A phase 3 trial highlights the importance of problem-led design, multidisciplinary commitment and patient-reported outcomes — with skilled oncology nurses having a crucial role.
Over the past 20 years, advances in digital health have transformed healthcare practice. The exponential growth in this field, and in the terminology that surrounds it, has led the World Health Organization to produce a classification of digital health interventions1 and a global strategy on digital health 2020–20252; this strategy emphasises the importance of developing and integrating appropriate, sustainable, and scalable digital interventions into healthcare systems. Moreover, a recent analysis suggested that in 2021, telehealth use across all health specialties was 38 times higher than pre-pandemic levels3.
Although digital interventions are not new to the oncology field, the COVID-19 pandemic has accelerated the wide adoption of technological solutions for remote monitoring4. This has created an urgent need for high-quality evidence to support the implementation of remote monitoring for patients with cancer. In this issue of Nature Medicine, Mir et al.5 report the findings of the first randomized controlled trial of a digital remote monitoring intervention (CAPRI) for patients receiving oral anti-cancer therapy.
The use of oral anti-cancer agents has increased dramatically in recent years, therefore the study conducted by Mir et al. is extremely relevant. In this study, patients receiving oral anti-cancer therapy were randomized to receive additional follow-up with a nurse navigator and a web portal or smartphone-based application as well as usual care, or to receive only usual care. Although there was no significant difference in objective response or survival, the trial provides convincing evidence that remote monitoring supports higher relative dose-intensity, as well as significantly fewer hospital admissions and emergency department visits, reduced length of hospital stays, and a lower rate of grade 3 toxicity. Moreover, remote monitoring was associated with improved overall patient experience and increased levels of supportive care (as measured by visits to dietitians or social workers). These results are particularly relevant given that over 80% of patients in the trial had metastatic disease. For this population, an intervention that reduces hospitalization and improves outcomes of importance to quality of life is highly valuable.
A recent review6 identified 11 published randomized controlled trials of remote monitoring and electronic patient-reported outcomes in oncology, and a further 9 ongoing trials, some of which have since reported positive results (for example, Maguire et al.7). The review found evidence of substantial benefits associated with remote monitoring, including reduced symptom severity, improved quality of life and improved survival. Most trials so far have enrolled patients receiving systemic chemotherapy, but there is also some evidence for benefits associated with remote monitoring after surgery or radiation therapy. These benefits must, however, be considered alongside the potential for exacerbating health inequalities through the ‘digital divide’8. Although relatively few patients over the age of 80 engaged in the current trial, Mir et al. achieved an impressive 92% recruitment rate across multiple tumour types, with 52% of patients using the smartphone application and 48% the web portal. The acceptability and reach of a digital intervention to a population with varying levels of digital literacy is a vital consideration for any trial of this type.
It is no coincidence that the results described by Mir et al.5 were achieved in the context of a nurse navigator-led system of care, whereby the nurse navigators provided the crucial link between the patient, the hospital and primary care professionals, and the web portal. There is increasing evidence of the role and effectiveness of nurse-led interventions in cancer care9,10 and this trial provides further reassurance that skilled nurses can manage the vast majority of clinical interventions without referral to an oncologist. It also confirms that digital interventions do not stand alone. Patients with cancer often feel isolated and overwhelmed, while at the same time experiencing unfamiliar and unpleasant symptoms related to their disease and its treatment. The support of an expert oncology nurse and skilled navigator is not only vital to the usability and safety of the technology but is also key to improving the experience of the patient using that technology.
As the authors point out, the detailed design and development phase for this study was critical to its success in a real-life context. Their excellent companion paper11 describes the process of developing over 80 decision support tools to support nurse navigators to prioritize and define the actions to be taken, based on alert parameters from remote monitoring. It also illustrates the close collaboration required between clinicians, managers and patients to identify and address barriers to successful implementation.
Given the likely continual growth in oral targeted therapies and the significant unmet needs of patients with advanced and metastatic disease12 — particularly in terms of information and psychological support — solutions such as the CAPRI intervention need to be rolled out and embedded into routine care. However, this is not likely to be a straightforward undertaking, as it requires a coordinated digital approach across the healthcare system of each country, and a regulatory and legal framework that is supportive of such an endeavour. As the authors of this trial point out11, regulatory and system constraints can prevent the optimization of digital health solutions across care settings and ultimately preclude their scalability. One of the guiding principles of the WHO digital strategy is to “recognize that successful digital health initiatives require an integrated strategy” to avoid “information fragmentation and, consequently, poor delivery of services”. In oncology, we should harness the expertise that has been developed by clinicians and researchers in this field.
The pragmatic and well-conducted trial reported by Mir et al.5 illustrates the importance of multidisciplinary commitment to digital innovations in cancer care, and confirms that a combination of patient-reported outcomes, specialist nursing support and carefully designed technology11 brings considerable benefits to the experience of patients who are receiving oral anti-cancer agents. Their insights into the complex challenges of implementing and evaluating supportive remote monitoring interventions offer valuable learnings that are crucial if we are to embrace the true potential of health technologies for patient care.
Classification of Digital Health Interventions v1.0 (World Health Organization; https://www.who.int/publications/i/item/WHO-RHR-18.06, 2018)
Global Strategy on Digital Health 2020–2025 (World Health Organization; https://www.who.int/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d.pdf, 2021)
Bestsennyy, O., Gilbert, G., Harris, A. & Rost, J. Telehealth: A quarter-trillion-dollar post-COVID-19 reality? McKinsey & Company https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality (2021).
Schrag, D., Hershman, D. L. & Basch, E. JAMA 323, 2005–2006 (2020).
Mir, O. et al. Nat. Med. https://doi.org/10.1038/s41591-022-01788-1 (2022).
McGregor, B. A., Vidal, G. A., Shah, S. A., Mitchell, J. D. & Hendifar, A. E. Cureus 12, e10156 (2020).
Maguire, R. et al. BMJ 374, n1647 (2021).
Cheng, C., Beauchamp, A., Elsworth, G. R. & Osborne, R. H. J. Med. Internet Res. 22, e18476 (2020).
Charalambous, A. et al. Int. J. Nurs. Stud. 86, 36–43 (2018).
Chan, R. J. et al. BMJ Support. Palliat. Care 10, 276–286 (2020).
Ferrua, M. et al. BMC Health Serv. Res. 20, 434 (2020).
Moghaddam, N., Coxon, H., Nabarro, S., Hardy, B. & Cox, K. Support. Care Cancer 24, 3609–3622 (2016).
M.W. is supported by the Imperial Biomedical Research Centre (BRC).
The author is an oncology nurse.
About this article
Cite this article
Wells, M. Key components of successful digital remote monitoring in oncology. Nat Med 28, 1128–1129 (2022). https://doi.org/10.1038/s41591-022-01841-z