Are we ready to mitigate time toxicity of cancer care? Oncologists’ perceptions on digital interventions to fast-track cancer care.
Authors: Bange Erin Mary , Coughlin Kerry Q. , Brown Timothy J , Bilger Andrea , Balar Eesha , Arasappan Dhivya , Nnaji Michelle , Chong Elise A. , Cappucci Pamela , Ragusano Daniel , Zinck Lindsey Joan , Fredo Adam , O'Neill Caitlin , Li Wenrui , Mamtani Mira , Guerra Carmen , Mamtani Ronac 
Published: June 2023

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Background: Patients spend substantial time receiving cancer care, and innovative strategies to decrease time toxicity are needed. We have shown that a text-based triage can identify patients tolerating checkpoint inhibitors (ICI) without toxicity who could safely fast-track directly to ICI infusion. However, oncologists’ readiness to implement this strategy is unknown. Methods: This sequential mixed-methods study included oncologists treating solid-tumor patients with ICIs at Penn Medicine. In phase 1, participants completed a 26-item survey assessing readiness to implement a digital strategy, using the Acceptability, Appropriateness, and Feasibility of Intervention Measures (AIM, IAM, and FIM), as well as perspectives of time toxicity. Each measure consisted of 4 items on a 5-point Likert scale for which means (M) and standard errors (SE) were calculated. In phase 2, a focus group (FG) was led by Penn’s Mixed Methods Research Lab to better understand the barriers and facilitators to implementing a digital strategy among oncologists. The FG transcript was reviewed and coded in NVivo with identification of emerging themes. Results: 32 faculty members were eligible, of whom 17 (53%) completed the survey and 14 (44%) participated in the FG. Respondents were 53% (n=9) female, 65% (n=11) White, and 53% (n=9) full-time clinicians (non-research faculty); 41% (n=7) reported > 10 years in practice. Quantitative analysis identified infusion (n=11, 65%), commuting (n=11,65%), and waiting for the physician (n=8, 47%) as the top 3 sources of time toxicity among oncologists. Most agreed that novel interventions are needed to improve the patient-experience (M=4.9, SE=0.08) on a Likert scale of agreeability (1-5, 5=strongly agree). On this scale, our text-based digital strategy to allow patients to fast-track care was found to be acceptable (M=3.8, SE =0.1), appropriate (M=3.8, SE=0.1), and feasible (M=3.9, SE=0.1). Qualitative analysis revealed the following major themes: 1) barriers to implementing a text-based digital strategy including a) health system built for clinician convenience, b) concern with being viewed as “slackers” by administration, c) concerns about overlooking symptoms, d) difficulties identifying appropriate patients, and e) communication issues; and 2) facilitators to adopting this new strategy including a) openness to change, 2) utilizing strengths of care team, and 3) optimism of this digital tool. Conclusions: Oncologists recognize time toxicity is a common complication of cancer care. Digital interventions to triage patients who are not experiencing treatment toxicity–thereby reducing time toxicity–were deemed acceptable, appropriate, and feasible. To integrate this technology, further research is required to address key barriers to uptake in routine care.