thirty out of 46 contacted survivors (65%) enrolled, exceeding the preregistered feasibility cutoff of 55%. The survey completion rate (83%) greatly exceeded the preregistered feasibility cutoff of 65%. Participants generally found the smartphone app easy and enjoyable to use and reported low levels of distress from answering surveys. Participants reported significantly more daily fear of cancer recurrence (FCR) and negative affect in the days before compared to the days after surveillance scans, aligning with the expected trajectory of scanxiety. Participants who reported greater FCR and scanxiety using comprehensive measures at baseline also reported significantly more daily FCR around their surveillance scans, indicating validity of EMA items. Bodily threat monitoring was prospectively and concurrently associated with daily FCR, thus warranting further investigation as a risk factor for scanxiety.

CONCLUSIONS

Findings indicate the feasibility, acceptability, and validity of EMA as a research tool to capture the dynamics and potential risk factors for scanxiety.

Smartphone-Based Ecological Momentary Assessment for the Measurement of the Performance Status and Health-Related Quality of Life in Cancer Patients Under Systemic Anticancer Therapies: Development and Acceptability of a Mobile App

Background

We have defined a project to develop a mobile app that continually records smartphone parameters which may help define the Eastern Cooperative Oncology Group performance status (ECOG-PS) and the health-related quality of life (HRQoL), without interaction with patients or professionals. This project is divided into 3 phases. Here we describe phase 1. The objective of this phase was to develop the app and assess its usability concerning patient characteristics, acceptability, and satisfaction.

Methods

The app eB2-ECOG was developed and installed in the smartphone of cancer patients who will be followed for six months. Criteria inclusion were: age over 18-year-old; diagnosed with unresectable or metastatic lung cancer, gastrointestinal stromal tumor, sarcoma, or head and neck cancer; under systemic anticancer therapies; and possession of a Smartphone. The app will collect passive and active data from the patients while healthcare professionals will evaluate the ECOG-PS and HRQoL through conventional tools. Acceptability was assessed during the follow-up. Patients answered a satisfaction survey in the app between 3-6 months from their inclusion.

Results

The app developed provides a system for continuously collecting, merging, and processing data related to patient's health and physical activity. It provides a transparent capture service based on all the available data of a patient. Currently, 106 patients have been recruited. A total of 36 patients were excluded, most of them (21/36) due to technological reasons. We assessed 69 patients (53 lung cancer, 8 gastrointestinal stromal tumors, 5 sarcomas, and 3 head and neck cancer). Concerning app satisfaction, 70.4% (20/27) of patients found the app intuitive and easy to use, and 51.9% (17/27) of them said that the app helped them to improve and handle their problems better. Overall, 17 out of 27 patients [62.9%] were satisfied with the app, and 14 of them [51.8%] would recommend the app to other patients.

Conclusions

We observed that the app's acceptability and satisfaction were good, which is essential for the continuity of the project. In the subsequent phases, we will develop predictive models based on the collected information during this phase. We will validate the method and analyze the sensitivity of the automated results.

A Narrative Review on the Collection and Use of Electronic Patient-Reported Outcomes in Cancer Survivorship Care with Emphasis on Symptom Monitoring

Electronic patient-reported outcome (ePRO) applications promise great added value for improving symptom management and health-related quality of life. The aim of this narrative review is to describe the collection and use of ePROs for cancer survivorship care, with an emphasis on ePRO-symptom monitoring. It offers many different perspectives from research settings, while current implementation in routine care is ongoing. ePRO collection optimizes survivorship care by providing insight into the patients' well-being and prioritizing their unmet needs during the whole trajectory from diagnosis to end-of-life. ePRO-symptom monitoring can contribute to timely health risk detection and subsequently allow earlier intervention. Detection is optimized by automatically generated alerts that vary from simple to complex and multilayered. Using ePRO-symptoms during in-hospital consultation enhances the patients' conversation with the health care provider before making informed decisions about treatments, other interventions, or self-management. ePRO(-symptoms) entail specific implementation issues and complementary ethics considerations. The latter is due to privacy concerns, digital divide, and scarcity of adequately representative data for particular groups of patients.

Social cognitive variables and physical activity during chemotherapy for breast cancer: An intensive longitudinal examination

OBJECTIVE

Although physical activity is associated with better health outcomes in breast cancer survivors (BCS), activity often declines during cancer treatment. Social cognitive theory (SCT) constructs have been associated with physical activity in post-treatment BCS, but little is known about the relation between these constructs and physical activity during chemotherapy.

METHODS

BCS (n = 67; Mage  = 48.6 [SD = 10.3]) undergoing chemotherapy wore accelerometers and completed prompts in the morning and at night assessing same-day and next-day exercise self-efficacy, physical and psychological outcome expectations, and goal-setting for 10 consecutive days (3 days pre-, day of, and 6 days post-chemotherapy dose) at three time points (beginning, middle, and end of chemotherapy). Separate mixed models assessed between- and within-person associations of each of the SCT constructs associations with same- and next-day moderate to vigorous physical activity (MVPA) and light physical activity (LPA), independently.

RESULTS

Within-person differences in all SCT variables were statistically significantly related to same-day MVPA (p's < 0.001) and LPA (p's < 0.001). Every one-point increase in SCT construct related to an increase in MVPA ranging from (a) 3.70 (self-efficacy) to 8.02 (physical outcome expectations) minute increase in MVPA and (b) 12.72 (self-efficacy) to 20.38 (physical outcome expectations) increase in LPA that day. No same-day between-person effects nor any next-day effects were significant.

CONCLUSION

MVPA and LPA were related to same-day within-person differences in SCT variables. Interventions targeted at increasing or mitigating chemotherapy-related declines in daily within-person changes in SCT constructs could help to increase physical activity among BCS during chemotherapy.

The Effect of Collaborative Reviews of Electronic Patient-Reported Outcomes on the Congruence of Patient- and Clinician-Reported Toxicity in Cancer Patients Receiving Systemic Therapy: Prospective, Multicenter, Observational Clinical Trial

Background

Electronic patient-reported outcomes (ePRO) are a relatively novel form of data and have the potential to improve clinical practice for cancer patients. In this prospective, multicenter, observational clinical trial, efforts were made to demonstrate the reliability of patient-reported symptoms.

Objective

The primary objective of this study was to assess the level of agreement κ between symptom ratings by physicians and patients via a shared review process in order to determine the future reliability and utility of self-reported electronic symptom monitoring.

Methods

Patients receiving systemic therapy in a (neo-)adjuvant or noncurative intention setting captured ePRO for 52 symptoms over an observational period of 90 days. At 3-week intervals, randomly selected symptoms were reviewed between the patient and physician for congruency on severity of the grading of adverse events according to the Common Terminology Criteria of Adverse Events (CTCAE). The patient-physician agreement for the symptom review was assessed via Cohen kappa (κ), through which the interrater reliability was calculated. Chi-square tests were used to determine whether the patient-reported outcome was different among symptoms, types of cancer, demographics, and physicians’ experience.

Results

Among the 181 patients (158 women and 23 men; median age 54.4 years), there was a fair scoring agreement (κ=0.24; 95% CI 0.16-0.33) for symptoms that were entered 2 to 4 weeks before the intended review (first rating) and a moderate agreement (κ=0.41; 95% CI 0.34-0.48) for symptoms that were entered within 1 week of the intended review (second rating). However, the level of agreement increased from moderate (first rating, κ=0.43) to substantial (second rating, κ=0.68) for common symptoms of pain, fever, diarrhea, obstipation, nausea, vomiting, and stomatitis. Similar congruency levels of ratings were found for the most frequently entered symptoms (first rating: κ=0.42; second rating: κ=0.65). The symptom with the lowest agreement was hair loss (κ=–0.05). With regard to the latency of symptom entry into the review, hardly any difference was demonstrated between symptoms that were entered from days 1 to 3 and from days 4 to 7 before the intended review (κ=0.40 vs κ=0.39, respectively). In contrast, for symptoms that were entered 15 to 21 days before the intended review, no congruency was demonstrated (κ=–0.15). Congruency levels seemed to be unrelated to the type of cancer, demographics, and physicians’ review experience.

Conclusions

The shared monitoring and review of symptoms between patients and clinicians has the potential to improve the understanding of patient self-reporting. Our data indicate that the integration of ePRO into oncological clinical research and continuous clinical practice provides reliable information for self-empowerment and the timely intervention of symptoms.

Trial Registration

ClinicalTrials.gov NCT03578731; https://clinicaltrials.gov/ct2/show/NCT03578731

Ecological Momentary Assessment and mHealth Interventions Among Men Who Have Sex With Men: Scoping Review

BACKGROUND

Ecological momentary assessment (EMA) is a research design that allows for the measurement of nearly instantaneous experiences within the participant's natural environment. Using EMA can help improve recall bias, ecological validity, and patient engagement while enhancing personalization and the ubiquity of interventions. People that can benefit from the use of EMA are men who have sex with men (MSM). Previous EMA studies have been successful in capturing patterns of depression, anxiety, substance use, and risky sexual behavior. These findings are directly relevant to MSM, who have high rates of each of these psychological and behavioral outcomes. Although there is a driving force behind the growing literature surrounding EMAs among MSM, no synthesizing reviews yet exist.

OBJECTIVE

The aims of this study were to (1) synthesize the literature across fields on how EMA methods have been used among MSM, (2) better understand the feasibility and acceptability of EMA interventions among MSM, and (3) inform designs for future research studies on best evidence-based practices for EMA interventions.

METHODS

Based on 4 library databases, we conducted a scoping review of EMAs used within interventions among MSM. The eligibility criteria included peer-reviewed studies conducted in the United States and the use of EMA methodology in an intervention for MSM. Modeling after the Centers for Disease Control and Prevention's Compendium of Evidence-Based Interventions as the framework, we applied a typology that used 8 distinct review criteria, for example, sample size, design of the intervention, random assignment, design of the follow-up investigation, rate of retention, and rate of engagement.

RESULTS

Our results (k=15, N=952) indicated a range of sample sizes; the smallest sample size was 12, while the largest sample size was 120. Of the 15 studies, 7 (47%) focused on outcomes related to substance use or outcomes related to psychological experiences. Of the 15 studies, 5 (33%) implemented an EMA intervention across 30 days. Of the 15 studies, 2 studies (13%) used random assignment, and 2 studies (13%) had quasi-experimental designs. Of the 15 studies, 10 studies (67%) reported acceptable retention rates greater than 70%. The outcomes that had event-contingent prompts (ie, prompts after engaging in substance use) were not as effective in engaging participants, with overall engagement rates as low as 37%.

CONCLUSIONS

Our systematic scoping review indicates strong evidence that the EMA methodology is both feasible and acceptable at high rates among MSM, especially, when examining psychological and behavioral outcomes such as negative or positive affect, risky sexual behavior, or substance use. Further research on optimal designs of EMA interventions for MSM is warranted.