Psychological Experience Psychological Experience of Using a Mobile Phone of Using a Mobile Phone to Self-Monitor Toxicity to Self-Monitor Toxicity During Individualised During Individualised

ChemotherapyChemotherapy

Rebecca IngramRebecca Ingram

Research in Focus DayResearch in Focus DayUoWUoW

2727thth February 2008 February 2008

Self-Responsibility of HealthSelf-Responsibility of Health

• UK Government (DoH, 2006)UK Government (DoH, 2006)

Technology in Health CareTechnology in Health Care

• Explosion in Mobile Explosion in Mobile TelecommunicationsTelecommunications

• 50 million in UK50 million in UK

ChemotherapyChemotherapy

• Serious Adverse Effects (Dikken et al Serious Adverse Effects (Dikken et al 1998)1998)

• Death Rates 0.8-2.2% Adjuvant Death Rates 0.8-2.2% Adjuvant RegimensRegimens

• Prompt Intervention Save Lives Prompt Intervention Save Lives

ChemotherapyChemotherapy

• Majority OutpatientsMajority Outpatients

• Manage Toxicity at HomeManage Toxicity at Home

Risk-Management:Risk-Management:

• Discussion pre-chemotherapyDiscussion pre-chemotherapy

• LeafletsLeaflets

• DiariesDiaries

• InternetInternet

ChemotherapyChemotherapy

• History of Telephone follow-upHistory of Telephone follow-up

BUTBUT

• Non-targetedNon-targeted

• Time-consumingTime-consuming

Also, Also,

• Patients reluctant to ‘bother’ nursesPatients reluctant to ‘bother’ nurses

Mobile Phone PotentialMobile Phone Potential

• Alert HCPsAlert HCPs

• Real-timeReal-time

• When necessaryWhen necessary• Diabetes Diabetes (Farmer et al, 2005)(Farmer et al, 2005)

• Asthma Asthma (Ryan et al, 2005; Neville et al, 2002)(Ryan et al, 2005; Neville et al, 2002)

• Feasibility Study Feasibility Study (Weaver et al, 2007)(Weaver et al, 2007)

Study ObjectivesStudy Objectives

• Develop system to manage side-Develop system to manage side-effects effects

• Individualise chemotherapy doseIndividualise chemotherapy dose

• Explore psychological consequences Explore psychological consequences of using the technologyof using the technology

The TechnologyThe Technology

Example Questions Example Questions

Example QuestionsExample Questions

Example QuestionsExample Questions

Example QuestionsExample Questions

Example AdviceExample Advice

Example Red Alert AdviceExample Red Alert Advice

Confirmation of Confirmation of UnderstandingUnderstanding

The TechnologyThe Technology

• All Data StoredAll Data Stored

• Patient can view historyPatient can view history

• Facilitate in-depth discussion at next Facilitate in-depth discussion at next aptapt

Any Concerns – Call Hospital Any Concerns – Call Hospital AnytimeAnytime

AlertsAlerts

• Symptoms & Temp Entered 2x DailySymptoms & Temp Entered 2x Daily

• Generate AlertGenerate Alert

Acceptable Toxicity: Acceptable Toxicity:

• Self-care AdviceSelf-care Advice

Unacceptable Toxicity: Unacceptable Toxicity:

• 30 mins Nurse to Contact30 mins Nurse to Contact

• If not heard MUST contact NurseIf not heard MUST contact Nurse

The PatientsThe Patients

Advanced Breast on:Advanced Breast on:

• CapecitabineCapecitabine

• Capecitabine & DoxcetaxelCapecitabine & Doxcetaxel

Advanced Colorectal on: Advanced Colorectal on:

• CapecitabineCapecitabine

• Capecitabine & OxaliplatinCapecitabine & Oxaliplatin

Capecitabine (Xeloda)Capecitabine (Xeloda)

• Oral fluouropyrimidine carbamateOral fluouropyrimidine carbamate• Converted to 5-FU in tumour tissue Converted to 5-FU in tumour tissue 3 steps3 steps• Rapidly Absorbed GI tractRapidly Absorbed GI tract• Metabolised in Liver to 5’DFCR Metabolised in Liver to 5’DFCR • 5-DFCR to 5’DFUR by Cytidine Deaminase in 5-DFCR to 5’DFUR by Cytidine Deaminase in

Liver and Tumour TissueLiver and Tumour Tissue• 5-DFUR to 5-FU in Tumour Site due to higher 5-DFUR to 5-FU in Tumour Site due to higher

concentrations of Thymidine Phosphorylaseconcentrations of Thymidine Phosphorylase

Capecitabine Common Capecitabine Common ToxicityToxicity

• Febrile Neutropenia -CAPOXFebrile Neutropenia -CAPOX

• DiarrhoeaDiarrhoea

• VomitingVomiting

• MucositisMucositis

• Hand-Foot SyndromeHand-Foot Syndrome

• Peripheral Neuropathy – Peripheral Neuropathy – CAPOX/CAPDOXCAPOX/CAPDOX

Cytotoxic Agent DosageCytotoxic Agent Dosage

• Steep Dose-Response Curve = Narrow Steep Dose-Response Curve = Narrow Therapeutic RatiosTherapeutic Ratios

DoseDose

• Phase 1 trials dose-limiting toxicity Phase 1 trials dose-limiting toxicity

• Premise that cytotoxics must induce a Premise that cytotoxics must induce a degree of cell kill in rapidly proliferating degree of cell kill in rapidly proliferating cell compartments (e.g. bone marrow, cell compartments (e.g. bone marrow, intestinal crypts etc) to be certain that intestinal crypts etc) to be certain that dose is within the therapeutic range. dose is within the therapeutic range.

Individualised DosageIndividualised Dosage

• Current Protocols all Dose Reductions – Current Protocols all Dose Reductions – can compromise disease control & survival can compromise disease control & survival in curable malignanciesin curable malignancies

ButBut, , • Dose Dense Schedules may increase Dose Dense Schedules may increase

survival ratessurvival ratesSoSo, , • Dose Reduction Dose Reduction andand Increases Increases• Driven by Toxicity Assessment 2x dailyDriven by Toxicity Assessment 2x daily

Psychological Consequences of Psychological Consequences of CancerCancer

• Depression, Anxiety & Somatisation Depression, Anxiety & Somatisation

>50% Patients (Zabora et al, 2001)>50% Patients (Zabora et al, 2001)

• QoL, Physical & Psychological functioningQoL, Physical & Psychological functioning

• Disease Progression = > DistressDisease Progression = > Distress

• QoL issues Vital End-Point in Palliative SettingQoL issues Vital End-Point in Palliative Setting

QoL End-PointQoL End-Point

• Real-time Monitoring of ToxicityReal-time Monitoring of Toxicity

• Enables Rapid Attendance to Side-effectsEnables Rapid Attendance to Side-effects

• Less Physical Effects for Shorter Time Less Physical Effects for Shorter Time Period Period

BUTBUT

• QoL Issues VitalQoL Issues Vital

Psychological Consequences of Psychological Consequences of Mobile PhoneMobile Phone

• Positive or Negative? Positive or Negative?

• Explore and understand the Explore and understand the psychological & practical experiencepsychological & practical experience

• Heideggerian Phenomenological Heideggerian Phenomenological ApproachApproach

PhenomenologyPhenomenology

• Study of conscious experience as Study of conscious experience as experienced from the subjective or experienced from the subjective or first person point of view. first person point of view.

• Study of phenomena: literally, Study of phenomena: literally, appearances as opposed to reality. appearances as opposed to reality.

• Concerned with the way individuals Concerned with the way individuals experience things and the meanings experience things and the meanings things have in individuals things have in individuals experiences. experiences.

Heidegger Vs HusserlHeidegger Vs Husserl

HeideggerHeidegger

• Experiences, and Experiences, and the meaning of the meaning of these experiences these experiences are embedded in, are embedded in, and cannot be and cannot be seperated from a seperated from a persons worldpersons world

HusserlHusserl

• De-contextualised De-contextualised experienceexperience

• ‘‘Epoche’ – Epoche’ – bracketing bracketing presuppositions & presuppositions & beliefsbeliefs

Heidegger: Implications for Heidegger: Implications for ResearchResearch

• Interested in patients understanding Interested in patients understanding of the experience and meaning of of the experience and meaning of using the mobile phone within the using the mobile phone within the context of the participants worldcontext of the participants world

• ClarificationClarification

• Interpretations of ResearcherInterpretations of Researcher

MethodMethod

LongitudinalLongitudinal

QualitativeQualitative

Semi-Structured InterviewsSemi-Structured Interviews

PatientsPatients

StaffStaff

Feasibility PatientsFeasibility Patients

TriangulationTriangulation

Reference ListReference List

• Balas A E and Lakovidis I (1999) Distance technologies for patient monitoring. BMJ, 319; 1309Balas A E and Lakovidis I (1999) Distance technologies for patient monitoring. BMJ, 319; 1309• Citron ML. Dose-density in adjuvant chemotherapy for breast cancer. Citron ML. Dose-density in adjuvant chemotherapy for breast cancer. Cancer Invest. Cancer Invest. 22(4):555-6822(4):555-68• Department of Health (2006) Supporting Self Care – A Practical Option: Diagnostic, Monitoring and Assistive Tools, Department of Health (2006) Supporting Self Care – A Practical Option: Diagnostic, Monitoring and Assistive Tools,

Devices, Technologies and Equipment to Support Self-Care. Accessed 30th October 2007 at Devices, Technologies and Equipment to Support Self-Care. Accessed 30th October 2007 at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4134006http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4134006

• Farmer, A.J., Gibson, O.J., Dudley, C., Bryden, K., Hayton, P.M., Tarassenko, L. and Neil, A (2005) A Randomised Farmer, A.J., Gibson, O.J., Dudley, C., Bryden, K., Hayton, P.M., Tarassenko, L. and Neil, A (2005) A Randomised Controlled Trial of the Effect of Real-Time Telemedicine Support on Glycaemia Control in Young Adults with Type 1 Controlled Trial of the Effect of Real-Time Telemedicine Support on Glycaemia Control in Young Adults with Type 1 Diabetes (ISRCTN 46889446). Diabetes (ISRCTN 46889446). Diabetes CareDiabetes Care, 28, 11, 2697-2702, 28, 11, 2697-2702

• Kimmel S REzai M, Kimmig R, Schmid P. 2007; Dose-dense chemotherapy for primary breast cancer. Kimmel S REzai M, Kimmig R, Schmid P. 2007; Dose-dense chemotherapy for primary breast cancer. Curr Opin Obstet Curr Opin Obstet GynecolGynecol 19(1): 75-81 19(1): 75-81

• Lyman GH, Dale DC Friedberg J et al. Lyman GH, Dale DC Friedberg J et al. Incidence and predictors of low chemotherapy dose-intensity in aggressive non-Incidence and predictors of low chemotherapy dose-intensity in aggressive non-Hodgkin's lymphoma: a nationwide study 2004; Hodgkin's lymphoma: a nationwide study 2004; JCOJCO 22 (21): 4302-11 22 (21): 4302-11

• Maglaveras N,m Koutkias V, Meletiadis S, Chouvarda I, Balas EA (2001) The Role of Wireless Technology in Home Care Maglaveras N,m Koutkias V, Meletiadis S, Chouvarda I, Balas EA (2001) The Role of Wireless Technology in Home Care Delivery. Medinfo 2001 V Patel et al (Eds) Amsterdam: IOS Press Delivery. Medinfo 2001 V Patel et al (Eds) Amsterdam: IOS Press

• Mark, TL, Fortner B, Johnson G (2007) Tablet PC Helps Doctors and Patinet Focus on Chemotherapy Side Effects – Jurnal Mark, TL, Fortner B, Johnson G (2007) Tablet PC Helps Doctors and Patinet Focus on Chemotherapy Side Effects – Jurnal of Supportive Care in Cancerof Supportive Care in Cancer

• Neville et al (2002) Mobile phone text messaging can help young people manage asthma. BMJ, 2002, 325, 600Neville et al (2002) Mobile phone text messaging can help young people manage asthma. BMJ, 2002, 325, 600• Ryan, D., Cobern, W., Wheeler, J., Price, D., and Tarrasenko, L. (2005) Mobile Phone Technology in the Management of Ryan, D., Cobern, W., Wheeler, J., Price, D., and Tarrasenko, L. (2005) Mobile Phone Technology in the Management of

Asthma. Asthma. Journal of Telemedicine and TelecareJournal of Telemedicine and Telecare, 11, (Suppl. 1), S1, 43-46, 11, (Suppl. 1), S1, 43-46• Schwarz, R.E., Coit, D.G., Groeger, J.S (2000) Transcutaneously tunnelled central venous lines in cancer pateins: an Schwarz, R.E., Coit, D.G., Groeger, J.S (2000) Transcutaneously tunnelled central venous lines in cancer pateins: an

analysis of device-related morbidity factors based on prospective data collection. Ann Sug Oncol, 7:441-449Balas, A., E analysis of device-related morbidity factors based on prospective data collection. Ann Sug Oncol, 7:441-449Balas, A., E and Lakovidis, I. (1999) Distance Technologies for Patient Monitoring. and Lakovidis, I. (1999) Distance Technologies for Patient Monitoring. British Medical JournalBritish Medical Journal, 319, 1309-1311, 319, 1309-1311

• Weaver A, Young AM, Rowntree J, Townsend N, Pearson S, Smith J, Gibson O, Cobern W, Larsen M. & Tarassenko L. Weaver A, Young AM, Rowntree J, Townsend N, Pearson S, Smith J, Gibson O, Cobern W, Larsen M. & Tarassenko L. Application of mobile phone technology for managing chemotherapy-associated side-effects Application of mobile phone technology for managing chemotherapy-associated side-effects Ann Oncol.Ann Oncol. 2007 2007 18(11):1887-92. 18(11):1887-92.

• Zabora, J., Brintzenhofeszoc, K., Curbow, B., Hooker, C., and Piantadosi, S. (2001) The Prevalence of Psychological Zabora, J., Brintzenhofeszoc, K., Curbow, B., Hooker, C., and Piantadosi, S. (2001) The Prevalence of Psychological Distress by Cancer Site. Psycho-Oncology, 10, 19-28Distress by Cancer Site. Psycho-Oncology, 10, 19-28