© AME Publishing Company. J Tho ac Dis 2025;17(2):531-534 | h ps://dx.doi.o g/10.21037/j d-24-1427
We commen on D . Dai e al.’s well-designed s udy in
Jou nal o Clinical Oncology (1). This a icle epo s he
esul s o a andomized clinical ial compa ing s anda d
pos ope a i e ca e wi h elec onic pa ien - epo ed
ou comes (ePROs), whe e pa ien s epo ed hei symp oms
immedia ely ac oss i e key domains, and hese epo s we e
ansmi ed di ec ly o he su gical eam. The ocus o he
s udy was on long- e m ou comes (1 yea ), ollowing an
ea lie publica ion om he same g oup de ailing da a om
he i s mon h (2).
In he ini ial s udy, ePRO was al eady shown o imp o e
symp om con ol, and his new s udy demons a ed ha
his imp o emen was sus ained o e he long e m. The
indings showed ha he ePRO g oup had lowe composi e
sco es o bo h physical and a ec i e in e e ence and
epo ed be e sco es (indica ing lowe symp om se e i y)
o a igue, dis ess, appe i e loss, wo k in e e ence,
enjoymen o li e, walking abili y, gene al ac i i y, mood,
and social ela ionships.
This wo k was buil on p e ious s udies wi h simila
indings. Fo example, Cleeland e al. [2011] compa ed
adi ional ollow-up ca e o cance su ge y pa ien s wi h
an au oma ed call sys em ha gene a es ale s o he
su gical eam based on pa ien - epo ed da a (3). This s udy
demons a ed ha such an app oach no only imp o ed
pa ien sa is ac ion bu also led o a signi ican educ ion
in o e all symp om in e e ence. Since he co ona i us
disease 2019 (COVID-19) pandemic, pos ope a i e ca e o
oncology pa ien s has unde gone subs an ial changes, wi h
an exponen ial inc ease in non- ace- o- ace ca e (4). In his
con ex , pa ien ollow-up using ePRO has been p o en
o be a aluable ool, as demons a ed in his s udy. The
same app oach could be adap ed o cen alized heal hca e
sys ems, whe e su gical se ices ca e o la ge popula ions,
making physical access o heal hca e mo e di icul .
When implemen ing his ype o me hod, i is c ucial o
conside ac o s such as he geog aphical loca ion o each
hospi al, he ypes o pa ien s ea ed, and he dis ances
o eme gency ca e acili ies. Addi ionally, we mus be
mind ul o he olume o ale s gene a ed. In his s udy, 65
pa ien s igge ed 968 symp om h eshold e en s du ing
pos ope a i e hospi aliza ion and he 4 weeks ollowing
discha ge, esul ing in 417 ale s. Heal hca e sys ems
need o be p epa ed o handle his olume o ale s and
espond app op ia ely. This may equi e alloca ing speci ic
esou ces, ime, and space o such asks. P e ious s udies
ha e iden i ied and ca ego ized a ious ba ie s o he
implemen a ion o such me hodologies. These include
Edi o ial Commen a y
Elec onic pa ien - epo ed ou come-based symp om
managemen , a new e a in su gical pa ien managemen
Bo ja Aguinagalde1,2,3^, Ike Lopez1,3^, Jon Ande Liza be1
1Depa men o Tho acic Su ge y, Osakide za Basque Heal h Se ice, Donos ia Uni e si y Hospi al, Donos ia, Spain; 2Depa men o Su ge y,
UPV/EHU, Leioa, Spain; 3Biogipuzkoa, Lung and Pleu al Diseases Resea ch G oup, San Sebas ian, Spain
Co espondence o: Bo ja Aguinagalde, PhD, MD. Depa men o Tho acic Su ge y, Osakide za Basque Heal h Se ice, Donos ia Uni e si y Hospi al,
Gab iel Ma ia La i e 4, 20014 Donos ia, Spain; Depa men o Su ge y, UPV/EHU, Leioa, Spain; Biogipuzkoa, Lung and Pleu al Diseases Resea ch
G oup, San Sebas ian, Spain. Email: [email p o ec ed].
Commen on: Dai W, Wang Y, Liao J, e al. Elec onic Pa ien -Repo ed Ou come-Based Symp om Managemen Ve sus Usual Ca e A e Lung
Cance Su ge y: Long-Te m Resul s o a Mul icen e , Randomized, Con olled T ial. J Clin Oncol 2024;42:2126-31.
Keywo ds: Lung esec ion; ollow up; elec onic pa ien - epo ed ou comes (ePROs)
Submi ed Aug 29, 2024. Accep ed o publica ion Jan 06, 2025. Published online Feb 23, 2025.
doi: 10.21037/j d-24-1427
View his a icle a : h ps://dx.doi.o g/10.21037/j d-24-1427
534
^ ORCID: Bo ja Aguinagalde, 0000-0003-4083-3579; Ike Lopez, 0000-0002-2777-0801.
Aguinagalde e al. ePRO-based symp om managemen
532
© AME Publishing Company. J Tho ac Dis 2025;17(2):531-534 | h ps://dx.doi.o g/10.21037/j d-24-1427
pa ien - ela ed ba ie s [e.g., ime equi ed o comple e
Pa ien -Repo ed Ou comes Measu es (PROMs), di icul y
using elec onic de ices, pe cei ed i ele ance o he da a,
conce ns abou p i acy], ba ie s ela ed o he medical
eam [e.g., insu icien ime o in e p e and ac on da a, lack
o aining in in eg a ing pa ien - epo ed ou comes (PROs)
in o clinical p ac ice, pe cei ed uselessness o ce ain PRO
da a], and sys emic ba ie s [e.g., inadequa e in eg a ion
in o clinical wo k lows, insu icien in o ma ion echnology
(IT) in as uc u e] (5).
An impo an conside a ion in s udies like his is wha
happens once he su gical eam ecei es he ale . The
eam’s i s publica ion desc ibed how he main ac ions
included pa ien consul a ions, educa ion, medica ion
p esc ip ions, and ecommenda ions o hospi al isi s, all o
which we e conduc ed acco ding o ele an guidelines and
clinical consensus. An in e es ing ques ion is whe he hese
ac ions can be s anda dized and op imized so ha a po ion
o hem could be handled by p ima y ca e physicians o
nu ses speci ically ained o hese asks.
Ano he key aspec o ePRO ools is accessibili y. Do
hey wo k o all pa ien s? I is no ewo hy ha only 40%
(166/418) o he pa ien s in his s udy me he eligibili y
c i e ia. One o he inclusion c i e ia was ha pa ien s mus
be willing and able o comple e he elec onic ques ionnai e
using sma phones o able s. Howe e , he s udy does
no speci y he p opo ion o excluded pa ien s due o
his limi a ion. This aises he ques ion: can we conclude
ha ePRO ools a e only use ul o a speci ic subse o
ou pa ien popula ion? In his ega d, a ecen s udy
ha explo ed he echnological ba ie s associa ed wi h
ePRO and examined he ac o s in luencing hei ini ial
adop ion and ongoing engagemen , using he Capabili y,
Oppo uni y, and Mo i a ion Model o Beha io Change
(COM-B), is pa icula ly ele an (6). I may also be he
case ha , in he absence o an ideal model o in ensi e
symp om moni o ing, a combina ion o se e al models may
be necessa y o maximum e ec i eness.
I is also impo an o no e ha clinical ials o his
na u e a e p one o ce ain biases, pa icula ly masking
bias. Pa ien s using hese ools, which a e some imes
pe cei ed as echnological ad ancemen s, may expe ience
a placebo e ec . In his sense, he ac ha he bene icial
e ec s o hese ools las o up o 1 yea is o conside able
signi icance.
In summa y, i is clea ha pa ien moni o ing, especially
du ing he i s mon h a e su ge y, leads o bo h sho -
and long- e m imp o emen s in symp oms. Di e en
me hods ha e been desc ibed o his pu pose, including
ePRO. We emphasize ha pa ien adhe ence o he
moni o ing sys em is c i ical. The e o e, each depa men ,
hospi al, o heal hca e ins i u ion should de elop a me hod
ailo ed o i s pa ien popula ion o o e in ensi e non- ace-
o- ace ca e du ing he i s pos ope a i e mon h, as his
signi ican ly imp o es ou comes.
The a icle p esen ed is he esul o a andomized
clinical ial compa ing usual pos ope a i e ca e e sus
ePRO, whe e pa ien s immedia ely epo hei symp oms
on i e a ge s and hese a e immedia ely epo ed o he
su geon. In his case, he a icle ocuses on long- e m
ou comes (1 yea ) as p e iously he same g oup published
da a on he i s mon h (2). In he i s s udy i was al eady
shown ha ollow-up wi h ePRO shows be e symp om
con ol, in his s udy i is shown ha his imp o emen
is p olonged in he long e m. In his s udy, i was ound
ha he g oup ollowed by means o ePRO had a lowe
composi e sco e o physical in e e ence and a ec i e
in e e ence and also epo ed lowe sco es (i means, be e
sco es) in a igue, dis ess, lack o appe i e, wo k, enjoymen
o li e, walking, gene al ac i i y, mood and ela ions wi h
o he s.
This wo k builds on p e ious wo k wi h simila esul s.
Fo example, in he wo k o Cleeland e al. compa es he
usual ollow-up o pa ien s unde going cance su ge y wi h
au oma ed calls ha pa ien s ecei e and ha c ea e ale s
o he su gical eam o ac on (3). This pape o 2011
al eady demons a es ha his p ac ice imp o es pa ien
sa is ac ion and signi ican e ec o educ ion in o e all
symp om in e e ence. A e he COVID-19 pandemic, he
pos ope a i e managemen o oncology pa ien s unde wen
a adical change in many espec s exponen ially inc easing
non- ace- o- ace ca e (4). In his sense, pa ien ollow-
up using ePRO can be a e y use ul ool as demons a ed
in his a icle. The same could be applied o cen alized
heal hca e sys ems whe e su gical se ices se e la ge
popula ion a eas and he e o e physical access may be mo e
complex.
When applying his ype o me hod, i is essen ial o
analyze he si ua ion and geog aphic loca ion o each
hospi al, he ype o pa ien s ea ed, he dis ances o i s
eme gency depa men , e c. We mus be awa e o he high
numbe o epo ed ale s; in ac , in his s udy 65 pa ien s
gene a e du ing he pos ope a i e hospi aliza ion and
4 weeks a e discha ge, 968 symp om h eshold e en s
ha b ough 417 ale s. We mus be p epa ed o ecei e
his amoun o ale s and ac on hem, so he heal hca e
Jou nal o Tho acic Disease, Vol 17, No 2 Feb ua y 2025 533
© AME Publishing Company. J Tho ac Dis 2025;17(2):531-534 | h ps://dx.doi.o g/10.21037/j d-24-1427
sys em will ha e o p o ide space/ ime o his ype o new
ask. This ac has been s udied in di e en wo ks whe e
he ba ie s o his ype o me hodology a e speci ied
and classi ied in o hose dependen on he pa ien [ ime
equi ed o comple e PROMs (pa ien epo ed ou come
measu es), pa ien inabili y o comple e PROMs, di icul y
using elec onic de ices o comple e PROMs, pe cei ed
i ele ance o PROMs and hei lack o alue, conce ns
ha PROMs may comp omise he doc o o pa ien
ela ionship, conce ns a ound p i acy], hose dependen
on he medical eam (insu icien ime o in e p e , ac ion
and discuss PRO da a wi h pa ien s du ing clinics, lack o
knowledge ega ding how o in e p e and in eg a e PROs
in o clinical p ac ice, pe cei ed uselessness o ce ain PRO
da a, di icul y using he elec onic PRO collec ion sys em)
and hose dependen on he heal hca e sys em i sel (lack o
in eg a ion in o clinical wo k lows, inabili y o ac ion ePRO
da a, inadequa e IT in as uc u e) (5).
In his line, i would be impo an o highligh in his
ype o s udy, wha was done once he su gical eam ecei ed
he ale . The i s pape published by his eam desc ibes
ha mainly included consul a ion, pa ien educa ion,
medica ion p esc ip ion, and hospi al isi sugges ions,
which we e conduc ed acco ding o ele an guidelines
and consensus. An in e es ing ques ion would be whe he
hese ac ions pe o med can be s anda dized and op imized
so ha a leas a pe cen age can be sol ed by p ima y ca e
physicians o nu ses ained speci ically o his ask.
An essen ial aspec when alking abou his kind o ool
is accessibili y. Do hey wo k o all ou pa ien s? I is
s iking ha in his same s udy only 40% (166/418) mee
he eligibili y c i e ia. One o he inclusion c i e ia was
de ined as pa ien s who we e willing and able o ill ou
he elec onic ques ionnai e (e-ques ionnai e) on hei
sma phones o able s. I is no speci ied, wha p opo ion
o no included pa ien s has been o his eason. In o he
wo ds, could we conclude ha hese ools a e use ul bu
only o a speci ic popula ion o ou pa ien s? In his line,
i is e y in e es ing he ecen ly published s udy whe e he
echnological ba ie s gene a ed by ePRO a e assumed and
he ac o s in luencing hei ini ial up ake o and ongoing
engagemen wi h ePRO symp om moni o ing guided by
he COM-B a e explo ed (6). I is also possible ha in
he absence o an ideal model o his ype o in ensi e
moni o ing a combina ion o se e al models will be
necessa y o maximum e ec i eness.
I should be no ed ha hese clinical ials inhe en ly
ha e a clea masking bias and pa ien s wi h he use o hese
ools, some imes pe cei ed by he gene al popula ion as
echnological ad ances, may ha e a ce ain placebo e ec .
In his sense, he ac ha he bene icial e ec o hese ools
las s up o 1 yea is a ma e o some ele ance.
In summa y, we belie e i is e iden ha pa ien
moni o ing, especially du ing he i s mon h, ob ains
sho - and long- e m imp o emen s in pa ien symp oms.
In his sense, di e en me hods ha e been desc ibed,
among hem he ePRO. We would like o emphasize ha
pa ien adhesion and adhe ence o he sys em used a e o
g ea impo ance. The e o e, each depa men , hospi al o
heal h ins i u ion mus c ea e he me hod ha bes sui s i s
pa ien s o o e in ensi e non- ace- o- ace ca e du ing he
i s pos ope a i e mon h, as his imp o es he esul s.
Acknowledgmen s
None.
Foo no e
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by he edi o ial o ice, Jou nal o Tho acic Disease. The a icle
has unde gone ex e nal pee e iew.
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a icle/ iew/10.21037/j d-24-1427/p
Funding: None.
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uni o m disclosu e o m (a ailable a h ps://j d.ameg oups.
com/a icle/ iew/10.21037/j d-24-1427/coi ). The au ho s
ha e no con lic s o in e es o decla e.
E hical S a emen : The au ho s a e accoun able o all
aspec s o he wo k in ensu ing ha ques ions ela ed
o he accu acy o in eg i y o any pa o he wo k a e
app op ia ely in es iga ed and esol ed.
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Ou come-Based Symp om Managemen Ve sus Usual
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Mul icen e , Randomized, Con olled T ial. J Clin Oncol
2024;42:2126-31.
2. Dai W, Feng W, Zhang Y, e al. Pa ien -Repo ed
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A e Lung Cance Su ge y: A Mul icen e Randomized
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Ci e his a icle as: Aguinagalde B, Lopez I, Liza be
JA. Elec onic pa ien - epo ed ou come-based symp om
managemen , a new e a in su gical pa ien managemen . J
Tho ac Dis 2025;17(2):531-534. doi: 10.21037/j d-24-1427
