August 2012, VOl 5, NO 7 by The Oncology Nurse

Supportive Care

Nurse Practitioner–Delivered Automated Telephone Remote Monitoring System Provides Good Control of Unrelieved Chemotherapy-Induced Symptoms By Alice Goodman

n automated computer-based telephone remote monitoring system with a built-in follow-up component involving nurse practitioners (NPs) appears to be feasible and effective for managing cancer patients’ unrelieved symptoms following chemotherapy. A study presented at the 2012 Annual Meeting of the American Society of Clinical Oncology showed that use of this system during chemotherapy cut the number of days with severe symptoms by two-thirds and the number of moderate symptom days by half, at the same time increasing the number of asymptomatic days and mild symptom days. “This is a case management system in which we monitor symptoms with our automated system and then automatically triage unrelieved symptoms to the nurse practitioner for follow-up. With the case management component, the nurse practitioner is able to see the data on symptom severity and distress and symptom trends over time, and then use the national symptom guidelines for further assessment and intervention,” explained Kathi Mooney, PhD, RN, College of

Nursing and Huntsman Cancer Institute, University of Utah, Salt Lake City. Prior to initiating chemotherapy, 335 patients were randomized to telephone care (TC; n = 173) or usual care (UC; n = 162). Regardless of randomization assignment, all patients called in to a

“We monitor symptoms with our automated system and then automatically triage unrelieved symptoms to the nurse practitioner for follow-up." —Kathi Mooney, PhD, RN

remote system daily and reported the presence, severity, and distress (on a scale from 0 to 10) for 11 common chemotherapy-associated symptoms (ie, fatigue, pain, insomnia, nausea, depression, anx-

iety, impaired thinking, numbness, diarrhea, mucositis, and appearance). Patients assigned to TC also received automated tailored symptom self-care messages and telephone calls from NPs for further treatment of their symptoms. The NP’s intervention was triggered by automated alerts about any unrelieved symptoms at moderate to severe levels. Participants’ median age was around 56 years, and about 77% were female. About 45% had breast cancer, 16% had lung cancer, and 10% had ovarian cancer; 45% of participants had stage IV cancer. Patients in the TC group experienced a significantly lower number of severe symptom days (mean, 3.16 vs 10.24, respectively; P <.001) and moderate symptom days (mean, 8.91 vs 19.06, respectively; P <.001) versus the UC group. The TC group also experienced significantly more asymptomatic days (mean, 66.06 vs 52.02, respectively; P = .015) and a somewhat higher number of mild symptom days (mean, 19.85 vs 13.75, respectively; P = .06) versus the UC group.

The incidence of each of the 11 common symptoms was significantly lower in the TC group (P <.001), with the exception of diarrhea. The study found that TC intervention significantly reduced alerting symptoms within 4 days of the NP telephone calls (P <.001). Mooney and colleagues hope to present further information about the system and both patient and NP satisfaction with using it at an Oncology Nursing Society meeting in the fall of 2012. In a separate interview, she explained that the system was first tested with symptom alerts sent to oncologists and nurses, and that the study showed no difference between UC and TC, because the providers did not follow up. Results of this new study, however, suggest that if there is follow-up, patients experience fewer days of unrelieved symptoms. l Reference Mooney KH, Beck SL, Wong B, Dunson WA Jr, Wujcik D. Outpatient chemotherapy supportive care: trial of an IT integrated, NP delivered system for unrelieved symptoms. Poster presented at: 48th Annual Meeting of the American Society of Clinical Oncology; June 1-5, 2012; Chicago, IL. Abstract 9137.

Renal Cell Carcinoma Quality of Life Drives Patient Preference... Continued from cover

AuguST 2012 I VOL 5, NO 7

mg of sunitinib as first-line cancer treatment; after a 2-week washout period, patients received 10 weeks of the alternate treatment. The primary end point was patient preference, measured at 22 weeks. Because patients with mRCC receive therapies for many months or even years, the team assessed whether the drug toxicity would be significant enough to make patients want to continue treatment with either drug or to switch therapy. A total of 126 patients completed a preference questionnaire. In the primary analysis, 70% of the patients preferred pazopanib, 22% preferred sunitinib, and 8% cited no preference. After adjustments for a modest sequence effect, the difference in preference was 49% in favor of pazopanib. All other analyses showed a significant preference for pazopanib. The most common reasons given for pazopanib preference were better QOL and less fatigue. Patients taking pazo-

patients to prefer one drug over the other because of adverse effects, but “we didn’t ever expect such a big difference between the 2 drugs.” —Bernard J. Escudier, MD

panib had fewer dose reductions than those taking sunitinib (13% vs 20%, respectively) and fewer treatment interruptions (6% vs 12%). Adverse events were compatible with known profiles for both drugs. The researchers, led by Bernard J. Escudier, MD, from the Institut Gustave Roussy, Villejuif, France, said

that they expected patients to prefer one drug over the other because of adverse effects, but “we didn’t ever expect such a big difference between the 2 drugs.” Physicians may perceive toxicity differences between 2 different therapies as relatively minor, but to patients, even low-grade toxicities over a long period

have a significant effect on QOL, according to Escudier and colleagues. How patients feel when they take a drug over many months is not reflected in traditional reporting of adverse events. A survey on physician therapy preferences, which was a secondary end point in this study, showed some difference in physicians’ drug preferences: 61% preferred pazopanib, 22% preferred sunitinib, and 17% had no preference. Patient-reported outcomes are increasingly being added to traditional efficacy outcomes to better understand the clinical relevance of differences in drug toxicities, Escudier and colleagues noted. l Reference Escudier BJ, Porta C, Bono P, et al. Patient preference between pazopanib (Paz) and sunitinib (Sun): results of a randomized double-blind, placebo-controlled, crossover study in patients with metastatic renal cell carcinoma (mRCC)—PISCES study, NCT 01064310. Presented at: 2012 Annual Meeting of the American Society of Clinical Oncology; June 2012; Chicago, IL. Abstract CRA4502.