New Study Examines How to Bring Digital Symptom Monitoring into Routine Cancer Care

December 22, 2025

A newly published study, “Implementation outcomes of a symptom management intervention in ambulatory oncology practices evaluated using a cluster randomized stepped wedge trial design,” led by David Cella, PhD, J. D. Smith, PhD, and a transdisciplinary team at Northwestern University Feinberg School of Medicine Department of Medical Social Sciences (MSS), and published in Implementation Science, offers one of the most comprehensive examinations to date of how large health systems can integrate digital symptom monitoring into everyday cancer care. The findings underscore both the promise and the complexity of real-world implementation.

The trial evaluated cPRO, an electronic health record integrated program that asks patients to report symptoms such as fatigue, depression, anxiety, and physical functioning. Previous research has consistently shown that collecting this information directly from patients can improve quality of life and, in some cases, lengthen survival. “That body of work led us to propose a study focused not on proving it works but on figuring out how to make it work in a complex health system,” Cella said.

The team launched a hybrid type 2 effectiveness implementation study that included more than thirty-four thousand outpatients across twenty-six oncology clinics between October 2020 and March 2024. Six clusters of clinics were randomly assigned to sequences that determined when each entered a six-month preparation period followed by full implementation of forty-six discrete strategies. These strategies targeted clinician practices, system operations, and patient engagement. They included staff training, technological refinements to how symptom reports appear in the electronic health record, and patient support to overcome barriers to completing assessments.

Despite the ambitious system wide rollout, the primary implementation outcome did not show a statistically significant improvement when comparing pre and post implementation periods. Completion of cPRO assessments increased overall from about twenty five percent to nearly 50 percent across the health system, but this rise was not linked to the stepped rollout schedule according to the formal cluster randomized analysis plan. “It doubled our rate, but not in the sequenced way the design tests,” Cella explained. “So the system improved even if the trial results were technically negative.”

Secondary outcomes revealed a similar pattern. The strategy package did not significantly improve patient enrollment reach in cPRO. However, clinician adoption told a different story. A referral tool called a dot phrase, triggered by elevated symptom scores, showed a positive trend. Although not statistically significant, clinicians increasingly used the dot phrase to connect patients to psychological support, rehabilitation, occupational therapy, and other services. “The dot phrase makes it easy. With one click clinicians can do the right thing,” Cella said.

The project highlighted the deep collaboration between the Division of Outcomes and Measurement Science and the Division of Implementation Science. Co investigators included leaders in patient reported outcomes, implementation frameworks, and oncology care delivery. “It has been incredibly gratifying to see outcomes and measurement science colleagues come together so seamlessly with implementation science collaborators on this project,” said Rinad Beidas, PhD, chair of MSS. “This work reflects what is possible when we intentionally bridge disciplines to not only generate rigorous evidence but also ensure that evidence is designed from the start to work in real world clinical settings.”

“It was really a marriage of measurement science with implementation science,” Cella said, noting early collaboration with J. D. Smith, PhD who was at Northwestern during the study’s launch. “We could not have done this without that expertise.”

The study was funded as part of a National Cancer Institute consortium created to accelerate symptom management integration into routine oncology practice. The team’s experience has already shaped future work. Ongoing studies led by Betina Yanez, PhD and Sophia Garcia, PhD focus on anxiety and depression in cancer populations and are testing more targeted approaches. Ultimately the study reinforces a central message. Digital symptom monitoring is not difficult because of what to ask patients or how to interpret their answers. The challenge is engineering these processes into the daily workflow of a complex healthcare system. “Over the last couple of decades there has been a real shift toward patient centered care,” Cella said. “This work is part of that movement and there is more to come.”

Along with lead authors Justin D Smith and David Cella, additional authors include: Katy Bedjeti; Nicola Lancki; Elizabeth A Sloss; James L Merle; Sheetal Kircher; Ava Coughlin; Susan Metzger; Kimberly A Webster; Mary O'Connor; September Cahue; Ann Marie Flores; Quan Mai; Betina Yanez; Michael Bass; Roxanne E Jensen; Ashley Wilder Smith; Allison J Carroll; Cynthia Barnard; Christopher M George; Dean G Tsarwhas; Kimberly Richardson; Frank J Penedo; Karla Hemming; Sofia F Garcia; and Denise M Scholtens.