Kidney Cancer Journal 101
CA S E S T U D I E S
Mobile Health Applications in Patients With
Metastatic Renal Cell Carcinoma
Introduction
During the last decade, 10 drugs have been approved by
the Food and Drug Administration (FDA) for the treatment
of metastatic renal cell carcinoma (mRCC). Many of
these treatments are oral tyrosine kinase inhibitors (TKI’s)
targeting the vascular endothelial growth factor (VEGF)
receptor. These TKI’s are known to cause a variety of side
effects including fatigue, hypertension, nausea, diarrhea,
weight loss, palmar-plantar erythrodysesthesia, rash, and
endocrine side effects. The exact timing and degree of side
effects are difficult to predict but can be serious in 50% or
more of cases. Given that these drugs are generally dosed
at near maximum tolerated doses in all patients (i.e. flat
dosing) and that the toxicities can be rapid onset in some
cases within days or weeks of starting therapy, prompt
recognition and management of toxicities are crucial to
ensure safe management that will still lead to clinical efficacy.
1-3 Other targeted therapies used in the treatment of
mRCC include mammalian target of rapamycin (mTOR)
inhibitors and immune checkpoint inhibitors, both of
which can also have a wide variety of toxicities requiring
close monitoring. Current and future indications may include
combinations of these agents that further enhance
their risks. Therefore, as new cancer therapies and indications
for treatment are developed, it is imperative we
maximize the ability to monitor patients in real time to
assess rapid physiologic changes that could be harbingers
of more serious safety concerns.
The mobile health (mHealth) industry is one of the
largest growing business sectors in the world.4 In recent
years, smart phone technology has advanced considerably,
and patients are able to use a variety of devices to
monitor health related parameters including physical activity,
diet, blood pressure, heart rate, weight, blood sugar
and many other important variables.4,5 Even prior to the
rise of mHealth, telemedicine has been shown to be an effective
tool to help manage many chronic medical problems
including diabetes, heart failure, COPD and mental
health.6-9 Although mHealth applications are being explored
in cancer care,10,11 there are no published clinical
trials evaluating the use of mHealth technology in clinical
monitoring of patients with mRCC.
Side effects are quite common with VEGF inhibitor
therapy. For instance a pooled analysis of clinical studies
of patients treated with the now FDA approved VEGF inhibitors
sunitinib, sorafenib, pazopanib, axitinib, and bevacizumab,
showed dose reductions in 13-52% of patients,
dose interruptions 21-72% of patients, and discontinuations
due to adverse events in 4-28% of patients.12
This is important as failure to maintain dose intensity
may lead to decrease in survival in patients with mRCC.13
Hypertension, a side effect of these drugs was found to
occur in 20-40% of patients. Gastrointestinal side effects
such as anorexia, nausea, vomiting, and diarrhea were
commonly reported in approximately 30-60% of patients
and fatigue was reported in 50-60% of cases.12 Physical
activity monitoring may be a valuable tool in assessing
functionality in cancer patients and also a potential tool
to encourage exercise, which may help combat symptoms
like fatigue.14 As a result, in a very small study, we sought
to investigate how mHealth technology could be used to
monitor important clinical parameters including blood
pressure, weight, and physical activity in patients initiat-
Sundhar Ramalingam, MD
Division of Medical Oncology
Duke University Department
of Medicine
Durham, North Carolina
Corresponding Author: Sundhar Ramalingam, MD, Division of
Medical Oncology, Duke University Department of Medicine,
Durham, North Carolina Address: 2301 Erwin Road/Durham, NC
27710 e-mail: sr20@duke.edu Phone: 919 244 7237
Fax: 919 854 6969
Daniel J. George, MD
Division of Medical
Oncology
Duke University
Department of Medicine
Durham, North Carolina
Richard A.
Bloomfield Jr, MD
Duke University Health
System
Durham, North Carolina
Zubin J. Eapen, MD, MHS
Division of Cardiology
Duke University
Department of Medicine
Durham, North Carolina
Michael R. Harrison, MD
Division of Medical
Oncology
Duke University
Department of Medicine
Durham, North Carolina
Source: Institutionally/self-funded