By: Liam Davenport
CHICAGO — Clinicians who care for cancer patients may someday want to text a smiley face, thumbs up, and red heart to Carrie A. Thompson, MD, an oncologist at the Mayo Clinic in Rochester, Minnesota, for her new study of the use of emojis to collect and measure patient-reported outcomes (PROs).
The hieroglyphics of the digital age may make it easier for patients to report outcomes such as fatigue and physical function and therefore make this vital information more accessible for clinicians, said Thompson and colleagues.
"Emoji scales are a promising tool for assessing patient-reported outcomes," she told an audience here at the American Society of Clinical Oncology (ASCO) 2018 annual meeting.
Collecting PROs via traditional pen-and-paper surveys can be burdensome for patients, so the Mayo team devised novel emoji scales for the outcomes reporting and developed apps for the iPhone and the Apple Watch.
The investigators randomly allocated 300 cancer patients into three groups on the basis of mode of PRO survey response: paper, iPhone, and Apple Watch. All patients responded to questions about their physical, emotional, and overall quality of life (QoL) for 12 weeks. The patients who used paper completed weekly text-based paper-and-pen questionnaires. The patients who used the iPhone and the Apple Watch also completed weekly text-based surveys on their devices and answered daily emoji-based questions.
Notably, regardless of their survey group, all of the study participants were issued an Apple Watch, which recorded their daily activity levels and heart rate via sensors.
Thompson and colleagues found that responses to the emoji scales correlated well to those of traditional PRO assessments and that records of physical activity logged via mobile technologies correlated well with function and QoL.
Although objective activity data from the Apple Watch were "significantly associated with patient-reported outcomes," weekly Apple Watch survey response rates were lower than those seen with either the iPhone or pen-and-paper surveys.
Thompson pointed out that the study is ongoing and that patients will be followed up every 3 months for 24 months for events such as relapse, retreatment, hospitalization, and death to examine the associations between activity levels, PROs, and clinical outcomes.
"In addition, we're performing further analyses to understand the discrepancies in response rates between groups," she said.
Currently, the findings show that "collection of patient-reported outcomes and activity data via mobile technology in cancer patients is feasible," Thompson added.
Study discussant Martin J. Taphoorn, MD, a neuro-oncologist from Haaglanden Medical Center, The Hague, the Netherlands, told the audience that awareness of patient functioning and well-being via PROs "may facilitate communication between the physicians and patient, as well increase health-related quality of life and inform physicians about the impact of a specific treatment...and may even help improve survival.".
He said that the possibility of replacing traditional methods of assessing PROs with use of emojis and modern technologies such as the Apple Watch and the iPhone is "very important, because we know that people may find it difficult to answer so many questions."
He added: "The good thing that [Thompson] and her colleagues did was to devise a randomized trial between these three groups of patients and demonstrate that we do indeed see a positive association between the activity of the patients in terms of a better functioning and symptoms in these patients."
Taphoorn said that weaknesses of the study included the fact that it required an Apple Watch and that the response rate was only moderate on that device.
He also wondered whether there would be cross-cultural differences in how the emojis would be interpreted, as well as whether results would vary on the basis of differences in the age of the patients.
However, Taphoorn said that the results are "promising" and "easily interpretable" and that such devices may improve compliance among patients.
More Study Details
The Mayo team developed technologies to measure physical activity and PROs using the Apple Watch and the iPhone via an app created with Apple's open-source ResearchKit development framework.
They then recruited adult patients diagnosed with lymphoma, myeloma, brain cancer, pancreatic cancer, breast cancer, or ovarian cancer within the past 5 years whose life expectancy was longer than 6 months.
All participants were required to own an iPhone of version 5.0 or higher. They were given an Apple Watch, and both devices were loaded with the study app.
The patients were asked to wear the Apple Watch for a minimum of 8 hours a day for 12 weeks, from which physical activity data were collected.
They completed the Patient-Reported Outcomes Measurement Information System (PROMIS) short forms, which assessed global health, physical function, fatigue, sleep disturbance, social/role function, and anxiety.
They also filled single-item linear analogue self-assessments (LASAs) on physical well-being, emotional well-being, fatigue, and QoL.
For the emoji questions, the team developed an emoji ordinal scale. Five faces were selected; the emojis were then validated in 20 cancer patients and were then tested against the LASA.
The researchers also developed an emoji mood scale, in which a series of emojis were chosen to correspond to feelings experienced by cancer patients, including tiredness, frustration, average/mediocre feelings, gratefulness, and happiness.
The median age of the patients was 53 years, and 94% were white. The median time since cancer diagnosis was 14.4 months. The majority (63%) of patients were undergoing active therapy.
With respect to computer literacy, 100% of patients were currently using an iPhone, and 99% had used a computer during the previous 12 months; 87% used a computer 5 to 7 days a week. Only 27% had previously used a smart watch.
Thompson noted that the groups were well balanced with respect to their baseline characteristics.
During the course of the study, the patients wore the Apple Watch for an average of 9.8 hours per day for an average of 131.6 days.
The average response rate to the weekly surveys was 76% in the pen-and-paper group, 77% in the iPhone group, and 60% in the Apple Watch group. In all groups, the response rates decreased over time.
For the daily emoji surveys, the response rate was 86% in the iPhone group and 69% in the watch group.
The team collected a total of 21.4 million records. The average number of steps per day was 4419.5, which Thompson noted was just below the average number of steps taken per day by the US population, as shown in previous studies.
More steps per day were associated with less fatigue (P < .0001), better physical function (P < .0001), better global physical well-being (P < .0001), better social function (P = .0127), and less sleep disturbance (P = .0233).
Having more minutes of exercise per day was associated with better global mental well-being (P = .0027) and less sleep disturbance (P = .0167).
The team also found that the results obtained with the emojis were highly significantly correlated overall and for individual emotions (P < .0001).
Furthermore, there were significant correlations between PRO scores for overall QoL, global physical and mental health, physical function, fatigue, anxiety, and sleep on the PROMIS short forms and their corresponding emoji (P < .001 for all).
Thompson would like to see more research with their apps. She called for further randomized studies to determine whether assessing PROs and activity data with wearable technology improves outcomes in cancer patients, including non-English speakers, older patients, and patients who are not computer savvy.
No funding for the study has been reported. Kathryn Jean Ruddy, MD, has stock and other ownership interests in Merck and Pfizer and has patents, royalties, and other intellectual property. Her husband is a coinventor of technology licensed by Mayo Clinic to AliveCor, which makes a smartphone-enabled remote ECG monitoring system. Joon H. Uhm, MD, has received honoraria, travel accomodations, and compensation for expenses from and has a consulting or advisory with Novocure. Thomas E. Witzig, MD, owns stock and has other ownership interests in Valeant Pharmaceuticals International; has served in a consulting or advisory role with Celgene and Seattle Genetics; and has received institutional research funding from Acerta Pharma, Celgene, Novartis, and Spectrum Pharmaceuticals.
American Society of Clinical Oncology (ASCO) 2018. Abstract 6501, presented June 1, 2018.