Capturing—and Responding to—Patients’ Experiences after Thoracic Surgery

TSF Research Award recipient Gita Mody, MD, MPH, adapted a system for patient-reported outcomes monitoring that specifically serves the needs of patients undergoing lung cancer surgery—and enables clinicians to respond to concerning symptoms in real time.

“This work will be important to understanding how electronic patient-reported outcomes systems can address disparities in postoperative symptom control and other important patient-centered outcomes,” Dr. Mody said.

For more than a decade, researchers at the National Institutes of Health and elsewhere have used the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE®) as a companion to the CTCAE standard lexicon for reporting adverse events in cancer clinical trials. Dr. Mody’s mentor, Dr. Ethan Basch, also at the University of North Carolina (UNC), first tested the feasibility of PRO-CTCAE® to capture adverse events directly from patients in the real world. They tested the use of an electronic patient-reported outcomes (ePRO) system in a 52-site trial of patients with metastatic cancer in community oncology practices. This ePRO system sent weekly surveys to patients between clinic visits, and it alerted providers when symptoms were classified as “severe,” “very severe,” or worsening by two points since the previous week.

Extracting a subset of patients with metastatic lung cancer, Dr. Mody found that of the 3,701 surveys delivered to patients, 3,334—90%—were completed, 60% online and 40% by telephone.

“We were impressed by the ability of the study patients, including older individuals receiving chemotherapy, to participate in these weekly electronic surveys,” Dr. Mody said. “We thought that patients who have just had surgery face similar barriers—but there also may be differences, so we knew it would be important to study the system in our patient population.”

In the Real World, Access Matters

To understand how best to communicate with diverse patients undergoing lung cancer treatment, Dr. Mody’s team looked closer at their education levels, as well as at their experience with and access to computers, smartphones, email and internet to better understand how they could interact with this digital health intervention.

Most patients found the ePRO survey length reasonable (89%) and the questions easy to understand (84%), despite some having never used smartphones, email, or internet.

These responses prompted Dr. Mody’s team to further refine the survey questions, making them even more accessible within their ePRO. “We saw that patients with lung cancer, perhaps due to their age or demographics, often used non-web-based completion methods for the surveys,” she said. “We have extended this option to our surgical patients, with 10% to 20% opting to use the phone-based survey completion system.”

For 86% of patients, an answer they provided prompted an alert to their provider. Practice nurses contacted patients for about 50% of these alerts.

“This work demonstrates ePROs are feasible and facilitate actionable medical communication in lung cancer patients,” Dr. Mody said.

With those findings in hand, her next step was to design an ePRO tailored for the needs of surgical patients.

Dr. Mody’s team conducted systematic literature reviews2, consultation with expert colleagues, and an analysis of the symptoms reported in the trial cohort. “I identified the most common complications, associated symptoms, and physical function recovery trajectory experienced after thoracic surgery,” she said. “The selected symptoms match important symptoms identified through prior focus group work in this population by the FDA.”

Tailored for Patients, Customized for Thoracic Surgery

Selecting questions from existing validated PRO libraries, Dr. Mody and colleagues employed UNC’s Patient-Reported Outcomes core software system to deliver surveys to patients—sending them daily for 2 weeks, and then weekly up to 90 days. The system generated alerts to providers when severe or worsening symptoms were reported after discharge, complete with graphical reports of the severity and trajectory of symptoms.

“In the first two weeks after surgery, an average of 53% of surveys were completed,” Dr. Mody said. “This rate increased to 65% on average during the later postoperative period, extending up to 90 days. A follow-up study on the patients’ experiences completing surveys showed some barriers in the early postoperative period, which we are working to address.”

Refining Equity and Accessibility in the Field

Dr. Mody’s 2019 TSF Research Award allowed her the time and resources to closely examine how a system like this performs in the community. The project gave her insights into some barriers to patient participation, and it shed light on what current systems are lacking.

“All patients should have the opportunity to engage meaningfully in their care,” Dr. Mody said. “Identifying and addressing barriers to participation is an important component of this work.”

The team has improved inclusivity with strategies such as broadening eligibility criteria to include non-English-speaking patients and offering options like telephone survey delivery. “However, adapting to diverse needs requires flexibility and ongoing learning,” Dr. Mody said. “Each step forward provides valuable lessons, but much work remains to create truly accessible and equitable patient-centered care.”

Aligning Clinical Success with What’s Most Important to Patients

Quality of life—and its central role in patient-centered care for those undergoing thoracic surgery—is a primary focus of this research, explained Dr. Mody. “We aim to capture the aspects of recovery that matter most to patients—physical comfort, emotional well-being, and the ability to resume daily activities.”

The approach aligns the research with what patients value, helping to ensure that outcomes reflect not only clinical success but also personal and meaningful improvements in their everyday lives.

A “Powerful Catalyst for a Career”

Following her TSF Research Award, Dr. Mody received an American College of Surgeons Faculty Award and subsequently a K23 Career Development Award from the National Heart, Lung, and Blood Institute to further advance her critical work.

“I am currently working on my K23 Award project, which utilizes a sequential explanatory design to optimize the ePRO system for post-discharge care,” she said. “This approach allows for a structured process of quantitative assessment followed by in-depth qualitative insights, helping to refine the system to better meet patients' and providers’ needs and improve post-surgical outcomes.

The support I received from the Thoracic Surgery Foundation has been instrumental in making these milestones possible.”

Dr. Mody currently serves as Director of Thoracic Surgical Oncology and an associate professor of surgery at the UNC School of Medicine.

She wants aspiring researchers to know that a TSF award can be a powerful catalyst for a career.

“TSF provides not only critical funding to support your research, but also offers recognition from a respected foundation in thoracic surgery, enhancing your credibility and visibility in the field.”

“A TSF award can open doors to further funding opportunities, mentorship, and collaborative networks, all of which are invaluable as you establish and grow your research program,” Dr. Mody added. This support enables you to make meaningful contributions that can impact patient care and outcomes while building a strong foundation for a successful research career.”

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References

1. Mody GN, Stover AM, Wang M, King-Kallimanis BL, Jansen J, Henson S, Chung AE, Jonsson M, Bennett A, Smith AB, Wood WA, Deal A, Ginos B, Dueck AC, Schrag D, Basch E. Electronic patient-reported outcomes monitoring during lung cancer chemotherapy: A nested cohort within the PRO-TECT pragmatic trial (AFT-39). Lung Cancer. 2021 Dec;162:1-8. doi: 10.1016/j.lungcan.2021.09.020. Epub 2021 Sep 30. PMID: 34634754.
2. Merlo A, Carlson R, Espey J 3rd, Williams BM, Balakrishnan P, Chen S, Dawson L, Johnson D, Brickey J, Pompili C, Mody GN. Postoperative Symptom Burden in Patients Undergoing Lung Cancer Surgery. J Pain Symptom Manage. 2022 Sep;64(3):254-267. doi: 10.1016/j.jpainsymman.2022.05.016. Epub 2022 Jun 2. PMID: 35659636; PMCID: PMC10744975.
3. Boisson-Walsh A, Cox C, O'Leary M, Shrestha S, Carr P, Gentry AL, Hill L, Newsome B, Long J, Haithcock B, Stover AM, Basch E, Leeman J, Mody GN. A Qualitative Study of Electronic Patient-Reported Outcome Symptom Monitoring After Thoracic Surgery. J Surg Res. 2024 Nov;303:744-755. doi: 10.1016/j.jss.2024.09.051. Epub 2024 Oct 25. PMID: 39461326; PMCID: PMC11602354.