PRO-Based Symptom Management Improves Postdischarge Outcomes After Lung Cancer Surgery

Implementation of patient-reported outcome (PRO)–based symptom management following lung cancer surgery resulted in lower symptom burdens and fewer complications among patients up to 4 weeks post discharge when compared with usual care, according to findings of a multicenter randomized controlled trial. Results were published in the Journal of Clinical Oncology.

Due to the use of CT for lung cancer screening, the number of patients who become eligible for surgery is increasing. These patients’ symptom burdens are typically high, especially in the early postoperative phase, authors explained.

As symptom management is usually reactive and reliant on ward rounds or hospital visits, clinicians can fail to detect patients’ severe symptoms in a timely manner, especially following discharge, they added.

However, the use of PROs to capture these symptoms can result in value-based, high-quality, and patient-centered care, potentially improving physical well-being, enhancing quality of life (QOL), and reducing emergency department visits, among other benefits.

To better elucidate efficacy and feasibility of PRO-based symptoms management in the early postoperative period among those with lung cancer, researchers conducted a randomized controlled trial at 3 tertiary hospitals in China.

All participants were between ages 18 and 75 years and had a clinical diagnosis of lung cancer at stage I to IIIA; any patient with previous chest surgery was excluded from the analysis.

“At enrollment (typically 1-3 days before surgery), eligible patients were randomly assigned in a 1:1 ratio to receive postoperative PRO-based symptom management (the intervention group) or usual care (the control group),” authors wrote.

Patients also completed the MD Anderson Symptom Inventory-Lung Cancer module (MDASI-LC) and single-item QOL scale (SIQOL) questionnaires once preoperatively, daily during postoperative hospitalization, and twice weekly post discharge until 4 weeks or when adjuvant therapy was commenced.

In the intervention group, real-time electronic alerts were sent to treating surgeons if questionnaire scores met preset thresholds of symptom severity with regard to pain, fatigue, disturbed sleep, shortness of breath, and coughing. Surgeons then responded to the alerts within 24 hours either in person or via messages or phone calls.

For those in the control group, symptoms reported in the questionnaires did not trigger alerts and surgeons could not access reported scores.

“During hospitalization, the surgeons assessed the patients' symptoms through patient complaints during morning and afternoon ward rounds,” researchers explained. “After discharge, patients did not receive proactive symptom management from their treating surgeons unless they actively sought medical help.”

A total of 65 patients were in the intervention group and 69 in the control group, with no significant between-group differences. Median postoperative hospital stay was 5 days in each group.

Number of symptom threshold events (score of ≥4) at discharge served as the primary outcome.

Analyses revealed:

• At discharge, the intervention group reported fewer symptom threshold events than the control group (median [interquartile range (IQR)] number, 0 [0-2] vs 2 [0-3]; P = .007).
• At 4 weeks post discharge, this difference was maintained between the intervention and control groups (median [IQR], 0 [0-0] vs 0 [0-1]; P = .018).
• The intervention group had a lower complication rate than the control group (21.5% vs 40.6%; P = .019).
• Mean QOL score was not significantly different between the 2 groups during the 4 weeks after discharge (adjusted mean difference, –0.10; 95% CI, –0.85 to 0.65; P = .790) and the 5-day postoperative hospitalization period (adjusted mean difference, 0.004; 95% CI, –0.70 to 0.71; P = .992).
• Surgeons spent a median of 3 minutes managing an alert.

Results showed that the PRO-based intervention yielded lower symptom burden, better functional status, and fewer complications in the early postoperative period, and the intervention also was found to have “acceptable surgeon burden, high surgeon acceptability, and high patient satisfaction from the current study.”

The positive findings may have been due to the fact that the PRO-based symptom management system prompted clinicians to intervene early, potentially preventing worsening of symptoms or development of complications. In addition, as the intervention could be administered remotely and in real time, it is especially helpful during the discharge period in which typical care may not include provide timely and remote responses.

“The PRO-based symptom management reduced complications and improved workflow efficiency, thus potentially saving clinicians’ time rather than increasing it,” authors added, noting the patients’ data were recorded on a password-protected account on an institution-owned system.

Furthermore, in the current trial, physicians responded to all alerts, which may have accounted for the intervention’s success. In previous studies, health care providers responded to 59.9% to 84% of all alerts.

“To further reduce the burden on doctors and improve real-world feasibility, the ideal model may be one in which symptom alerts are intelligently triaged and then automatically fed into an appropriate pathway for intervention by self-management or a collaborative team of nurses and doctors,” researchers suggested.

Future studies may want to include different modalities of reporting PROs outside of electronic methods and include follow-up beyond 4 weeks. Findings are also limited due to the strict inclusion/exclusion criteria.

Overall, “our findings suggest that PRO-based proactive symptom monitoring and intervention may be the preferred patient care approach following lung cancer surgery,” authors concluded.

Reference

Dai W, Feng W, Zhang Y, et al. Patient-reported outcome-based symptom management versus usual care after lung cancer surgery: a multicenter randomized controlled trial. J Clin Oncol. Published online January 7, 2022. doi:10.1200/JCO.21.01344