Use of Mobile Messaging System for Self-Management of Chemotherapy Symptoms in Patients with Advanced Cancer

Cancer and cancer-related treatment can cause a myriad of adverse effects.^1,2 Early identification and management of these symptoms is paramount to the success of cancer treatment completion; however, clinic and telephonic strategies for addressing symptoms often result in delays in care.¹ New strategies for patient engagement in the management of cancer and treatment-related symptoms are needed.

The use of online self-management tools can result in improvement in symptoms, reduce cancer symptom distress, improve quality-of-life, and improve medication adherence.^3-9 A meta-analysis concluded that online interventions showed promise, but optimizing interventions would require additional research.¹⁰ Another meta-analysis found that online self-management was effective in managing several symptoms.¹¹ An e-health method of collecting patient self-reported symptoms has been found to be acceptable to patients and feasible for use.^12-14 We postulated that a mobile text messaging strategy may be an effective modality for augmenting symptom management for cancer patients in real time.

In the US Departmant of Veterans Affairs (VA), “Annie,” a self-care tool utilizing a text-messaging system has been implemented. Annie was developed modeling “Flo,” a messaging system in the United Kingdom that has been used for case management of chronic obstructive pulmonary disease, heart failure, stress incontinence, asthma, as a medication reminder tool, and to provide support for weight loss or post-operatively.^15-17 Using Annie in the US, veterans have the ability to receive and track health information. Use of the Annie program has demonstrated improved continuous positive airway pressure monitor utilization in veterans with traumatic brain injury.¹⁸ Other uses within the Veterans Health Administration (VHA) include assisting patients with anger management, liver disease, anxiety, asthma, diabetes, HIV, hypertension, weight loss, and smoking cessation.

Methods

The Hematology/Oncology division of the Minneapolis VA Healthcare System (MVAHCS) is a tertiary care facility that administers about 260 new chemotherapy regimens annually. The MVAHCS interdisciplinary hematology/oncology group initiated a quality improvement project to determine the feasibility, acceptability, and experience of tailoring the Annie tool for self-management of cancer symptoms. The group consisted of 2 physicians, 3 advanced practice registered nurses, 1 physician assistant, 2 registered nurses, and 2 Annie program team members.

We first created a symptom management pilot protocol as a result of multidisciplinary team discussions. Examples of discussion points for consideration included, but were not limited to, timing of texts, amount of information to ask for and provide, what potential symptoms to consider, and which patient population to pilot first.

The initial protocol was agreed upon and is as follows: Patients were sent text messages twice daily Monday through Friday, and asked to rate 2 symptoms per day, using a severity scale of 0 to 4 (absent, mild, moderate, severe, or disabling): nausea/vomiting, mouth sores, fatigue (Figure 1), trouble breathing, appetite, constipation, diarrhea (Figure 2), numbness/tingling, pain. In addition, patients were asked whether they had had a fever or not. Based on their response to the symptom inquiries, the patient received an automated text response. The text may have provided positive affirmation that they were doing well, given them advice for home management, referred them to an educational hyperlink, asked them to call a direct number to the clinic, or instructed them to report directly to the emergency department (ED). Patients could input a particular symptom on any day, even if they were not specifically asked about that symptom on that day. Patients also were instructed to text, only if it was not an inconvenience to them, as we wanted the intervention to be helpful and not a burden.