Systemic Treatment Related Toxicity Identified With a Smartphone APPlication Measuring Step Count

Study Overview
=================
Brief Summary
-----------------
The goal of this observational study is to investigate whether daily physical activities measured with a smartphone are related to the possible side effects or other physical complaints that arise as a result of cancer treatment. The investigators want to test whether the number of steps per day, both before and during treatment, are related to possible side effects or other physical complaints of the treatment using a smartphone. Knowledge about this relationship gives us possible starting points to prevent and/or reduce side effects and improve treatment outcomes. Additional research would then be needed. The investigators also want to investigate whether these daily measurements are feasible for patients undergoing treatment. Participation in the study involves measuring daily physical activity from the week before treatment until the first 3 months of treatment have been completed. This is done by tracking daily steps with patients own phone using the OncoSTAPP application.

Detailed Description
-----------------
Rationale: Systemic treatment of patients with cancer has a multimodal approach with the goal of balancing quantity and quality of life. Treatment decisions are influenced by tumour and patient-related characteristics. Additionally, in clinical practice performance status is used to identify whether a patient is sufficiently fit for systemic treatment, as it has shown to be a valid prognostic factor for survival and adverse events during treatment. However, treatment-related toxicities and hospitalisations occur frequently during systemic treatment. The disadvantages of performance status assessed with ECOG or Karnofsky, is that it is a subjective measurement which is prone to bias and has high interobserver variability. Also a patient's self-reported physical function is significantly associated with shorter (progression-free) survival, but it is also subjective and is prone to multiple forms of bias. Objective assessment of physical function might be a good alternative to counteract these shortcomings. A higher level of physical activity is associated with a reduction in cancer specific mortality and can be measured with accelerometers, pedometers or multisenor systems like smartphones. Wearable measured step count assessed with a wrist worn device provided by the investigators has shown to be associated with adverse events. However, these devices cannot be provided to all patients in clinical practice. Recently, the investigators showed that the smartphones' assessments of physical activity (step count), have excellent agreement with accelerometer assessments of physical activity and good test-retest reliability. Furthermore this smartphone measurements were associated with early trial discontinuation in phase 1/2 cancer trials. The investigators hypothesize that a low baseline and/or a reduction in physical activity (step count) measured with smartphones will be predictive for clinically relevant adverse events during systemic treatment. Adding objective information of physical function in the process of selecting the best treatment for a patient may help prevent unnecessary adverse events. Additionally, a detection of a decline in physical activity during treatment may identify upcoming adverse events early, allowing timely management/support. This may help to optimize treatment and quality of life. Objective: Primary objectives: 1) To determine whether baseline physical activity, measured by the number of steps per day with a smartphone, is associated with clinically relevant adverse events during treatment. 2) To determine whether changes in physical activity, measured by the number of steps per day with a smartphone, are associated with clinically relevant adverse events during treatment. Clinically relevant adverse events during treatment are defined as hospitalizations, early treatment discontinuation, relative dose intensity below 70% and mortality. Secondary: Patients' acceptability of the application. The association of physical activity with relative dose intensity, progression free and overall survival. The association between the oncologists' estimates and clinically relevant adverse events during treatment, and the possible added value of objective assessments of physical activity. Study design: Prospective observational cohort study. Study population: 411 patients with cancer referred for systemic treatment at the departments of Medical Oncology at participating centres. Intervention: N/A. Main study parameters/endpoints: Collection of daily number of steps will start in the week before treatment and will continue for the first 3 months of systemic treatment. Mean number of steps per day will be measured passively with a smartphone application on patients' own smartphones. Primary endpoint is any clinically relevant adverse events during treatment, defined as hospitalizations, significant dose modifications of treatment and mortality. Nature and extent of the burden and risks associated with participation, benefit and group relatedness: Participation in this study will not cause any additional risks or expected benefits for participants. No extra visits to the hospital will be necessary. It will provide us knowledge, which may be used in the future to better select patients for systemic treatment. Patients will be asked to carry their smartphone on them during the duration of the study.

Official Title
-----------------
Systemic Treatment Related Toxicity Identified With a Smartphone APPlication Measuring Step Count - Prospective Cohort Study

Conditions
-----------------
Cancer, Systemic Treatment, Physical Activity, Toxicity Due to Chemotherapy

Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Age ≥18 years; Diagnosis of cancer with an indication of starting systemic treatment Knowledge how to handle smartphone with iOS version 11 or higher or Android version 7.0 or higher. Mastery of Dutch language Able and willing to give written informed consent Exclusion Criteria: Cognitive disorders or severe emotional instability Wheelchair-depended at home, or immobile due to for example fracture Already participating in an exercise trial

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Study population<br>Patients with cancer referred for systemic treatment of the outpatient clinic at the departments of Medical Oncology at participating centres. | |

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Physical activity | Mean number of steps per day measured with a smartphone. At baseline and during treatment | From enrollment to the end of observation period (90 days on systemic treatment) | 
| Number of patients with a hospitalization | Hospitalizations during treatment related to the therapy; will be combined into Clinically relevant adverse events during treatment | From enrollment to the end of observation period (90 days on systemic treatment) | 
| Number of patients with a treatment discontinuation | Early treatment discontinuation, within the first 3 months; will be combined into Clinically relevant adverse events during treatment | From enrollment to the end of observation period (90 days on systemic treatment) | 
| Number of patients with a RDI <70% | Relative dose intensity (RDI) below 70%; will be combined into Clinically relevant adverse events during treatment | From enrollment to the end of observation period (90 days on systemic treatment) | 
| Rate of mortality | Mortality due to treatment toxicity; will be combined into Clinically relevant adverse events during treatment | From enrollment to the end of observation period (90 days on systemic treatment) | 
| Relative dose intensity (RDI) of systemic treatment | The percentage of planted dose and time between doses will be retrieved form patients' medical records (EPIC). The RDI will be calculated by total percentage of given dose divided by the proportion of the actual time in relation to the standard time. RDI=(Total percentage of given dose)/((Actual time)/(Standard time))*100 | From enrollment to the end of observation period (90 days on systemic treatment) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Physician's rated performance status | The Eastern Cooperative Oncology Group/World Health Organization Performance Status (ECOG/WHO-PS) will be determined by the treating physician before treatment as stated in the current treatment guidelines of the departments of Medical Oncology. scale 0 to 5, with 0 denoting perfect health and 5 death. | At enrollment | 
| Oncologists' estimates of high toxicity risk during treatment | Question if patients are defined as at high (>50%) or low risk of dose limiting (>25% or discontinuation) toxicity during the first 3 months of systemic treatment. This will be documented in patients' medical records (e.g. EPIC). | At enrollment | 
| Overall survival | Overall survival is defined as the time between start of trial participation and death of any cause and will be tracked via the patients' medical records (e.g. EPIC). | From enrollment until the date of death from any cause, assessed up to 2 years | 
| Progression free survival | Progression free survival is defined as the time between start of systemic treatment and the clinically or radiologically confirmation of progressive disease (established via RECIST-criteria) and will be tracked via the patients' medical records (e.g. EPIC). | From enrollment until the date of first documented progression assessed up to 2 years | 
| Proportion of patients with correctly collected data | Validity of the smartphone application will be assesed by the proportion of patients correctly collected the data. | From enrollment to the end of observation period (90 days on systemic treatment) | 
| Patients experience with smartphone application | A consecutive sample of patients will be contacted for a short interview about the use of the smartphone application, until data saturation. Any spontaneously reported reactions about the smartphone application will be collected. | At the end of the observation period (90 days on systemic treatment), or reported spontaniously by the patient | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Cancer, Systemic treatment, Toxicity, Physical activity, Smartphone, wearable, Daily step count