JCO After Hours: A Discussion With Virginia Sun - a podcast by American Society of Clinical Oncology (ASCO)

Shannon Westin and Virginia Sun discuss the JCO article "Patient-Reported Outcome-Based Symptom Management Versus Usual Care After Lung Cancer Surgery: A Multicenter Randomized Controlled Trial"

 

TRANSCRIPT

Speaker 1: The guest on this podcast episode has no disclosures to declare.

Dr. Shannon Weston: Hello everyone. This is Dr. Shannon Weston, your JCO Social Media Editor here with another episode of Journal Clinical of Oncology After Hours Podcast. So excited to bring you in depth discussion on some of the amazing studies and manuscripts that have been published in the JCO. I am joined today by Dr. Virginia Sun, who's Associate Professor in the Division of Nursing Research and Education and the Department of Population Sciences Education at City of Hope.

Dr. Shannon Weston: She has 17 years experiences as an oncology nurse, four years experience as a nurse practitioner, before becoming a full-time nurse scientist. And her research program is meant to develop and test interventions to improve patient and family-centered care and outcomes, specifically on cancer surgery and cancer survivorship populations. And what better person to have with us today as we're discussing the article, Patient Reported Outcome Based Symptom Management Versus Usual Care After Lung Cancer Surgery, a multi-center randomized control trial by Dr. Dye and colleagues. So welcome, Dr. Sun. So excited to chat with you today.

Dr. Virginia Sun: Thank you so much for the opportunity to be here.

Dr. Shannon Weston: So let's get right into it. I think this article caught several of the editors' attention, because it really is an exciting [inaudible 00:01:42] into how we might take care of patients after surgery. And as a surgeon myself, I was completely intrigued so I can't wait to get your perspective. So let's start off first, the author's note that patients with lung cancer have a high symptom burden after surgery, as a non lung cancer expert, can you walk those of us through a typical post op course and some of the issues that might be experienced by these patients?

Dr. Virginia Sun: Sure. So, I think symptoms is something that probably all of our patients who just underwent surgery experience. But for our patients with lung cancer, some of the common symptoms would include pain. I think pain is one of those universal symptoms that many of our patients experience after a procedure. But particularly for this population, they would also experience shortness of breath, of course, because anatomically there were certain parts of their lung that were removed as part of the procedure.

Dr. Virginia Sun: Cough is something that they would experience regularly as well. And I think sleep disturbance is one of those general symptoms that all of our patients may experience. And also just emotionally, the anxiety perhaps, and the stress may continue probably in the immediate post op timeframe when they just transition home. And then also the functional decline, also happening along with the fatigue. Many of our patients, although we get them up and out of bed as soon as possible, as a nurse, I know that's generally sort of our responsibility in the post-op recovery period. Certainly fatigue and the functional decline is something that our patients will experience in this population as well.

Dr. Shannon Weston: Certainly many of those are universal across what we see in patients in the postoperative period. But I know personally, and I'm sure you could speak to this as well, we're busy post op, right? Especially whether you're rounding in the hospital, or you're seeing patients in post op in the clinic, I don't know how much we really get super deep dive into a lot of these symptoms. So I think that's what makes this work so important. So I'll just have you, if you could, briefly discuss this study design that was performed by Dr. Dye, and Dr. She, and their colleagues.

Dr. Virginia Sun: Sure. So the intervention is really patient report outcome based symptom management. And this is done by way of alerts and completion of the MD Anderson Symptom Inventory, which is very well known symptom inventory tool well validated within this population as well. And also when patients share that information after surgery, and while they're recovering in the hospital, that will prompt an alert. So there were predetermined thresholds by way of the symptom score. So if a patient on the trial that reported a four to 10, which is generally a moderate to severe intensity for a symptom, and that will trigger an alert to the surgeon and the surgical team for management purposes.

Dr. Virginia Sun: Now, in terms of this trial, the investigators chose several very relevant symptoms to focus on for this population to assess. And that would include pain, fatigue, cough, shortness of breath, and sleep disturbance, although the MD Anderson's Symptom Inventory does cover more of symptoms and beyond those as well. And in addition, I think, to the surgeons in response to the alerts, there were also other management, I think, that were triggered from the alert itself. So there may have been other services that were triggered as part of the intervention. But the first line of response to the alert were from the surgeons for this particular trial.

Dr. Virginia Sun: So the patients after they were discharged home continued to provide, I believe, twice weekly symptom information by way of completing the MD Anderson Symptom Inventory. These are all done electronically, and then the alerts I think were continued. And this was done up to four weeks post discharge. And they also did include on data that's collected in the pre-op setting, I think, one baseline, and then after post-op there were several data collection time points. In the hospitalization period I believe it was a daily symptom report, and then after they return home in the first four weeks, it's I think twice a week.

Dr. Shannon Weston: I think it's perfect to have a way to automatically alert the surgeon and their team. Because again if we just don't have time to engage on that level with the patients on.... Can you imagine every day your team having to call? Just the amount of operationalizing that that would take, it would just be bonkers. And so I love this because I'm already kind of thinking tick, tick, tick in my mind, "Okay, how would I incorporate this to the patients of mine that are in the postop setting?" So tell us, should I do that? What are the benefits of incorporating patient reported outcomes into the post op care? And then of course, were there any negatives to the strategy?

Dr. Virginia Sun: Sure. I think we have quite a bit of evidence now by way of patient report outcomes guided management. This was done in many different settings, I think primarily starting in the chemotherapy setting, but now more and more in the surgery population as well. And so I think first and foremost, it's a great way to make care more patient centered, right? Everything is driven by the patient's needs. And everyone may be presenting different symptoms at the same time, even though there are common symptoms that we may see from patients with lung cancer after surgery. But it makes it really personalized and relevant to each of the individual patients.

Dr. Virginia Sun: Another way I think about it is sort of the proactive versus reactive approach of postoperative care. In most settings, perhaps, I don't want to say all, but certainly in most settings our approach to postoperative management, while the patients are at home and in the community, I think are more largely reactive. So most of the time we may... We have information that we give to patients, "If you are having any symptoms, or you're meeting any of these criteria where you have a fever or anything like that, please call us." And many institutions may have a phone number that patients can contact during business hours or after hours.

Dr. Virginia Sun: But this approach gives patient an opportunity and places to contact us when they're experiencing challenges. But it relies on the patients, right? So it's still the patients who need to remember that, "Oh, I need to call when I have these things." In most situations unfortunately, it may be a little too late. We may get a phone call from patients or families when it's kind of at a crisis mode and we need to bring them in or they need to be you readmitted. So I think the patient reported outcomes approach to me is more of a proactive way.

Dr. Virginia Sun: The patients share their information with us at certain time points, during the perioperative setting or postoperative setting. And the healthcare team and oncology team, the surgical team, somebody on that team is the one who is monitoring or getting the alerts from this team, and then we proactively contact the patients to perhaps assess and manage. So I think another way that I kind of tend to look at it is that, the responsibility is really on the healthcare team to sort of act on the patient's information rather than sort of more of the reactive approach, where we wait for patients to call us when they're having pain issues, when they're having sleep disturbance issues, or shortness of breath issues. By that, it kind of makes also for a more patient centered approach too that patients have a way communicate with us and they know that someone is on the other end that will be reacting.

Dr. Shannon Weston: Well, and I think some of the symptoms that you're covering, I feel like patients will call for, "Oh, gosh, I'm really short of breath, or my pain is uncontrolled." People feel really comfortable with that. But some of the other things like, "Well, I'm not sleeping that well," or some of the other things that could be precautious to a worse issue, exactly to your point, they may not call early on, and then you get behind the eight ball and you're in a really serious situation.

Dr. Shannon Weston: So I do. I like this and I like that they know, "Okay, there's someone on the other end of this. I'm not just shouting my issues out into the ether. Someone is going to hear this and respond." And then conversely, the care team is prepared. They know, "Okay, these are coming in and these are the triggers. These are the thresholds at which we're going to mobilize what. Okay, we're going to get pulmonology involved for this, so we're going to bring the patient into clinic to have them look at a wound," or whatever. I think to me, this makes so much sense. Do you see any negative? How's the burden on the patient, I guess, is one obvious question.

Dr. Virginia Sun: From this trial, we see that the investigators did assess and try to examine sort of the burden on both the patients, and I believe the surgical team as well. And the patients were very favorable in their response in terms of the system, because it's another way for them to communicate with the care team. Especially for our surgery patients who were before surgery at home, right? There may be had been some visits, but they're mainly out of the community, and in the home setting. And then of course, when they're discharged after.

Dr. Virginia Sun: So one of the things I think we should think about is, this is of course.... And this is a great study but it's done in, I would think, a different healthcare system. So this is a study out of China. And so is it replicable, perhaps, within the United States Healthcare System, where there may be differences in terms of when we get patients into the OR versus sort of the care that's provided after. And who will be monitoring this information? It's great to see that the surgeons, and I think the data from this trial shows that on average, it took them three minutes to manage some of the symptom alerts, which is great. Three minutes, it's actually really, really amazingly quick, right?

Dr. Shannon Weston: That's incredible for that.

Dr. Virginia Sun: I know.

Dr. Shannon Weston: Well, which is great.

Dr. Virginia Sun: But is it possible for example, within a healthcare system in the United States? And of course within the United States different healthcare systems have different systems too. And so it's identifying who are the people that are going to be receiving this information, and then are there resources for them to be able to react in a timely fashion? And then communication processes in place with the surgeon and the surgical team, if there is a need. Because I think that would be helpful in terms of these types of information, these types of trials, being helpful for surgeons in surgical teams to make decisions about care. Should we be bringing the patient in a little bit earlier, for example, for the first post-op visit or do we need to see them a little bit more often?

Dr. Virginia Sun: The other thing I think that would be very important for us to think about, is the digital health and the digital technology disparities. Technology is great. Being able to capture symptoms in a remote fashion electronically and in a relatively quick fashion is great. But we also, I think, need to be mindful of the fact that, what is the comfort in terms of using these kind of programs and devices, and does everyone have access to this? During the pandemic we've heard a lot about Telehealth. We use Telehealth quite often. And Telehealth has great potential. But Telehealth and digital health can also create disparities. And so, I think we just need to be mindful of the population. And perhaps be mindful of the fact that not all patients and families will come with the knowledge in relation to using mobile applications, or technology based programs. And just have those support systems in place, so that we can make things at equitable, right? And that everyone will be able to access these kind of systems to communicate with their surgical team.

Dr. Shannon Weston: That's a great point. And I could see something around the fact that for the patient population that maybe doesn't have the devices necessary, needing to kind of lend out devices to the patients, and make sure that the nursing staff or medical assistance can counsel the patients. Then they should walk them through the process. So yeah, I could see where that would be a place where making sure that it was generalizable to the population here and equitable will be essential. The other thing, and this may be completely off base is, for us and I think for you all as well, we use quite a bit of enhanced recovery. We have a pretty elaborate enhanced recovery program request. Really all of our surgical services. And I noticed that wasn't something that was mentioned in this particular article. I don't know if that's something that they were doing. Do you think that that would have an impact in any way on these findings, or if there's a way to incorporate this into some type of enhanced recovery pathway?

Dr. Virginia Sun: I think definitely. Perhaps the more long-term, if there is a need to do more long-term remote monitoring when patients are out in the community, or more frequent timeframes in terms of follow up. A lot of this work can also be thinking about what does the data mean? And how can this data not only drive sort of the symptom management piece, but is there a way for us to utilize this data perhaps at the very beginning, as part of that ERAS program, right? In terms of being able to identify those who may need a little bit more communication, or monitoring after they're discharged home. So I don't see this as replacing the ERAS program, I see it as something that could potentially enhance, and perhaps really be able to bring in that program and that approach where we are able to see what's happening to our patients when they're in the community, or at home while they're recovering. So I see it as an augmenting rather than a replacement, if you will.

Dr. Shannon Weston: Well, and I think that's really how enhanced recovery has been. I feel like when we first started, we had some of the basics and then we added on, "Okay, let's reduce opioids and let's send less opiates home. And okay, we're going to inject the incision." So I feel like that's what's great about that pathway is you can keep kind of adding to it. And I guess that leads to my final question. I can't believe how quickly time has passed. This discussion went fun. What do you think ultimately this study is going to mean for clinical practice? Do you think this is ready for Prime Time or kind of what are next steps for us here in the states, or our colleagues in Europe? Is this something that we can start doing?

Dr. Virginia Sun: Sure. Great question. So I think definitely there's pretty strong evidence now within oncology care that remote monitoring, whether it's symptoms and other approaches, definitely has a benefit. Our patients appreciate the opportunity to communicate with their care team this way. And it's beneficial for the clinical team as well to understand what's happening to our patients out in the communities, and especially for surgery patients, when they're recovering. In terms of whether it's ready for Prime Time, I think we definitely need to maybe replicate a trial like this within the United States or a European healthcare system, and really be able to understand who are the key stakeholders in this process, right? The patients, the surgeons, the surgical team, or nurses, or other team members that are going to either be monitoring this data or benefit from the data that's being collected from patients in terms of guiding the clinical care.

Dr. Virginia Sun: I think it would be important to understand the processes a little bit better in terms of who's responding, and then what happened during these encounters? For example. What are the things that we're hearing from patients? So that within a system or within an institution, we can understand what are the resources needed to have a program like this take place, but also understand more from the patient and the surgeon, surgical team perspective, in terms of how this could benefit care.

Dr. Virginia Sun: And then also I think the other piece, I think would be important for us to think about is, beyond symptom monitoring, are there other, perhaps, information that would be worthwhile to remote monitor or collect from patients? For example, for surgical population, perhaps functional recovery is something that is quite important. And so is there some other data that we could incorporate beyond sort of the subjective reports? Which are very important, but is there a way perhaps to think about subjective and objective measures combined together? And really be able to understand what it means in terms of the data that we're collecting.

Dr. Virginia Sun: And then also, what types of symptoms data, for example, and other kinds of data that we absolutely should collect versus everything under the sun, right? That is going to be most helpful in terms of informing care for our patients. This is because by way of thinking about burden, we can collect data. I think the technology's there to collect data as much as possible, but how we use it and what does that data mean, we still need to understand a lot of that work. And so I think bottom line, no doubt, this is something that's beneficial from the patient's perspective, and the cancer care delivery surgical team perspective as well. But understanding a little bit more about the stakeholders' perspectives and the details of the care, I think, will make it much more efficient and more successful, perhaps, in terms of implementing into standard of care.

Dr. Shannon Weston: Great. Wow. Well, thank you so much. This was an awesome discussion and I know our listeners will be intrigued and hopefully are planning some trials of their own to explore these patient reported outcomes. So, listeners, thank you so much again for tuning in to JCO After Hours, and we will see you again next time.

Speaker 1: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.

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