Telephone-based strategies for chemotherapy toxicities in early breast cancer patients did not reduce emergency visits or hospital admissions
Remote, telephone-based strategies designed to deal with toxicities during chemotherapy for early stage breast cancer, do not lead to a reduction in either emergency department visits or hospital admissions compared to standard care. This was an important finding of a randomised, trial by researchers from the Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
Chemotherapy is an important aspect of cancer management but since chemotherapy is normally administered in an outpatient setting, toxicities invariably occur between visits to a cancer centre. While the treatment-emergent adverse effects from chemotherapy are well recognised, a 2019 systematic review revealed how 42% of patients in receipt of systemic chemotherapy in routine clinical practice had at least one hospitalisation for any cause during therapy.
With many chemotherapy-related toxicities highly predictable, it is possible that remote interventions such as telephone-based support, have the potential to manage toxicity-related problems and reduce the demand on acute care services. In fact, a recent, single-arm pilot study designed to evaluate potential impact of a telephone symptom management intervention on healthcare utilisation during chemotherapy for early stage breast cancer, concluded that such an approach could may be associated with lower rates of acute care use.
Building on this pilot study, the Canadian team, undertook a pragmatic, cluster randomised trial using nurse-led telephone-based management of patient’s symptoms, to explore the impact on the number of visits to an emergency department or hospital admission. Participants were randomised to an intervention or control arm. The intervention involved provision of a symptom self-management patient booklet and two structured follow-up calls in each cycle of chemotherapy up to 3 and 10 days after the start of each cycle. During these telephone calls, the oncology nurses assessed several, common chemotherapy toxicities and provided unscheduled calls to follow-up on symptoms or to provide more support at their own discretion. Patients in the control received standard according to the institution’s in-house standard. The primary outcome was the cluster level mean number of visits to an emergency department or admission to hospital per patient during the first day of chemotherapy to 30 days after the last treatment.
Findings
A total of 2158 patients with a median age of 55 years were started on adjuvant or neoadjuvant chemotherapy and 944 were assigned to the telephone-based intervention with 51% of intervention participants having stage 2 cancer.
Overall, 47% (1014/2158) of all patients had at least one visit to the emergency department visit or required admission to hospital during chemotherapy.
The mean number of visits or admissions per patient was 0.91 for the intervention arm and 0.94 for the control arm (p = 0.94). In addition, in a separate analysis, there was no difference between emergency department visits or hospital admissions.
Data on patient outcomes revealed how at least one grade 3 toxicity was reported by 48% of intervention patients and 58% of control patients (p = 0.005) but there were no differences in self-efficacy, anxiety or depression between the two groups.
The authors concluded that although their study did not find any important differences between the two arms, given the current COVID-19 pandemic, it was necessary to identify scalable strategies for remote management of patients during cancer therapy.
Citation
Krzyzanowska MK et al. Remote, proactive, telephone based management of toxicity in outpatients during adjuvant or neoadjuvant chemotherapy for early stage breast cancer: pragmatic, cluster randomised trial. BMJ 2021
