Neutropenic fever is a common and potentially serious complication of cytotoxic chemotherapy. The American Society of Clinical Oncology estimates that half of people receiving chemotherapy have some level of neutropenia, and the adjusted risk of mortality in patients with febrile neutropenia (FN) is at least 15 percent higher than in comparable patients who do not experience FN. Early detection and treatment are key to effective management of this condition; however, spot checks using traditional thermometers are not always effective at detecting episodes since neutropenic fever sometimes occurs without symptoms or during non-waking hours.
Conceptually, while thermometer technology has evolved over time, the process of doing spot checks with thermometers has not changed significantly since they were first introduced into clinical practice in the 1700s. The essence of what is required-that a patient must take deliberate action to obtain temperature information-has remained the same. In modern cancer care and research, this translates into patients being asked to take their temperature multiple times per day or if they experience concerning symptoms. This approach is inherently more limited than what's possible using a remote patient monitoring (RPM) device.
New Era of Technology
RPM devices such as automated temperature patches could signal a paradigm shift away from requiring patients or study participants to remember to take action to facilitate data collection. Instead, they can simply wear a patch that houses a medical-grade Bluetooth-enabled device which continuously transmits data to secure, HIPAA-compliant remote servers. This can help streamline patient care and, in the context of research studies, help decentralize data collection.
Investigators at UCLA Jonsson Comprehensive Cancer Center are conducting a prospective study of 80 cancer patients who are undergoing outpatient chemotherapy treatment using a continuous temperature monitor. It is a clinical grade wearable thermometer accurate to within 0.1[degrees]C that checks body temperature every 10 minutes. Patients with breast cancer, colon cancer, lung cancer, or one of two types of non-Hodgkin's lymphoma undergoing TC (docetaxel/cyclophosphamide), mFOLFOX6, cisplatin/pemetrexed, or R-CHOP will be enrolled.
They will wear a temperature monitor continuously for the first 3 months of chemotherapy treatment. If a fever is detected, both patients and their treating oncologists will be notified in real-time via email. Each fever episode will generate two emails: one when a fever first occurs, and another when the maximum temperature for the fever episode is identified. Patients will then get their blood drawn to confirm neutropenia.
The study seeks to quantify the incidence of neutropenic fever with these common chemotherapy regimens to allow for earlier detection and treatment of neutropenic fever than what is currently possible using spot check thermometers, and to quantify morbidity, mortality, health care utilization, and costs of care among patients with neutropenic fever detected using an automated temperature patch.
Beginning several decades ago, as new chemotherapies were discovered and new regimens formulated, the rates of neutropenic fever with a wide variety of regimens were studied and published. These studies ultimately helped inform professional guidelines that group regimens into high risk (>20%) and intermediate risk (10-20%) of causing neutropenic fever, and recommend use of or consideration of, respectively, myeloid growth factors, white blood cell-boosting medications that can be given with each chemotherapy cycle and lower the risk of neutropenic fever. These guidelines thus influence insurance coverage of these effective but expensive medications.
However, as all of these studies relied on traditional spot check thermometers to detect fevers, they were subject to the same limitations as using spot check thermometers in clinical practice. It is therefore possible that neutropenic fever is more common than previously understood, which might lead to reclassification of risk status in two ways: 1) intermediate risk chemotherapy regimens may actually carry a high risk, which could change guideline recommendations and insurance reimbursement of myeloid growth factors; and 2) there may exist a patient population with neutropenic fever detected using wearable technology whose fever would otherwise not have been known yet who may safely forego treatment, which would represent a novel risk category of neutropenic fever.
While this study is not designed to codify "low risk" neutropenic fever formally, it could begin to generate hypotheses about what constitutes such a syndrome. Neutropenic fever accounts for approximately 5 percent of cancer-related hospitalizations and 8 percent of cancer-related hospitalization costs. When safe, triaging FN patients away from the hospital can improve patient care and reduce strain on existing health care resources.
Viable Opportunities
While this study will focus on temperature as its key metric, remote monitoring of other vital signs can yield potentially important insights into the real-time health of cancer patients, who can be at an especially high risk of complications resulting from treatment. RPM devices can collect enormous amounts of data, which has pros and cons.
Clinicians and researchers must be able to efficiently and effectively analyze and utilize the data, so these devices must be paired with intuitive management platforms that organize and present information in usable ways. Parsing this data with algorithms, ranging from the simple to the complex, can assist clinicians and researchers in making use of RPM insights. There are myriad ways in which RPM can aid oncology clinical practice and research. The key moving forward will be continuing to design and validate use cases of these technologies as the landscape of RPM expands.
ADAM E. SINGER, MD, PHD, is a hematology/oncology fellow and health technology, health services, and cancer supportive care researcher. He holds an MD from UCLA and a PhD in policy analysis from the Pardee RAND Graduate School, where his doctoral work studied palliative health services interventions. His research focuses on the impact of novel technologies on a variety of cancer patient-oriented outcomes, including symptoms, functional status, quality of life, health care utilization, costs of care, and health equity.