SMART-ESAS: Smartphone Monitoring and Assessment in Real Time of Edmonton Symptom Assessment System Scores for Patients With Cancer

Abstract

Purpose: Serial patient-reported outcome (PRO) measurements in clinical practice are associated with a better quality of life and survival. Recording electronic PROs using smartphones is an efficient way to implement this. We aimed to assess the feasibility of the electronically filled Edmonton Symptom Assessment System (e-ESAS) scale in the lower-middle-income country (LMIC) setting.

Methods: Baseline clinical features and conventional paper-based ESAS (p-ESAS) were collected in newly diagnosed patients with solid organ tumors. Text message link was sent to these patients for filling e-ESAS. ESAS was categorized into physical, psychological, and total symptom domains. Scores were divided into none to mild (0-3) and moderate to severe (4-10). Intraclass correlation coefficients (ICCs) were used to determine the correlation between p-ESAS and e-ESAS. Multivariable logistic regression was used to identify independent factors affecting symptom burden.

Results: Of 1,160 participants who filled out p-ESAS, 595 completed both e-ESAS and p-ESAS questionnaires and were included in the final analysis. Moderate to severe physical, psychological, and total symptom scores were seen in 39.8%, 40%, and 39% of participants. Tiredness and anxiety were the most common physical and psychological symptoms, respectively. ICCs between the p-ESAS and e-ESAS varied between 0.75 and 0.9. Total symptom scores were independently predicted by metastatic disease (odds ratio [OR], 1.83; 95% CI, 1.26 to 2.67; P = .001) and a higher level of education (OR, 0.42; 95% CI, 0.25 to 0.72; P = .001).

Conclusion: Paper-based and electronically filled ESASs have good intraobserver reliability across individual symptoms and domain scores in a representative cohort at a tertiary care institute in the LMIC. This may help us incorporate e-ESAS in routine clinical care in the real-world setting with financial, infrastructural, and manpower limitations.

FIG 1

Workflow of the study. e-ESAS, electronically filled Edmonton Symptom Assessment System.

FIG 2

(A) Box plot showing physical, psychological, and overall symptom scores in e-ESAS and p-ESAS (mean ± SD labeled at the top of each box plot). (B) Bar graph showing means of individual psychological and best well-being domains in p-ESAS and e-ESAS (mean ± SD labeled at the top of each bar). (C) Bar graph showing means of individual physical domains in p-ESAS and e-ESAS (mean ± SD labeled at the top of each bar) e-ESAS, electronically filled Edmonton Symptom Assessment System; p-ESAS, paper-based Edmonton Symptom Assessment System; SD, standard deviation.

FIG 3

Bland-Altman plots for (A) total, (B) physical, and (C) psychological symptoms. e-ESAS, electronically filled Edmonton Symptom Assessment System; p-ESAS, paper-based Edmonton Symptom Assessment System; SD, standard deviation.

FIG A1

(Left) e-ESAS - format and visual analogue scale (VAS) used in English (Right) e-ESAS - format and VAS used in Hindi. AIIMS, All India Institute of Medical Sciences; e-ESAS, electronically filled Edmonton Symptom Assessment System.