Online symptom monitoring for lung cancer patients receiving systemic therapy: a feasibility implementation project

Modern systemic anti-cancer therapies have resulted in an improved prognosis for lung cancer patients. However, their complex toxicities require close monitoring. An existing e-Health platform called eRAPID (Electronic patient self-Reporting of Adverse events: Patient Information and aDvice), enables patients to report symptoms and receive automatic severity-dependent advice to self-manage or contact the hospital. Symptom data is available in real-time for clinicians in the patients' electronic patient record (EPR). The feasibility study aimed to implement eRAPID for symptom/toxicity monitoring of lung cancer patients during and after systemic therapy. Primary outcomes were recruitment and consent rates, attrition rates and adherence to symptom reporting. Secondary outcomes were: (I) type, frequency, and severity of self-reported symptoms; (II) activated clinical algorithms for patient advice; and (III) patient and staff acceptance and views.

Consecutive patients starting systemic therapy were recruited and followed up for 12-months. Participants joined Cohort 1 (online access, reporting weekly from home) or Cohort 2 (no online access, completing before appointments every 4-6 weeks with assistance). Patients completed symptom reports, designed with the lung clinicians, plus 3 monthly quality-of-life questionnaires (EuroQol-5 dimensions). Descriptive analysis was employed for the quantitative outcomes. Semi-structured interviews and online feedback gathered views from a subset of patients and clinicians, using thematic framework analysis. Study project registration number: NCT04324437.

Between August 2020 and July 2022, eighty-five patients were eligible, 43 (50.6%) consented, 33 Cohort 1, 10 Cohort 2. The attrition rate was 65.1% (28/43) primarily due to disease progression. For all patients, a total of 841 symptom reports were generated. For Cohort 1, the mean weekly adherence for symptom reporting was 68.9% (range, 50-70%). The most reported symptoms were fatigue (77%), physical limitations (76%), pain (60%) and shortness of breath (59%), but they were mainly mild. The clinical algorithm generated 56 notifications to the clinical team for severe symptoms (6.7%, 56/841), with physical limitations and rash most common. Three-monthly adherence to quality-of-life questionnaires was 60-90%. Patient and staff feedback (n=14 and n=9) revealed reassurance and confidence from patients in self-managing side-effects. Although clinicians did not always discuss the reported symptoms, patients felt more connected to their healthcare team. Clinicians valued eRAPID for tracking symptoms, planning consultations, making timely clinical decisions and improving patient relations.

The eRAPID approach was accepted by half of the patients who were eligible to take part. There was good adherence over time, and willingness to complete 3-monthly quality of life measures. Clinicians and patients supported the intervention for routine practice but required further investment and support from the hospital to make the symptom monitoring sustainable.