I recently consented a patient for a phase I trial of a bispecific antibody. In addition to hours of screening tests, once enrolled, the patient will need to come in weekly—theoretically indefinitely—with multiple planned admissions throughout his treatment to mitigate potential cytokine release syndrome. Many days of his life will be devoted to receiving treatment.
With the advent of immunotherapy in all its flavors (checkpoint inhibitors, bispecific antibodies, CAR T-cell therapy, vaccines, tumor-infiltrating lymphocytes, etc), as well as other cytotoxic drugs that can often be tolerated for long periods (eg, enfortumab vedotin), our patients are spending progressively more time engaged with the health care system. With the expansion of therapy into the neoadjuvant and adjuvant settings, this engagement will only increase.
Time toxicity, a cousin of financial toxicity, is now a real dilemma in oncology. Although in many ways this is a welcome change—if you don’t have effective treatments, not much time will be spent on them—innovative approaches are necessary to address it. Unfortunately, few, if any, patient-specific interventions have been tested.
Thus, I see it as a welcome development that a recent mixed-methods trial published in NEJM Catalyst began to chip away at this problem.1 An oversimplified summary is that patients receiving single-agent checkpoint inhibitors were engaged to provide a symptom assessment via text message. Those with no concerning new events and reasonable laboratory studies were permitted to bypass a provider visit and go directly to infusion on the day of treatment.
This e-triage tool saved patients an average of 66 minutes per encounter. Importantly, those who bypassed clinician visits did not experience any other detrimental adverse events, such as an increase in unexpected emergency department or hospital visits.
Coupled with subcutaneous administration of checkpoint inhibitors, now FDA approved, this approach can lead to substantial time saving and, hopefully, improved quality of life for our patients.
Ronac Mamtani, MD, from the University of Pennsylvania and senior author of the study, acknowledged that they are not yet ready to implement this e-triage tool in routine care.
“Our qualitative analysis found that some patients still want to see their physicians, and some physicians still want to see their patients. We need to work with clinicians to find the right patient at the right time. Once we do, we’ll be ready for prime time,” he said.
Erin Bange, MD, from Memorial Sloan Kettering Cancer Center and lead author of the study, added, “During cancer treatment, patients have little control over many aspects of their care, and approaches such as this can serve as one small way to give patients choice over how their care looks when safe and appropriate.” She said she hopes the next steps will involve a large pragmatic trial.
Undoubtedly, challenges and limitations, such as appropriate patient selection and potential impacts on reimbursement, will need to be addressed, but this trial represents a concrete step toward improving the lives of our patients who are often on long-term therapies for their cancers.
Reference
Bange EM, Coughlin KQ, Li W, et al. A text message intervention to minimize the time burden of cancer care. NEJM Catal Innov Care Deliv. Published online February 19, 2025. doi:10.1056/CAT.24.0201
DANIEL M. GEYNISMAN
Daniel M. Geynisman, MD, is an Associate Professor in the Department of Hematology/Oncology at Fox Chase Cancer Center and the Division Chief of Genitourinary Medical Oncology, as well as the Vice Chair for Quality Improvement. He is also the Editor-in-Chief of JNCCN as of May 2024.
Dr. Geynisman clinically sees patients with all urologic malignancies—bladder, kidney, prostate, penile, testicular, and adrenal cancers. His research interests focus on health outcomes evaluations in urologic malignancies, quality improvement in oncology, and new drug development for genitourinary malignancies. He is an active investigator on a number of past and ongoing clinical trials, with a particular focus in bladder and kidney cancer, and he has co-authored more than 130 manuscripts in peer-reviewed journals.
He serves on the NCCN Guidelines Panel for Testicular Cancer, is on ASCO’s Ethics Committee, and is the prior medical oncology editor for Urologic Oncology.
Dr. Geynisman earned his medical degree from the University of Pittsburgh School of Medicine and completed a residency in internal medicine at the University of Pittsburgh Medical Center, serving an additional year as chief resident. He then went on to a fellowship in hematology/oncology at the University of Chicago, serving as a chief fellow in his final year of training.
