Remote Monitoring Enhances Care for Patients With Head and Neck Cancer

Brian A. Moore, MD, FACS

Medical Director, Ochsner Cancer Institute, and Chairman of

Otorhinolaryngology

and Communication

Sciences, Ochsner Health

System, New Orleans, LA

Patients who receive a diagnosis of head and neck cancer pose multiple unique challenges to multidisciplinary treatment teams. One such challenge is the impact of multimodality therapy on swallowing function and oral intake, which can put patients at risk for malnutrition, dehydration, secondary acute kidney injury, emergency department (ED) visits, hospital admissions, and potential interruptions in their treatment course. Such interruptions and delays may increase the total treatment package time either in the primary or adjuvant setting and potentially lead to worsened outcomes, including local/regional recurrence and in overall survival (OS).^1-3

Although many factors, including social determinants of health and access to care, contribute to delays in initiation of treatment or postoperative radiation therapy, inadequate management of expected toxicities and symptoms seems to be the primary contributor to treatment prolongation. If clinicians can identify complications earlier and take appropriate prophylactic or therapeutic measures, treatment plan adherence and outcomes may be improved.

Increasing attention to patient-reported outcomes measures (PROMs), with improved symptom management, has been associated with improved quality of life, increased OS, and fewer ED visits in patients with advanced cancer.^4-6

Similarly, the potential to remotely monitor patients’ activity and vital signs via Web-based portals or the electronic medical record (EMR) has provided a new dimension to remote monitoring.⁷ Previous studies have reported on a similar association with increased ambulation and decreased readmission rates after surgical interventions.^8,9

Pilot Program Developed

Our team at Ochsner Cancer Institute in New Orleans, Louisiana, has been investigating ways of using electronic tools to improve outcomes for patients with head and neck cancer. Important toxicities for this population include pain and mucositis, which can lead to decreased oral intake and dehydration with potential acute kidney injury in the short term and dysphagia and feeding tube dependence in the long term.^10-12

The potential to merge PROMs with remote monitoring of vital signs and activity for these patients prompted our team to devise a pilot program. All participants are required to have a smartphone, which is used to sync monitoring devices and the EMR via a patient portal.

Click to Enlarge

Patients receive a brief, twice-weekly text message or portal-based questionnaire (Figure), as well as a digital scale and activity tracker (Fitbit) to monitor their weight, heart rate, and steps. When objective patient measures or responses fall below certain predetermined thresholds, automated alerts are sent via the EMR to clinic staff, who actively contact patients to facilitate evaluation or intervention as needed. Patients also receive coaching reminders to perform their swallowing exercises throughout therapy.

Early Findings Support Model

The early experience was presented at the 2019 American Head and Neck Society Annual Meeting. Ten patents were successfully enrolled into the pilot program in its first several months; however, only 9 had sufficient information for analysis. All 9 patients were able to record their steps, heart rate, and daily weight measurements, and all responded to the majority of questionnaire solicitations. The average age was 59.6 years (SD, 9.1); the evaluable group comprised 2 female and 7 male patients.¹³

Data were collected on the number of steps taken daily and on weight. Eight of 9 patients did not have any significant complications during their treatment, and these patients were grouped into the “nonadmit” group. One patient had an unplanned hospital admission and was grouped separately.

Steps and weights were compared between the 2 groups. Patients in the nonadmit group walked 2350 to 9239 steps per day, whereas the patient who was admitted seemed to have taken fewer steps per day, on average, with a range of 3 to 6863. The steps for each group were averaged daily and plotted into a graphical format. Not surprisingly, all patients in the study lost weight, with an overall average of 18.1 pounds, amounting to 7.7% of pretreatment body weight in the nonadmit group, but no trends could be identified.

Although the pilot included a small number of patients, it has been an iterative process, with ongoing evolution of the program and the monitoring thresholds. Patients who were found to have significant symptoms or changes were actively encouraged to come to the oncology acute care clinic for evaluation and perhaps supportive care infusions, potentially avoiding admissions and ED visits.

Patient satisfaction with this enhanced attention to their symptoms and more tangible connections to their care team was high. This pilot has demonstrated that remote monitoring not only is feasible in patients with head and neck cancer but also merits further study and application in other settings, most notably for patients receiving chemotherapy or perioperative care and even for cancer survivors.

The Ochsner Cancer Institute has expanded its efforts in this arena, now offering 3 active digital oncology programs: head and neck, a chemotherapy companion for common chemotherapy regimens, and a preoperative optimization effort for patients undergoing major abdominal surgery.

In the program’s current form, the care team is still reacting to the symptoms reported by patients or identified by remote monitoring. Soon the team will be able to apply artificial intelligence or machine learning to the data gathered from these programs, potentially identifying key symptom and/or vital parameter inflection points so that the interventions can become more proactive.

Remote monitoring or PROMs with smartphones and digital devices connected to the EMR is feasible in patients with head and neck cancer undergoing multimodality therapy. More investigation is needed to define the potential to improve cancer-related outcomes and quality of life for patients.

References

1. Graboyes EM, Kompelli AR, Neskey DM, et al. Association of treatment delays with survival for patients with head and neck cancer a systematic review. JAMA Otolaryngol Head Neck Surg. 2019;145(2):166-177. doi:10.1001/jamaoto.2018.2716/.
2. Rosenthal DI, Liu L, Lee JH, et al. Importance of the treatment package time in surgery and postoperative radiation therapy for squamous carcinoma of the head and neck. Head Neck. 2002;24(2):115-126. doi: 10.1002/hed.10038.
3. Chao HH, Schonewolf CA, Tan EX, et al. The impact of treatment package time on locoregional control for HPV+ oropharyngeal squamous cell carcinoma treated with surgery and postoperative (chemo)radiation. Head Neck. 2019;41(11):3858-3868. doi: 10.1002/hed.25914.
4. Basch E, Deal AM, Dueck AC, et al. Overall survival results of a trial assessing patientreported outcomes for symptom monitoring during routine cancer treatment. JAMA. 2017;318(2):197-198. doi: 10.1001/jama.2017.7156.
5. Basch E. Patient-reported outcomes—harnessing patients’ voices to improve clinical care. N Engl J Med. 2017;376(2):105-108. doi: 10.1056/NEJMp1611252.
6. Basch E, Deal AM, Kris MG, et al. Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial [erratum in J Clin Oncol. 2016;34(18):2198. doi: 10.1200/JCO.2016.68.4555] [erratum in J Clin Oncol. 2019;37(6):528. doi: 10.1200/JCO.19.00057]. J Clin Oncol. 2016;34(6):557-565. doi: 10.1200/JCO.2015.63.0830.
7. Daskivich TJ, Houman J, Lopez M, et al. Association of wearable activity monitors with assessment of daily ambulation and length of stay among patients undergoing major surgery. JAMA Netw Open. 2019;2(2):e187673. doi: 10.1001/jamanetworkopen.2018.7673.
8. Low CA, Bovbjerg DH, Ahrendt S, et al. Fitbit step counts during inpatient recovery from cancer surgery as a predictor of readmission. Ann Behav Med. 2018;52(1):88-92. doi: 10.1093/abm/kax022.
9. Rossi A, Frechette L, Miller D, et al. Acceptability and feasibility of a Fitbit physical activity monitor for endometrial cancer survivors. Gynecol Oncol. 2018;149(3):470-475. doi: 10.1016/j.ygyno.2018.04.560.
10. Eskander A, Krzyzanowska MK, Fischer HD, et al. Emergency department visits and unplanned hospitalizations in the treatment period for head and neck cancer patients treated with curative intent: a population-based analysis. Oral Oncol. 2018;83:107-114. doi: 10.1016/j.oraloncology.2018.06.011.
11. Moore ZR, Pham NL, Shah JL, et al. Risk of unplanned hospital encounters in patients treated with radiotherapy for head and neck squamous cell carcinoma. J Pain Symptom Manage. 2019;57(4):738-745.e3. doi: 10.1016/j.jpainsymman.2018.12.337.
12. Van Liew JR, Brock RL, Christensen AJ, Karnell LH, Pagedar NA, Funk GF. Weight loss after head and neck cancer: a dynamic relationship with depressive symptoms. Head Neck. 2017;39(2):370-379. doi: 10.1002/hed.24601.
13. Barton B, Parsel S, Peevy Y, Winters R, Hasney C, Moore B. The feasibility of remote monitoring in patients with head and neck cancer. Poster presented at: 2019 American Head and Neck Society Annual Meeting; May 1-2, 2019; Austin, TX. Abstract D260. ahns.jnabstracts.com/Detail?ID=97299.

Beginning in spring 2018, patients with head and neck cancer undergoing radiation therapy with or without concurrent chemotherapy in both the primary and adjuvant settings have been eligible to participate in this program, which is funded by hospital philanthropy.