Enabling symptom self-management via use of an electronic patient-reported outcomes (ePRO)

system to increase self-efficacy of patients with cancer receiving active chemotherapy treatment
Grigorios Kotronoulas1*, Roma Maguire1, Constantina Papadopoulou1, Eileen Furlong2, Patricia
Fox2, Emma Ream1, Jo Armes3, Lisa McCann1, Christine Miaskowski4, Elisabeth
Patiraki5, Kathi Apostolidis6 and Nora Kearney1
 1
University of Surrey, School of Health Sciences, United Kingdom
 2
University College Dublin, Ireland
 3
King’s College London, United Kingdom
 4
University of California San Francisco, United States
 5
National and Kapodistrian University of Athens, Greece
 6
European Cancer Patient Coalition, Belgium
Background: In recent years, the shift in cancer services from traditional tertiary care to care
delivered within communities has increased the need for patients to engage in self-care activities
in order to prevent or reduce the severity of numerous and complex-side effects (McCorkle et al.,
2011) and make important health decisions when at home in the absence of clinicians (Butow et
al., 2012). The actual degree of engagement in self-management may be dependent on patients’
perceived competence or self-efficacy to perform such activities (Fenlon et al., 2015). Self-
efficacy has been defined as “a person’s belief to execute courses of action required to deal with
a prospective situation” (Bandura, 1977, 2001). One’s beliefs in their capability to successfully
manage tasks and consequently influence situations that impact their lives constitutes a central
part of human agency, and can be influenced by performance accomplishments (Bandura, 1989,
2001). Whilst self-efficacy can enable engagement in self-management, actual participation in
self-management activities can further increase one’s perceived ability to undertake such
activities; it is thus obvious that a bi-directional association between self-management and self-
efficacy exists. Supporting a shift in clinical practice with innovative technological systems
affords a solution to the increasing demands placed on acute care by enabling the delivery of care
in the home and community setting (Basch et al., 2011; Carpenter et al., 2008). Such remote
monitoring systems facilitate the provision of clear lines of real-time communication between
patients and their health care providers (Basch et al., 2011), and can deliver organised self-
management advice tailored to the individual’s clinical characteristics and severity/distress of
symptoms of anti-cancer treatment.

Aim(s): Funded by the European Union (FP7 programme), a multi-centre European project (the
eSMART study) has been designed to investigate the effects of an electronic patient-reported
outcomes (ePRO) system, the Advanced Symptom Management System (ASyMS), on patient
outcomes including improvement in self-efficacy, symptom management, supportive care needs,
psychological status, work presenteeism, and well-being; health system costs; and the current
clinical practice. The primary aim of eSMART is to evaluate the short and long term impact of
the ASyMS technology on patient reported outcomes in people with breast cancer, colorectal
cancer or haematological malignancies receiving first-line chemotherapy. In addition, eSMART
will evaluate the cost-benefit of remote patient-monitoring and changes in clinical practice as a
result of the application of the ASyMS intervention in different European healthcare settings.
The study is currently recruiting patients, thus no data will be available for presentation. This
presentation will nonetheless aim to present and discuss the hypothesis that provision of
symptom self-management advice may be an important mechanism to improve patient self-
efficacy, which may establish a self-sustained cycle where self-care advice provision enables
patient self-efficacy and this in turn further increases patient involvement in self-management
that can ultimately lead to improved patient outcomes. Method(s)/Results: The current study has
been informed by the Medical Research Council Complex Interventions Framework (Anderson,
2008; Craig and Petticrew, 2012; Mackenzie et al., 2010), and the Holistic Framework to
improve the Uptake and Impact of e-Health Technologies (van Gemert-Pijnen et al., 2011). The
eSMART programme of work comprises two parts that will take place over a period of five
years. The first part consists of preparatory work to refine the ASyMS intervention for use in a
multi-national context, and concludes with a feasibility testing period to establish the
technological readiness of the system prior to its use in the second part. The second part will
employ a repeated-measures, parallel-group, stratified randomised controlled trial methodology
to demonstrate the effects of the ASyMS intervention in supporting patients who receive
chemotherapy treatment through individualised symptom management. The second part will test
the short- (i.e. during the treatment phase) and long-term effects (i.e. at one-year follow-up) of
the ASyMS intervention versus standard care across the participating countries (Austria, Greece,
Ireland, Norway and the UK).

The ASyMS intervention comprises use of a mobile phone (i.e. ASyMS patient handset) and a
tympanic thermometer. The patient handset will enable participants on the intervention group to
enter symptom/temperature data on a dedicated, electronic symptom questionnaire daily and
whenever they feel unwell. Upon successful submission of their data, patients will immediately
receive automated, evidence-based self-care advice based on their symptom reports. Patients will
also have access to a self-care library, symptom graphs (detailing trends in individual symptoms
experienced) and contact numbers of care teams and patient support organisations in their
country, available within the ASyMS patient handset.

Via dedicated tablet PCs, all participants will complete an electronic version of the
Communication and Attitudinal Self-Efficacy scale for cancer (CASE-Cancer) (Wolf et al.,
2005) at baseline; after each CTx; and 3, 6, 9 and 12 months post-chemotherapy treatment. The
CASE-Cancer is a validated, 12-item measure that yields scores on three factors: understanding
and participating in care, maintaining a positive attitude, and seeking and obtaining information.
In accordance with latest recommendations for pragmatic research in healthcare (Oakley et al.,
2006; Treweek and Zwarenstein, 2009), the longitudinal nature of the trial will aid to establish
sustainability of intervention effects and further stress its benefits when compared to standard
care.
Conclusions: This anticipatory model of care supports symptom management within the patient’s
home, where the early toxicities of chemotherapy can be managed, utilising self-care and local
community services. This model is also expected to contribute to the health literacy of patients
with cancer in relation to early identification, report and self-management of their most common
symptoms.

As part of the project’s objectives, we will aim to show improved self-efficacy (as shown by
statistically significantly higher self-efficacy scores) during active chemotherapy for breast
cancer, colorectal cancer, or haematological malignancies, and/or at one-year follow-up. It is
hoped that an enhanced self-efficacy (evidenced by patients’ greater understanding and
participation in care, positive attitude, and engagement in seeking health-related information)
will in turn enable a smoother rehabilitation process for patients in the post-treatment
survivorship period and beyond. EU FP7 Programme Grant agreement No. 602289. Trial
registration identifier (clinicaltrials.gov) NCT02356081.

Acknowledgements

The authors gratefully acknowledge the contribution of the eSMART Collaborative Work Group
in this project.

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Keywords: Cancer, Technology, self-management, self-efficacy, ePRO system, patient-reported
outcomes, chemotherapy, randomized controlled trial, empowerment

Conference: 2nd Behaviour Change Conference: Digital Health and Wellbeing, London, United
Kingdom, 24 Feb - 25 Feb, 2016.

Presentation Type: Oral presentation

Topic: Academic

Citation: Kotronoulas G, Maguire R, Papadopoulou C, Furlong E, Fox P, Ream E, Armes J,

McCann L, Miaskowski C, Patiraki E, Apostolidis K and Kearney N (2016). Enabling symptom
self-management via use of an electronic patient-reported outcomes (ePRO) system to increase
self-efficacy of patients with cancer receiving active chemotherapy treatment. Front. Public
Health. Conference Abstract: 2nd Behaviour Change Conference: Digital Health and
Wellbeing. doi: 10.3389/conf.FPUBH.2016.01.00077

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Received: 27 Nov 2015; Published Online: 09 Jan 2016.

* Correspondence: Dr. Grigorios Kotronoulas, University of Surrey, School of Health Sciences,

Guildford, United Kingdom, grigorios.kotronoulas@strath.ac.uk