Promoting Self-management and Patient Activation Through eHealth: Protocol for a Systematic Literature Review and Meta-analysis

BACKGROUND

Major advances in different cancer treatment modalities have been made, and people are now living longer with cancer. However, patients with cancer experience a range of physical and psychological symptoms during and beyond cancer treatment. New models of care are needed to combat this rising challenge. A growing body of evidence supports the effectiveness of eHealth interventions in the delivery of supportive care to people living with the complexities of chronic health conditions. However, reviews on the effects of eHealth interventions are scarce in the field of cancer-supportive care, particularly for interventions with the aim of empowering patients to manage cancer treatment-related symptoms. For this reason, this protocol has been developed to guide a systematic review and meta-analysis to assess the effectiveness of eHealth interventions for supporting patients with cancer in managing cancer-related symptoms.

OBJECTIVE

This systematic review with meta-analysis is conducted with the aim of identifying eHealth-based self-management intervention studies for adult patients with cancer and evaluating the efficacy of eHealth-based self-management tools and platforms in order to synthesize the empirical evidence on self-management and patient activation through eHealth.

METHODS

A systematic review with meta-analysis and methodological critique of randomized controlled trials is conducted following Cochrane Collaboration methods. Multiple data sources are used to identify all potential research sources for inclusion in the systematic review: (1) electronic databases such as MEDLINE, (2) forward reference searching, and (3) gray literature. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for conducting the review were followed. The PICOS (Population, Interventions, Comparators, Outcomes, and Study Design) framework is used to identify relevant studies.

RESULTS

The literature search yielded 10,202 publications. The title and abstract screening were completed in May 2022. Data will be summarized, and if possible, meta-analyses will be performed. It is expected to finalize this review by Winter 2023.

CONCLUSIONS

The results of this systematic review will provide the latest data on leveraging eHealth interventions and offering effective and sustainable eHealth care, both of which have the potential to improve quality and efficiency in cancer-related symptoms.

TRIAL REGISTRATION

PROSPERO 325582; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=325582.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38758.

Abstract P6-01-16: Circulating Tumour DNA (ctDNA) Detection and Dynamics in Patients with Early Breast Cancer (EBC): Results of the Neoadjuvant TRACER cohort

Background: ctDNA dynamics are associated with treatment response, and ctDNA detection following treatment is associated with disease recurrence in early breast cancer (EBC). Highly sensitive assays may permit effective risk stratification and guide interventional strategies. RaDaR, a bespoke assay using deep sequencing of tumour-specific variants, has been shown to detect recurrence in the postoperative setting. We quantified ctDNA using RaDaR in serial samples from a large prospective cohort of EBC patients who received standard neoadjuvant chemo- (+/- HER2- targeted) therapy.

Methods: Patients with EBC of all receptor subtypes receiving neoadjuvant therapy were enrolled in the TRACER cohort from 2015. Plasma samples (Streck) were collected at baseline, during treatment, perioperatively, and during follow-up. RaDaR was performed on all available timepoints for patients with tissue available for exome sequencing (assay requirement). Clinical and pathologic characteristics, treatment, and recurrence outcomes were collected.

Results: 145 patients were recruited as of April 2021, and over 700 plasma samples were collected through December 2021 (patient characteristics, Table 1). 115 (79%) tissue samples were retrieved for assay design. Data are presented for the initial 43 patients and 265 samples analyzed, including 82 post-surgical time points. Median time since diagnosis was 3.5 years (range, 1.5-5.0). Exome sequencing and assay generation were successful in all patients (n=43), yielding assays targeting a median of 48 (range 22-50) variants. 88% (38/43 patients) had ctDNA detected at baseline, with median variant allele frequency (eVAF) in positive patients of 0.15% (range, 0.0019-4.9%). ctDNA levels fell rapidly with treatment: 19/37 (51.3%; median eVAF in positive patients: 0.0098%, range 0.001-0.156%) had ctDNA detected prior to cycle 2, and 4/32 (12.5%) had ctDNA detected at cycle 4 or 5 (mid treatment; median eVAF in positive patients: 0.001%, range, 0.0007-0.011%). In the perioperative period, 17/18 (94%) of patients with available pre-operative specimens and 27/28 (96%) of patients with available post-operative samples had clearance of ctDNA. In adjuvant follow up, ctDNA was detected in 4 of the 43 analyzed patients, with ctDNA clearance observed following planned switch of endocrine therapy in one. Clinical follow-up continues, and analysis of the remaining samples (72 patients and over 425 samples) is underway.

Conclusion: RaDaR demonstrated high sensitivity for ctDNA prior to treatment in patients receiving neoadjuvant therapy for EBC, permitted dynamic monitoring of treatment effect, and identified patients with persistent ctDNA after curative-intent therapy, as well as ctDNA emergence prior to clinical recurrence. Full results for the TRACER cohort and analysis of clinical covariates will be presented at the meeting. ClinicalTrials.gov NCT03702309.

Table 1. Patient Baseline Characteristics

Citation Format: Mitchell J. Elliott, Zachary Veitch, Philippe Bedard, Eitan Amir, Aaron Dou, Jesus Fuentes Antras, Michelle Nadler, Nicholas Meti, Nancy Gregorio, Elizabeth Shah, Helen Chow, Nathan Campbell, Samantha Terrell, Charlene Knape, Karen Howarth, Lillian Siu, Hal Berman, David W. Cescon. Circulating Tumour DNA (ctDNA) Detection and Dynamics in Patients with Early Breast Cancer (EBC): Results of the Neoadjuvant TRACER cohort [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-01-16.

Development of a remote monitoring program for melanoma/skin oncology patients at Princess Margaret Cancer Centre

e18630

Background: The Melanoma/Skin Oncology (MSO) clinic supports > 200 patients on active treatment at any given time. In September 2018, the MSO clinic implemented a nurse-led proactive management program (IMBRASE) to support the monitoring of adverse events (AEs) in patients receiving immunotherapy (IO). Nurses conducted telephone calls at a pre-determined frequency to identify those who required immediate in-person assessment. Despite an initial 40% drop in emergency department visits in the first few months of implementation, insufficient human resources and lack of prioritization of assessments impacted the clinic’s ability to sustain this program. We sought to overcome this limitation by employing digital health technology to monitor and triage on-treatment patients for assessment (eIMBRASE program). Methods: MSO team worked alongside an internal innovation team (Cancer Digital Intelligence) to develop a remote assessment program with an algorithm able to prioritize patients by combining real-time biometrics and automatically scheduled electronic patient-reported outcomes (ePROs) data of individuals undergoing targeted-therapy and IO. This new digital tool will be accessible via smartphone/computer. It will enable patients to send their data to the clinical team and establish priorities based on patients’ complexity of symptoms. Results: eIMBRASE algorithm requires four data points to be displayed for the clinical team: overall priority, cumulative score (CS), biometric alert, and no response alert. The first two points are based on ePROs, for which we established a set of symptoms of interest for each treatment modality. Each symptom can be categorized in 1 of the 6 priority levels. Each priority is associated with a number of complexity points on a logarithmic scale from 0 - 400. After a questionnaire is submitted, a CS is generated for clinicians to determine which patient may be the most complex and deserve priority assessment. Regarding the third data point, oxygen saturation (SpO2) and temperature (T) measures are collected throughout the day and patients are flagged according to the following predefined thresholds: T - red alert > 38.5C, orange 38.1-38.4C, yellow 37.5-38C; and SpO2 - red alert £93%. Patients under the highest risk of AEs, for instance those on anti-CTLA4 + anti-PD1, are required to complete ePROs daily during the first 12 weeks. Patients under low-risk therapies are required to complete ePROs 1x/week. The tool triggers priority-oriented timeframe for medical contact. To minimize the influence of poor electronic literacy, patients will have their apps set up at clinic before treatment initiation. Conclusions: eIMBRASE development presents an alternative way to use digital health tools to potentially improve quality of care for MSO patients. A pilot study will be conducted to assess its feasibility, the impact in patients’ outcomes and satisfaction.

Management of Pyrexia Associated with the Combination of Dabrafenib and Trametinib: Canadian Consensus Statements

The combination of dabrafenib and trametinib is a well-established treatment for BRAF-mutated melanoma. However, the effectiveness of this approach may be hindered by the development of treatment-related pyrexia syndrome, which occurs in at least 50% of treated patients. Without appropriate intervention, pyrexia syndrome has the potential to worsen and can result in hypotension secondary to dehydration and associated organ-related complications. Furthermore, premature treatment discontinuation may result in a reduction in progression-free and overall survival. Despite existing guidance, there is still a wide variety of therapeutic approaches suggested in the literature for both the definition and management of dabrafenib and trametinib-related pyrexia. This is reflected in the practice variation of its prevention and treatment within and between Canadian cancer centres. A Canadian working group was formed and consensus statements were constructed based on evidence and finalised through a two-round modified Delphi approach. The statements led to the development of a pyrexia treatment algorithm that can easily be applied in routine practice. The Canadian working group consensus statements serve to provide practical guidance for the management of dabrafenib and trametinib-related pyrexia, hopefully leading to reduced discontinuation rates, and ultimately improve patients' quality of life and cancer-related outcomes.

Investigating coping strategies and social support among Canadian melanoma patients: A survey approach

Complex support needs are involved in coping with a diagnosis of melanoma. The purpose of this study was to determine the perceived social support levels and utilization of adaptive and maladaptive coping strategies by Canadian melanoma patients. The impact of social support level on coping strategy utilization was also examined. Social support and coping strategies were assessed using the Medical Outcomes Study Social Support Survey (MOS-SSS) and the 28-item Brief COPE, respectively. Perceived levels of emotional/informational support were significantly lower than affectionate support and positive social interaction. Acceptance, active coping, and use of emotional support were the most frequently utilized coping strategies. Patients with higher perceived levels of social support had significantly higher adaptive coping scores than patients with lower levels of social support. Health care professionals have an important role in promoting awareness of and access to emotional and informational support resources in order to improve perceived social support levels.

Radiological Assessment of the Anatomic Adequacy of Locoregional Lymphatic Radiotherapy Target Volumes for Locally Advanced Breast Cancer (LABC)

Background: Women with LABC are at high risk of regional nodal metastases. Failure to control nodal disease can not only result in lymphedema and brachial plexopathy but may also reduce overall survival. Locoregional radiotherapy is typically delivered in an adjuvant manner using standard field borders. An analysis of the anatomic extent of lymphatic nodal disease at the time of presentation of LABC could provide insight into the adequacy of standard locoregional radiotherapy target volumes.Material and Methods: Staging CT and MRI DICOM image sets from a prospective LABC dataset were obtained for analysis. The locations of the lymph node metastases within the lymphatic nodal basins were transposed upon a reference CT DICOM image set in relation to relevant anatomic landmarks. The locoregional lymph nodes were classified into separate categories according to recognized boundaries (Dijkema et al.). Standard four-field borders to treat the breast/chest wall and regional lymphatics were defined and the percent coverage of the lymphatic nodal basins and the lymphatic metastases by 95% of the prescribed dose calculated. Radiotherapy treatment planning was completed using Pinnacle3 software (Version 8.0, Philips Medical System, Bothell, WA, USA).Results: From July 2006 to December 2008, 120 women with LABC were identified. Median age 52 years (range 27 to 93) with 64 left-sided and 56 right-sided primaries (1 cT1N1, 2 cT1N2, 6 cT2N0, 3 cT2N1, 3 cT2N2, 18 cT3N0, 30 cT3N1, 25 cT3N2, 2 cT3N3, 10 cT4N0, 9 cT4N1, 8 cT4N2, 1 cT4N3, 2 not available). The primary disease was situated within: all 4 quadrants and axillary tail in 14, centrally in 10, 3 quadrants in 1, 2 quadrants in 22 and 1 quadrant in 13 of the patients. Of the 60 woman analyzed to date, a total of 165 metastatic lymph nodes were identified by the radiographic staging investigations (127 level I axilla, 20 level II axilla, 4 level III axilla, 2 interpectoral, 2 medial supraclavicular, 1 lateral supraclavicular, 1 infraclavicular, 1 internal mammary, 7 intra-mammary lymph nodes). After placement of the four-field borders all of the lymphatic nodal basins were covered within the treatment fields except for the level I axillary, and lateral and medial supraclavicular regions, where the volume outside of the 95% prescribed dose was 18%, 6% and 28% respectively. With the exception of the level I axillary region, all of the metastatic lymph nodes were encompassed within each of the nodal basins and by the prescribed dose.Conclusions: Increased knowledge of the anatomical distribution of nodal disease in LABC patients prior to systemic therapy facilitates the validation of population based nodal clinical target volumes and affords assurance as to their adequacy. The lymph nodes identified in this series support the current definitions used to account for potential locoregional spread and may be used to further refine specific boundaries. With incorporation of the topographic distribution of gross nodal disease and the improving ability to detect micrometastatic disease, patient specific precision radiotherapy treatment planning is becoming possible.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4115.