Electronic Symptom Monitoring Reduces Disparities in Advanced Cancer Care, PRO-TECT Trial Shows
Key Insights
Weekly electronic symptom check-ins significantly improved symptom control and physical function in patients with advanced cancer, with the greatest benefits seen among historically underserved groups including Black patients and those with lower educational attainment.
The PRO-TECT trial enrolled 1,191 adults across 52 U.S. community oncology clinics, finding that remote monitoring bridged communication gaps rather than exacerbating health disparities.
Black patients using the system reported feeling more in control of their care, with 61% strongly agreeing that home symptom reporting improved their sense of agency compared to 42% of white patients.
A secondary analysis of the randomized PRO-TECT trial has found that a home-based electronic symptom monitoring system not only improves quality of life for patients with advanced cancer but may also help close long-standing gaps in health equity. The findings, published in JCO Oncology Practice, show that historically underserved groups—including Black patients and individuals with less formal education—derived the greatest benefit from the intervention.
"Although implementation of new technologies sometimes exacerbates health disparities, this did the opposite—it actually closed the gap," said lead author Allison M. Deal, MS, senior biostatistician at UNC Lineberger Comprehensive Cancer Center. "The evidence suggests historically underserved or marginalized groups potentially are benefitting even more."
Trial Design and Patient Population
AFT-39, the PRO-TECT (Patient Reported Outcomes To Enhance Cancer Treatment) trial, enrolled 1,191 adults with metastatic solid tumors receiving systemic therapy across 52 community oncology practices in the United States. The median age was 63 years. Participants were randomly assigned to either electronic symptom monitoring (n = 593) or usual care (n = 598).
Patients in the intervention arm completed a brief symptom survey weekly from home. To ensure internet access was not a barrier, they could respond via a web-based program or an automated telephone system—64% chose email surveys, while the remainder opted for telephone interactive voice response. When a patient reported severe or worsening symptoms, an electronic alert was sent directly to a nurse on their care team for prompt intervention.
Overall survival served as the primary endpoint, with secondary outcomes including emergency department (ED) visits and time to deterioration of symptoms, physical function, or health-related quality of life.
Overall Clinical Benefits
As previously reported, the trial showed no difference in overall survival between the intervention and control groups (HR = 0.99; 95% CI, 0.83–1.17). However, patients assigned electronic symptom monitoring had a significantly longer time to their first ED visit (adjusted HR = 0.84; 95% CI, 0.71–0.98) and fewer emergency visits at 12 months (1.02 vs. 1.3; P < .001).
Between baseline and three months, the intervention group demonstrated greater improvement in symptom control (+2.37 vs. –0.2; P = .002) and physical function (+1.54 vs. –0.93; P = .02), as measured by European Organisation for Research and Treatment of Cancer QLQ-C30 scales.
Closing Gaps Across Subgroups
The exploratory analysis examined outcomes stratified by race, age, educational attainment, and sex. Baseline scores for the overall cohort averaged 76.97 for symptom control and 73.9 for physical function.
By race, Black participants had numerically lower symptom control and physical function scores at baseline. At three months, Black patients in the intervention arm showed a +4.84 point improvement in symptom control (P = .03), while white patients improved by +1.81 points (P = .01). The larger gain among Black patients essentially erased the baseline gap, bringing their symptom control on par with white patients by the third month.
By educational attainment, individuals with a high school education or less experienced the single greatest boost in the study. They showed greater improvement in symptom control (+4.02 vs. –0.74; P < .001) and physical function (+2.43 vs. –3.24; P < .001) compared to similar patients receiving standard care.
Women and younger patients (under age 65)—two groups that traditionally report higher distress and more burdensome side effects during cancer treatment—also experienced substantial quality-of-life gains. Women assigned the intervention reported greater improvement in symptom control (+3.36 vs. –0.57; P < .001) and physical function (+3.13 vs. –0.49; P = .009). Among younger patients, the intervention group showed greater improvement in symptom control (+2.95 vs. –0.92; P < .001) and physical function (+2.2 vs. –0.76; P = .03).
"The magnitude of changes we observed was so large that it suggests this intervention is more beneficial to particular groups," Deal said. "We are not focusing on one single P value that was significant. We made a point to look at magnitudes, and 4- or 5-point increases on these 100-point scales are truly meaningful differences."
Patient Experience and Communication
A majority (81%) of trial participants assigned to electronic symptom monitoring provided feedback about the intervention. The responses revealed striking differences in how various groups perceived the system.
A higher percentage of Black participants than white participants strongly agreed that reporting symptoms each week improved discussions with their physician or nurse (57% vs. 35%; P = .0002), that their physician or nurse used the symptom information reported (61% vs. 49%; P = .04), and that reporting symptoms from home helped them feel more in control of their own care (61% vs. 42%; P = .0008). Additionally, 75% of Black participants indicated they used the advice they received in response to their reported symptoms, compared to 52% of white participants (P = .02).
Among those with lower educational attainment, 75% strongly agreed that symptom questions had been relevant to them, versus 58% of those with higher education (P = .0012).
"By giving people a simple way to report health issues during cancer treatments, we were able to bypass common hurdles like communication gaps or clinician bias, sending patient concerns straight to the medical team for quick action, delaying emergency department visits and improving outcomes," Deal said.
Implications and Next Steps
Victoria Blinder, MD, breast medical oncologist at Memorial Sloan Kettering Cancer Center and senior author of the study, emphasized the equity implications: "When novel technologies are developed, there is a risk that they might leave historically underserved groups behind, widening rather than reducing health disparities. Here, we see that the opposite seems to be happening. Rather than exacerbating disparities, implementation of remote symptom monitoring is bridging an important communication gap and improving healthcare access for underserved groups."
Ethan Basch, MD, M.Sc., study chair of AFT-39 and the Richard M. Goldberg Distinguished Professor of Medicine at the University of North Carolina School of Medicine, noted: "Our results suggest that remote monitoring may provide underserved cancer patients with a new avenue to communicate concerns that might go underrecognized in routine practice. Broad implementation of these systems may represent an effective and highly practical strategy to advance health equity."
Researchers acknowledged study limitations, including smaller sample sizes in race-stratified subgroups and the potential for nonresponse bias during feedback survey completion. The inclusion of only adults with metastatic cancer (search) may limit generalizability.
Based on the PRO-TECT results, a nationally funded initiative called OncoPRO—launched in partnership with ASCO (search) and the American Cancer Society—is now supporting oncology practices in implementing remote symptom monitoring. "The goal is to move this beyond the trial setting and into regular practice, which is a great next step," Deal said. "We want to make sure we get the intervention into the hands of all patients who need it."