Real-world use and clinical impact of an electronic patient-reported outcome tool in patients with solid tumors treated with immuno-oncology therapy

BACKGROUND

Utilization of electronic patient-reported outcome (ePRO) tools to monitor symptoms in patients undergoing cancer treatment has shown clinical benefits. Tennessee Oncology (TO) implemented an ePRO platform in 2019, allowing patients to report their health status online. We conducted a real-world, multicenter, observational, non-interventional cohort study to evaluate utilization of this platform in adults with solid tumors who initiated immuno-oncology (IO) therapy as monotherapy or in combination at TO clinics.

METHODS

Patients initiating IO therapy prior to platform implementation were included in a historical control (HC) cohort; those initiating treatment after implementation were included in the ePRO cohort, which was further divided into ePRO users (platform enrollment ≤ 45 days from IO initiation) and non-users. Data were extracted from electronic medical records; patients were followed for up to 6 months (no minimum follow up). Outcomes included patient characteristics, treatment patterns, duration of therapy (DoT), and overall survival (OS).

RESULTS

Data were collected for 538 patients in the HC and 1014 in the ePRO cohort; 319 in the ePRO cohort were ePRO users (uptake rate 31%). Baseline age was higher, more patients had stage IV disease at diagnosis, and more received monotherapy (82 vs 52%, respectively) in the HC vs the ePRO cohort. Median follow-up was 181.0 days (range 0.0-182.6) in the HC and 175.0 (0.0-184.0) in the ePRO cohort. Median DoT of index IO regimen was 5.1 months (95% confidence interval [CI], 4.4-NE) in the HC cohort vs not estimable (NE) in the ePRO cohort. Multivariable regression adjusting for baseline differences confirmed lower risk of treatment discontinuation in the ePRO vs HC cohort: hazard ratio (HR) 0.83 (95% CI, 0.71-0.97); p < 0.05. The estimated 6-month OS rate was 65.5% in the HC vs 72.4% in the ePRO cohort (p < 0 .01). Within the ePRO cohort, DoT of index IO regimen and OS did not differ between users and non-users. In ePRO users, patient platform use was durable over 6 months.

CONCLUSION

Improvements in DoT and OS were seen after ePRO platform implementation. Conclusions are limited by challenges in separating the impact of platform implementation from other changes affecting outcomes.

Real-world use and clinical impact of electronic patient-reported outcomes (ePROs) in patients with solid tumors treated with immuno-oncology (IO) therapy

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Background: Patients with cancer can experience disease- and treatment-related symptoms that are underreported and underestimated by physicians. This observational, non-interventional study evaluated the use of ePROs and their impact on duration of treatment (DoT) in patients with solid tumors receiving IO therapy in community practice. Methods: Patients initiating index IO therapy immediately prior to (Jan-2017 to Dec-2018) and after (Sep-2019 to Dec-2020) implementation of Noona, the ePRO platform at Tennessee Oncology clinics, were included in a retrospective historical control (HC) and ePRO cohort, respectively, and followed for up to 6 months. The ePRO cohort was further divided into ePRO users (platform enrollment ≤45 days from index) and non-users. ePRO questionnaires, based on Common Terminology Criteria for Adverse Events (CTCAE), were sent within a week after each IO infusion and could be completed using an internet browser or smartphone app. Patient characteristics and DoT were described and compared between the HC and ePRO cohorts and between the HC cohort and ePRO users subgroup. Use of ePROs was evaluated within the ePRO cohort. Differences in baseline characteristics between cohorts were adjusted using Cox proportional hazards models. Results: Data were collected for 538 HC and 1014 ePRO patients (319 ePRO users and 695 non-users). Patient characteristics were generally similar between cohorts, but more HC patients were diagnosed with Stage IV disease (54% vs 47%; p < 0.01) and initiated IO as monotherapy (82% vs 52%), while more ePRO patients initiated IO as combination therapy (48% vs 18%). ePRO users were more likely than non-users to be female, white, married, living with a spouse, and have higher education (college or graduate degree) (all p < 0.05). Use of ePROs was durable over follow-up, with a consistent number of questionnaires sent over Months 1-3 and Months 4-6 (median: 6 questionnaires in each period) and a slight decrease in the number answered (median: 4 vs 3 questionnaires). ePRO patients had a longer DoT than HC patients (median time to end of first IO regimen: not estimable vs 5.1 months). Significantly more ePRO than HC patients remained on their first IO regimen at 6 months (54% vs 46%; p < 0.05). Multivariate Cox regression showed the risk of ending first IO therapy was lower for ePRO versus HC patients (p < 0.05). Conclusions: The increased DoT observed in the ePRO versus HC cohort in this study suggests that use of ePROs may facilitate improved care coordination and enable patients to remain on IO therapy longer. However, ePRO uptake was only 31% in the ePRO cohort, with several social determinants appearing to influence use. Overcoming barriers in ePRO uptake is an area for future study.

Impact of clinical pathways on treatment patterns and outcomes for patients with non-small-cell lung cancer: real-world evidence from a community oncology practice

Introduction: The evolving treatment landscape for non-small-cell lung cancer (NSCLC) and complexities of regulations and reimbursement present challenges to community oncologists. Clinical pathways are tools to optimize care, but information on their value in the real world is limited. This retrospective study assessed treatment patterns and clinical outcomes in patients with Stage I-III NSCLC pre- and post-pathways implementation at Tennessee Oncology, a large, community-based oncology practice in the USA. Methods & Materials: Chart data were abstracted for adults diagnosed with Stage I-III NSCLC who received systemic treatment. Patients were divided into pre-pathways (treatment initiation 2014-2015) and post-pathways (treatment initiation 2016-2018) cohorts. Patient characteristics, treatment patterns and outcomes were summarized descriptively. Kaplan-Meier curves were used to assess time-dependent outcomes, and log-rank test was used to compare the cohorts. Results: 291 patients were included (Stage I-II: 38 pre-pathways, 55 post-pathways; Stage III: 105 pre-pathways, 93 post-pathways). Duration on first-line (1L) therapy was similar for Stage I-II patients pre- and post-pathways (median 1.9 months vs 2.1 months; p = 0.75), but increased for Stage III patients post-pathways (2.1 months vs 1.4 months pre-pathways; p < 0.01). Achievement of a complete or partial response with 1L therapy was similar post-pathways among Stage I-Stage -IIII patients (60.0% vs 55.2% pre-pathways), but increased for Stage III patients (56.0% vs 35.2% pre-pathways). Conclusion: Given that improvements in rates of treatment response post-pathways occurred only for patients diagnosed with Stage III NSCLC, among whom immunotherapy uptake increased post-pathways, such improvements may be attributable to evolving practices in cancer care, including advances in treatment and care delivery, rather than clinical pathways implementation. Further research is warranted to assess the impact of clinical pathways in the current treatment era, given that immunotherapy has now become the standard of care in NSCLC.

Clinical pathways implementation in a community-based oncology practice: Real-world outcomes in patients with non-small cell lung cancer segmented by disease stage at diagnosis

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Background: Clinical pathways have been introduced as tools to optimize cancer care delivery, but evidence of their value in the real world is limited. This retrospective study was performed to assess treatment patterns and clinical outcomes in patients with non-small cell lung cancer (NSCLC) before and after pathway implementation at Tennessee Oncology (TO). Methods: Chart data were abstracted for patients (≥18 years) diagnosed with Stage I-IV NSCLC who initiated first-line (1L) systemic treatment at a TO clinic and had follow-up for ³6 months or until death. Patients were divided into two cohorts: pre-pathways (treatment initiation 2014–2015) and post-pathways (treatment initiation 2016–2018). Patient characteristics, treatment patterns, and outcomes were described and compared across cohorts. An exploratory study endpoint was the evaluation of outcomes based on disease stage at diagnosis. Results: Among 501 patients (251 pre-pathways and 250 post-pathways), most had advanced or metastatic NSCLC at diagnosis (Stage III: 40%; Stage IV: 42%). Chemotherapy comprised almost all 1L systemic therapy used pre-pathways (Stage I/II: 100%; Stage III: 96%; Stage IV: 83%). Post-pathways, chemotherapy remained the most common 1L therapy in patients with Stage I/II (89%) and Stage III (72%) disease, but among patients with Stage IV disease, use of chemotherapy decreased (47%) and immuno-oncology (IO) therapy alone or in combination became common (45%). Median duration of 1L therapy was longer post-pathways in patients with Stage III (2.1 months vs 1.4 months pre-pathways; P < 0.01) and Stage IV disease (3.3 months vs 2.3 months pre-pathways; P < 0.01) but did not differ among Stage I/II patients. Median progression-free survival was significantly longer post-pathways in patients with Stage IV disease (7.0 months vs 4.2 months pre-pathways; P < 0.05), but not in other disease-stage subgroups. Median overall survival increased non-significantly post-pathways for all disease stage subgroups (Stage I/II: 26 months vs 20 months pre-pathways; Stage III: 26 months vs 20 months; Stage IV: 10 months vs 9 months). For each disease stage, rates of severe adverse events were similar between cohorts. Conclusions: While outcomes for patients diagnosed with Stage III/IV NSCLC were generally improved following the implementation of clinical pathways, this change coincided with a dramatic shift in available treatment options. Improvements post-pathways were mainly observed in patients diagnosed with advanced disease. Thus, differences in outcomes between pre-pathways and post-pathways cohorts in our study are more likely attributable to other evolving practices in cancer care, particularly the availability of newer, more effective treatments such as IO therapy as part of standard practice, than implementation of the clinical pathways.

Electronic patient-reported outcomes (ePRO) platform engagement in cancer patients during COVID-19

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Background: Tennessee Oncology partnered with an ePRO platform solution to support patients during their cancer care journey. This cloud-based ePRO platform is designed to assist in improving the management of symptoms. Providing two core pieces of functionality allow both the patient and care teams to retrieve information quickly and communicate effectively. The patient portal is patient input driven and allows the patient to communicate with their care team, track symptoms, and access their health records via website or mobile app. The clinician portal provides multiple care teams the ability to manage and prioritize patient needs as well as communicate directly with patients. In March 2020, due to the pandemic, patients needed a convenient and remote way to communicate with the care team. Our communication plan had to be nimble and provide immediate updates to our large patient population. We leveraged our ePRO platform to meet this need. Methods: We focused efforts on increasing patient engagement by educating them on the benefits of this communication platform. We utilized secure messaging to send appointment details and for Telehealth visits a link to the visit was sent. We were able to provide weekly updates outlining our latest information regarding our safety protocols. Results: We noted an increase in the activation of patient accounts and patient-initiated messages in our ePRO platform. We saw an average of 1,000 new patient accounts activated each month during March, April and May. We saw that patient-initiated messages through the platform showed a 15% increase from February to March. The response rate for patients completing post-treatment questionnaires increased 8% from February to May. Conclusions: By providing patients with a single communication platform to contact their care teams outside of their office visits, patients become an active part of their care journey. As an organization, we continue to identify ways to connect our patients to their care team in a meaningful way through technology. Whether during normal business hours or after-hours, patients need a simple, reliable and consistent way to engage with their care team.