Despite advances in surgical techniques and perioperative recovery pathways, persistent high complication¹ and hospital readmission rates² after radical cystectomy underscore high-yield opportunities for intervention during postsurgical recovery. Symptom assessment and management after hospital discharge have historically been limited to episodic patient-initiated phone calls and routine postoperative clinic visits, which may incompletely capture developing complications. Mobile health technologies offer an appealing and increasingly accessible platform for structured symptom reporting and incorporation of patient-reported outcome (PRO) during postoperative recovery at home.³

Figure 1. Patient-facing mobile POSIT.

While integration of mobile and wearable health technology with PROs has the potential to transform how patients communicate with their care teams during recovery from major cancer surgery, data supporting its use are limited. We recently presented a multi-phased feasibility and usability study culminating in a prospective cohort study of a mobile application-based postoperative symptom intervention tool (POSIT) for bladder cancer patients during recovery from radical cystectomy.

First, the National Cancer Institute’s PRO-CTCAE⁴ was rigorously adapted to include symptom domains relevant to major surgery and a 15-item questionnaire programmed onto a mobile application administered via iPad Air® devices (Fig. 1). Focus groups of cystectomy patients and their caregivers positively appraised POSIT content and app usability.

A prospective pilot of 15 cystectomy patients with a mean age of 71 years was then asked to complete the symptom questionnaire daily for the first 30 days after hospital discharge and continuously wear a Garmin biometric monitoring wristwatch. Participants completed a mean 78% of daily surveys over the 30-day recovery period and 99% of symptom questions were answered after survey initiation. All patients responded that they agreed/strongly agreed that POSIT was easy to use and the majority reported it was a better way to communicate with the care team about symptoms than calling the clinic. Heart rate, physiological stress, and activity metrics were available for a mean of 17 days per participant.

Visual analogue mapping of sym­ptom score heatmaps and biometric data for the 6 patients who experienced a postoperative complication and 2 who required readmission demonstrated that frequency and severity of PROs appeared to cluster prior to or at the time of complication (Fig. 2).

Figure 2. Data visualization and utility of daily SAT profiles in absence of complication (a), presence of complication (black line) and absence of readmission (b), and presence of unplanned health care encounters (red lines) and complication requiring readmission (c).

Given the specific challenges related to complication frequency and significant patient engagement required after radical cystectomy and urinary diversion, other groups have highlighted the overwhelming amount of education required for bladder cancer patients to feel comfortable discerning between normal and abnormal symptoms.⁵ Integration of incremental symptom-directed self-care resources for patients prompted by daily symptom assessment tools or vital signs have previously been trialed in pancreaticoduodenectomy⁶ and cystectomy.⁷ Incorporating this strategy into future mobile health applications may present a promising mechanism to bridge the gap between improved patient education and outcomes.

The prospective nature of this pilot advantageously mirrors real-
time data collection during the 30-day home recovery phase after cystectomy. However, as the broader surgical community navigates incorporation of technology into clinical care, challenges in the clerical burden of reviewing patient-generated symptom and biometric data remain. Dedicated clinical workflows and leveraging of technology for data interpretation and prompt patient communication will likely be vital to the success of large-scale implementation of such technology.

Smartphone and wearable technology used to capture patient-reported symptoms and biometric data are feasible and rated as highly usable by bladder cancer patients after cystectomy. Symptom scores and patient-generated health data may signal developing complications. Ultimately, a thorough understanding of the correlation of these data with clinical outcomes will help clinicians identify postsurgical patients who may benefit from intervention prior to adverse events such as complication or readmission and has potential to improve outcomes during home recovery from major cancer surgery such as cystectomy.