Discussion
lung cancer
LUNG CANCER, SECONDARY, RECRUITMENT, METASTATIC CANCER
In this trial assessing the effect of patient-reported symptom monitoring on HRQOL in lung cancer patients, we observed that a reactive approach (patient receives alert) and an active approach (health-care provider receives alert) are equally effective on HRQOL. Furthermore, we confirmed that patient-reported outcomes symptom monitoring was significantly associated with improved HRQOL across almost all scales compared with care as usual. Because of the increasing time demands placed on health-care providers (Our findings are consistent with earlier studies on PRO symptom monitoring, which reported similar results with respect to HRQOL in metastatic cancer patients (Several limitations of our study should be noted. First, random assignment at the level of hospital resulted in some differences between the study groups with regard to the characteristics of the patients recruited. However, we were able to adjust for these baseline differences and still observed large effect sizes. Second, primarily because of the COVID-19 pandemic, we did not reach our intended sample size in the reactive intervention group. However, when taking the observed differences into account, using a noninferiority margin of 0.2*standard deviation, a power of 59% was reached for the summary score and 99% power for physical functioning. We believe that this provides sufficient evidence that the 2 approaches yield comparable HRQOL outcomes. Third, 58 (11%) still living patients did not complete their T1 HRQOL questionnaire of which 40 (69%) were from the intervention group. The dropout rate could be a sign of selective dropout in the intervention group due to worse health statuses. Therefore, it might be that the reported effects are a slight overrepresentation. However, the patients for whom data were missing in the intervention and control groups were similar in their baseline health status characteristics. Thus, we assume that this effect is marginal. Additionally, only 15 (25%) patients in the intervention groups reported that using the app was too burdensome compared with 4 (10%) patients in the control group (There may have been selection bias during the recruitment phase because the application was only available on an electronic device. However, of the 112 patients who received study information and declined participation, only 8 (7%) patients reported that it was because of the electronic aspect of the intervention. Although, the minimal role of internet access as a barrier is reinforced by the fact that in 2022, 96% of the Dutch population aged 65-75 years and 80% of age those aged 75 years and older made use of the internet (A major strength of our study is that we conducted a head-to-head comparison of a reactive and an active approach to web-based symptom monitoring. By including hospitals in our study from throughout the Netherlands and recruiting patients with all stages of lung cancer who were receiving all types of treatment, our study population is comparable to the real-world population, improving generalizability. Finally, the multicenter, stepped wedge cluster design made it possible to implement the intervention in daily clinical practice, specifically adapting the logistics to the work method of each participating hospital. This increases the relevance of our findings to the real world of clinical care for patients with lung cancer. Future research will further reveal the effect of PRO symptom monitoring on long-term HRQOL and our secondary outcomes overall survival, cost-effectiveness, usefulness, and implementation fidelity of the application.In conclusion, our results indicate that PRO symptom monitoring statistically and clinically significantly improves HRQOL in lung cancer patients. The reactive approach was equally effective to the standard active approach. Therefore, the reactive approach, which is logistically less intensive and less demanding for health-care providers, may be a better fit for efficient implementation within real-world clinical practice. Health-care providers can choose the symptom-altering approach that best suits their situation and that of their patients.