Researchers Address the Barriers to Remote Breast Cancer Symptom Monitoring in the US

Gabrielle Rocque, MD

Although the remote collection of patient-reported outcomes (PROs) has been proven to be feasible and effective in breast cancer in several studies, barriers to the wide adoption of the practice in the US persist, according to Gabrielle Rocque, MD.

“To me, we’ve answered the question as to whether remote symptom monitoring works; that is a definitive yes,” Rocque said in an interview with OncologyLive. “The real questions are about how we implement this at large scale. How do we make sure we do this in a way that is patient and provider friendly? How do we tailor and customize [these interventions] to have them fit into the local context and fit for that patient and provider? There’s a lot of ongoing implementation work in this space.”

Rocque is an associate professor of medicine in the divisions of hematology

and oncology and gerontology, geriatrics, and palliative care at the University of Alabama at Birmingham.

During the 2024 San Antonio Breast Cancer Symposium, Rocque was a panel discussant for a presentation by Maria M. Karsten, MD, a managing senior physician at the Breast Center of the Charité-Universitätsmedizin Berlin in Germany, on PRO B, an alert-based PRO monitoring system.1 The PRO B system combined a weekly survey sent to patients’ smartphones, including questions from The European Organization for Research and Treatment of Cancer Computerized Adaptive Test Core item banks with an automated system, which alerted the treating center in the event of deteriorating PRO values, which then connected with the patient within 48 hours to address the reported symptoms. Patients in the control arm received PRO questionnaires sent to their smartphone every 3 months and were not connected to the alert monitoring system.

The PRO B trial included patients from 52 centers in Germany treated between May 2021 and June 2023. Patients were randomly assigned 1:1 to the PRO B intervention arm (n = 456) or the control arm (n = 453). The primary end point was patient-reported fatigue at 6 months after random assignment; secondary end points included physical functioning, quality of life, and overall survival (OS).

At baseline, the mean fatigue T-scores in the intervention and control arms were 57.6 and 60.2, respectively. The mean 6-month fatigue T-score in the intervention group was 53.2 compared with 58.7 in the control group. The respective scores at 12 months were 53.9 and 59.2.

Patients in the intervention group achieved a 12-month OS rate of 87.6% compared with 84.7% among patients in the control group (adjusted HR, 0.71; 95% CI, 0.51-0.99; P = .043). Patients with visceral metastases in the intervention (n = 66) and control (n = 68) arms experienced 12-month OS rates of 88.5% and 82.7%, respectively (adjusted HR, 0.51; 95% CI, 0.13-2.00; P = .331). The respective rates among patients with triple-negative breast cancer in the interventional (n = 36) and control (n = 49) arms were 88.5% and 82.7%, respectively (adjusted HR, 0.61; 95% CI, 0.24-1.53; P = .289). Patients with estrogen receptor–positive disease experienced a 12-month OS rate of 88.5% in the interventional arm (n = 287) vs 82.7% in the control arm (n = 269; adjusted HR, 0.71; 95% CI, 0.48-1.04; P = .076).

“This presentation was exciting because it was breast cancer focused, and it brought to a breast cancer audience some of the knowledge of [this type of] intervention,” Rocque said. “Most of us in the health care delivery and health services space are very familiar with this body of work, but the breast cancer world and [those involved] in breast cancer trials are not necessarily as familiar with this. This is a place where we have a win-win. If you’re a clinical trialist, you should watch your patients via remote symptom monitoring because they’re going to have fewer symptoms potentially [fewer] adverse effects, and be on the drug longer.”

Rocque noted that the value of remote PRO monitoring in various tumor types has been demonstrated across multiple other studies. In a 2017 study, Basch et al demonstrated that patients who received PRO monitoring via an automated email system experienced a significant OS benefit compared with those who received usual care; the median OS was 31.2 months (95% CI, 24.5-39.6) vs 26.0 months (95% CI, 22.1-30.9), respectively (HR, 0.83; 95% CI, 0.70-0.99; P = .04).2

Additionally, data from the phase 3 CAPRI trial (NCT02828462) showed that patients with metastatic disease who were being treated with oral anticancer agents who participated in a nurse navigator–led symptom follow-up system with a smartphone-based symptom monitoring system received a higher treatment dose intensity compared with those who received usual care.3 Those who received the intervention also reported an improved patient experience, reduced hospitalization times, and fewer grade 3 or higher toxicities compared with those who did not.

Tackling Roadblocks to Widespread Implementation

Despite the proven ability of remote symptom monitoring to improve patient outcomes, widespread uptake of the technology in the US has lagged, Rocque said. She noted that the current payment models are not equipped to support widespread remote symptom monitoring due to a historic lack of billing codes for the technology. Additionally, hospital staffing and support staff are often not set up to address the increased call volumes that result from this type of symptom monitoring. There are also outdated electronic health record systems that need to be addressed, administrative level buy-in challenges, and patient comfortability issues with the technology, she said.

“A big piece [to address these barriers] is changing the payment models to include remote symptom monitoring,” Rocque said. “Sharing information on best practices is also helpful. Pressure from patients that this is something they want is a differentiator. We want to be able to show that this is important and [leads to] better outcomes. More research on implementation is needed to move the field forward. My ideal scenario is that someday we get to a point where we have a more nuanced idea of who exactly needs what based on their symptoms and treatment.”

Rocque is collaborating with Ethan Basch, MD, MSc, of UNC Health in Chapel Hill, North Carolina, on a Patient-Centered Outcomes Research Institute (PCORI)–funded project that is aiming to make the use of electronic PROs a routine aspect of care in the US.4 The project is adding software to the electronic health record that collects PROs and alerts health care staff when patients experience worsening symptoms. It will also educate patients on the use of electronic PROs, train clinical staff on the use of electronic PROs, and provide resources to help clinics implement the technology.

The study will include more than 34,000 patients and 7800 clinical staff members. The PCORI project was initiated in November 2023 and is slated to end in February 2030.

“[Future research should examine] how we can start tailoring these surveys to individual, personalized patient needs,” Rocque said.

References

1. Karsten MM, Gebert P, Pross T, et al. Evaluating the effect of an alert-based patient-reported outcome monitoring compared with usual care in metastatic breast cancer patients. Presented at: San Antonio Breast Cancer Symposium; December 10-13, 2024; San Antonio, TX. Abstract GS1-06.
2. Basch E, Deal AM, Dueck AC, et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA. 2017;318(2):197-198. doi:10.1001/jama.2017.7156
3. Mir O, Ferrua M, Fourcade A, et al. Digital remote monitoring plus usual care versus usual care in patients treated with oral anticancer agents: the randomized phase 3 CAPRI trial. Nat Med. 2022;28(6):1224-1231. doi:10.1038/s41591-022-01788-1
4. Using electronic patient-reported outcomes (ePROs) to monitor symptoms during cancer treatment. Patient-Centered Outcomes Research Institute. Accessed March 24, 2025. bit.ly/41SBTZ6