A systematic review of randomized controlled trials on telecommunication technologies for pain management in patients with advanced cancer: incorporating electronic patient-reported outcomes (ePROs)

Introduction

Background

Pain is a common symptom among cancer patients, with prevalence rates reaching up to 50% in those undergoing active treatment and up to 90% in those with advanced disease (1). As cancer-related pain intensifies, it can significantly affect patients’ daily functioning and overall quality of life (2). Consequently, effective palliation and self-management of cancer pain are of paramount importance.

Telemedicine has emerged as a valuable strategy for supporting pain management in cancer patients recovering at home. Defined as an action related to health promotion and medical care that utilizes information and communication devices (3), telemedicine has become an integral component of modern healthcare delivery. Devices such as telephones, cell phones, smartphones, tablets, and personal computers facilitate remote consultations with healthcare professionals, allowing patients to receive care from the comfort of their homes. This approach offers the important advantage of reducing the need for frequent hospital visits.

Effective cancer pain management requires a collaborative relationship between patients and healthcare professionals, along with the patient’s ability to self-manage symptoms, including the adjustment of analgesic medications and the maintenance of emotional stability (4). Research has shown that patients with advanced self-management skills related to opioid regimens experience higher rates of pain relief (5). The integration of follow-up methods—such as telecommunication technologies for pain management—can improve medication self-management skills and support patients in their daily lives at home.

In Japan, telemedicine for cancer pain management has recently gained traction through the widespread adoption of information and communication technology (6). Online treatment for patients receiving home-based cancer care is expected to enhance the quality of pain management (7).

The use of remote technologies to assess patients’ subjective symptoms for their own care has gained significant attention and is often referred to as electronic patient-reported outcomes (ePROs). The term patient-reported outcomes (PROs) refers to health status reports provided directly by patients without interpretation by healthcare professionals or others, whereas ePROs are PROs collected electronically (8). These reports are typically gathered using information and communication technologies, such as smartphones. The 2022 Clinical Practice Guideline issued by the European Society for Medical Oncology (ESMO) recommends the use of digital devices for collecting patients’ subjective information, particularly in oncology settings (9). This underscores the growing importance of ePROs in recent years.

Rationale and knowledge gap

A substantial body of research has evaluated the efficacy of telemedicine interventions for cancer patients. Study have shown that telephone-based educational interventions and cognitive behavioral therapy can be as efficacious as, if not more effective than, face-to-face interventions for symptom management in adult cancer patients (10). Additionally, remote symptom monitoring—when combined with conventional symptom management and educational interventions—has been found to improve cancer pain outcomes (11,12). One study has demonstrated the usefulness of telemedicine interventions in this context, providing important insights into how remote care can support the management of cancer symptoms (13).

Although the effectiveness of these interventions is well-supported, the terminology used varies across studies. In these reviews, the terms telehealth, mHealth, and eHealth were commonly used to denote telemedicine. However, no review has specifically included ePRO as a keyword, highlighting a gap in the literature.

Given this gap, it is valuable to examine the unique characteristics of ePROs in greater detail. It is important to emphasize that our intention is not to suggest that electronically administered tools are inherently more reliable or valid than traditional methods such as telephone-based interviews conducted by research assistants. Rather, our aim was to explore and synthesize evidence on the distinct potential advantages of ePROs, such as enhanced accessibility, patient autonomy, and data integration on digital platforms, in the specific context of pain management.

Objective

The objective of this review is to focus on telemedicine, with particular emphasis on subjective patient evaluation, by exploring novel telemedicine concepts such as ePRO. We present this article in accordance with the PRISMA reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-25-33/rc) (14).

Methods

Formation of research questions

The PICO framework was used to guide the study:

• P (Population): adult patients with advanced cancer-related pain.
• I (Intervention): randomized controlled trials (RCTs) in which healthcare professionals used telecommunication technologies to palliate cancer pain in patients with advanced cancer.
• C (Comparison): usual care.
• O (Outcome): change in pain levels.

Search methods and eligibility and exclusion criteria

A comprehensive literature search was conducted across multiple databases, including PubMed, the Cochrane Library, CINAHL, MEDLINE, Web of Science, and Scopus. The search covered all records from the inception of each database up to December 31, 2024.

The search strategy included the following terms and Boolean operators: (randomized controlled trial OR randomized OR randomly OR RCT) AND (cancer OR tumor OR cancer patient OR oncolog patient* OR patient* with cancer) AND pain AND (telecommunication OR telemedicine OR telehealth OR mHealth OR eHealth OR remote consultation OR telenursing OR telehomecare OR telemonitor* OR ePRO OR electronic PRO OR electronic patient-reported outcome)*.

The selection of search terms was determined through extensive discussion between two researchers and a third reviewer. Notably, only English-language references were included in the analysis.

The eligibility criteria were as follows: (I) adult cancer patients experiencing cancer-related pain; (II) description of a telecommunication-based intervention; (III) inclusion of cancer pain as an outcome measure; (IV) use of an RCT design; and (V) comparison with a control group receiving usual care, in accordance with the established PICO framework.

The exclusion criteria comprised observational studies, protocol articles, case reports, and review articles. Two researchers independently reviewed the titles and abstracts of the articles to determine eligibility. In cases of disagreement, they engaged in discussion to reach a consensus. If the two researchers held differing opinions, a third reviewer was consulted to make the final decision regarding article inclusion.

While acknowledging the potential for observational studies to contribute to this area, and with a view to ensuring a higher level of methodological rigor and minimizing the risk of bias, we chose to include only RCTs in this review. This methodological approach facilitates a more reliable inter-study comparison of intervention effects.

During the secondary screening, two researchers independently assessed the full texts for eligibility. If discrepancies arose, they initially attempted to resolve them through discussion. If a consensus could not be reached, a third reviewer intervened to make the final determination regarding inclusion.

Risk of bias in individual studies

The quality of the included articles was evaluated according to the five domains of Cochrane’s Risk of Bias version 2 (15). Two researchers independently responded to the signaling questions in each of the five domains using a five-point scale: “Yes” (definitely yes), “Probably yes” (tentatively yes), “No” (definitely no), “Probably no” (tentatively no), and “No information” (insufficient data to determine a response).

In instances where a divergence of opinion was observed, a thorough discussion was conducted to reach a consensus. If consensus could not be achieved, a third reviewer was consulted to make the final determination.

The publication of review protocols

The review protocol for this study was prospectively registered with the International Prospective Register of Systematic Reviews and subsequently published (registration number CRD42022353191).

Results

Results of the search

The comprehensive literature search identified a total of 1,536 references. After removing duplicates, 1,026 references remained for the primary screening. Of these, 992 articles were excluded, resulting in the selection of 34 references.

During the secondary screening, 25 articles were excluded, and 9 articles were selected. Additionally, one article was manually included, bringing the final number of articles selected for further analysis to ten (Figure 1).

Figure 1 PRISMA flow diagram of study selection. RCT, randomized controlled trial.

Study characteristics

Four studies were conducted in China, two in the United States, and one each in the United Kingdom, South Korea, the Netherlands, and Turkey. Six studies included patients with various types of cancer, while one study focused exclusively on women with breast cancer. The age of the patients ranged from middle-aged to older people, with an average age of approximately 50 years. Most studies included patients in their 50s to 60s, while only one study included patients in their late 40s, representing a relatively younger cohort.

The pain assessment tools used in the studies included the Brief Pain Inventory (BPI) (16) in three studies, the Numerical Rating Scale (NRS) in three studies, and the MD Anderson Symptom Inventory (MDASI) (17), the Pain Intensity Number Scale (PINS) (18), the Edmonton Symptom Assessment Scale (ESAS) and BQII, and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) in one study each.

The frequency of intervention was reported as “daily” in six studies, “twice a week” in one study, while three studies did not specify the frequency. The duration of intervention ranged from 6 days to 12 weeks.

Quality of the evidence

The risk of bias for the included RCTs is illustrated in Figure 2. Due to the inherent challenges associated with telemedicine interventions—particularly the difficulty of implementing blinding procedures—the measurement of the outcome domain was classified as high risk in all studies.

Figure 2 Risk of bias summary: review authors’ judgments on each risk of bias domain for each included randomized controlled trial.

Regarding outcome selection, it was often difficult to obtain relevant information such as study protocols. Consequently, it was challenging to determine whether the reported results were analyzed according to a pre-specified analysis plan. Additionally, it was unclear whether the numerical results were selectively reported from among multiple eligible outcome measures (e.g., different scales, definitions, or time points) or multiple analytical approaches within the same outcome domain. As a result, most studies were assessed as having a high risk of bias.

In light of these findings, the overall risk of bias across all studies—which employed a range of research methodologies—was evaluated as high.

Telemedicine intervention effectiveness

A total of eight studies reported significant improvement in the telemedicine intervention group compared to the control group (Tables 1,2).

Kim et al. (19) compared a telemonitoring intervention group with a control group that received standardized education and nurse-led telephone calls. The intervention lasted 1 week with daily implementation, using telephones, including cell phones and smartphones. The study found that the proportion of patients with a mean pain intensity score of 4 or higher on the BPI (16) decreased by 13% in the control group and by 22% in the intervention group. This difference was statistically significant (P=0.02).

Zhang et al. (20) examined the effects of active interventions including medication reminder alerts, pain diaries for symptom tracking, and real-time monitoring by physicians and pharmacists via chat tools. The intervention lasted 4 weeks with daily implementation. The results showed a significant decrease in pain intensity in the intervention group compared to the control group.

Yang et al. (21) evaluated an intervention group that used a smartphone-based application, Pain Guard, for reminders, symptom recording, and real-time medication counseling, compared to a control group receiving conventional pharmacotherapy. All interventions, including instruction on how to use Pain Guard, were provided by a clinical pharmacist. The intervention lasted 4 weeks, with at least one session per day. At baseline, no significant differences in pain scores were observed between the two groups. However, over the 4-week study period, the intervention group exhibited significantly lower intensity of breakthrough cancer pain (BTcP) compared to the control group [control: median 13, interquartile range (IQR), 9.5–14; intervention: median 3, IQR, 2–7; P<0.001]. Additionally, there was a significant difference in the extent of pain relief between the two groups (control: median 0, IQR, 0–25; intervention: median 50, IQR, 45–63; P<0.001).

Anderson et al. (22) conducted a comparative analysis of two groups: one receiving physician monitoring with an interactive voice response (IVR) system, and the other receiving standard pain and symptom management. The intervention lasted 8 weeks, with sessions conducted twice weekly. A significant difference in pain change scores (higher scores indicate less pain) was observed from baseline to 4–6 weeks post-enrollment [control: 0.6; intervention: 2.3; P=0.03; 95% confidence interval (CI): 0.13–3.3]. A similar significant difference was noted from baseline to 8–10 weeks post-enrollment (control: 0.6; intervention: 3.5; P=0.02; 95% CI: 0.47–4.2), with greater pain reduction observed in the intervention group in both comparisons.

Sun et al. (23) compared a group of patients whose pain data were tracked using an Intelligent Pain Management System (IPMS) with a control group receiving routine office-based care. The intervention lasted 2 weeks, with daily sessions conducted via smartphones. At baseline, no statistically significant differences in pain scores were observed between the two groups {intervention: 3.28 [standard deviation (SD) 0.68] vs. control: 2.90 (SD 0.62); P>0.05}. During the 2-week study period, the intervention group demonstrated a significant reduction in mean pain scores compared to the control group [control: 2.81 (SD 0.47) vs. intervention: 2.53 (SD 0.42); P<0.001]. At the end of the intervention period, the intervention group demonstrated a further significant reduction in pain scores compared to the control group [control: 2.95 (SD 0.59) vs. intervention: 2.20 (SD 0.50); P<0.001]. Additionally, the intervention group exhibited superior pain management knowledge, suggesting increased adherence to pain management protocols.

Geerling et al. (24) conducted a Pain Education Program (PEP) group (n=156) with a control group (n=152) of 308 patients with cancer. The intervention lasted 12 weeks and included multifaceted support such as pain education, symptom monitoring, and self-management guidance. Pain was assessed using an NRS (0–10). At 12 weeks, the proportion of patients with controlled pain was significantly higher in the intervention group (71%) than in the control group (52%) (P=0.008). The median times to pain control was significantly shorter in the control group than in the control group (29 vs. 56 days; P=0.003). Worst pain decreased from 7.2 to 3.5 in the intervention group and from 7.2 to 4.3 in the control group, and average pain decreased from 5.6 to 2.8 and from 5.5 to 3.6, respectively—all showing significant between-group differences.

Weng et al. (25) conducted a study in which 96 patients with cancer were randomly assigned to an intervention group (n=48) or a control group (n=48). The intervention involved smartphone-assisted pain management over 4 weeks (specific details not reported). Pain was assessed using the EORTC QLQ-C30. At baseline, there were no significant differences between groups in any quality of life domain. However, after 4 weeks, the intervention group showed significantly lower pain scores compared to the control group (P<0.001).

Bilmiç et al. (26) conducted a study with 110 patients with cancer, who were randomly assigned to an intervention group (n=55) and a control group (n=55). The intervention consisted of an individualized educational program that included relaxation exercises, analgesic use, and side effect management. Pain was measured using the NRS. NRS pain scores significantly decreased across all categories with in the intervention group (P<0.05).

A total of one study (27) reported a time-series intervention effect of telemedicine, although no significant between-group difference was observed between the control and intervention groups (Tables 3,4).

Bennett et al. (27) conducted a comparative analysis of an intervention group that received direct counseling from a healthcare professional and a control group that received conventional care through booklets and DVDs. The intervention lasted 12 weeks, with at least one session per day, utilizing internet-connected devices such as computers and tablets. The investigators reported no significant treatment differences in the primary or secondary outcomes related to the BPI pain severity items. However, both groups showed improvements in all secondary outcomes, including pain severity, train interference, patient pain knowledge and experience [Patient Pain Questionnaire (PPQ)], and cancer-specific quality of life.

A total of one study (28) reported that no significant difference was observed between the control and intervention groups.

Discussion

This review focused on telemedicine, with particular emphasis on patients’ subjective evaluations and the integration of novel telemedicine concepts such as ePROs.

Compared with previous systematic reviews that have addressed telehealth or digital interventions more broadly (−), our review focused specifically on interventions utilizing ePRO as the primary tool for symptom monitoring and intervention delivery. Chen et al. (29) conducted a meta-analysis that assessed the use of app-based interventions, and concluded that they are effective in reducing cancer pain. However, their review combined studies of postoperative pain and pain due to advanced cancer, which may have complicated the interpretation in this specific population. By contrast, we excluded studies that targeted postoperative pain to ensure a clear focus on cancer-related chronic pain.

Eight studies (19-26) demonstrated significant results using self-reporting of symptom tracking via telecommunication technologies as an intervention. In these studies, the intervention group showed significant improvement compared to the control group. The information collected through these interventions was incorporated into pain management strategies, including patient communication with healthcare professionals and the receipt of guidance and education on pain management. Additionally, five of these studies (19-22,25) allowed patients to receive real-time responses from healthcare professionals.

These findings suggest that patient-reported information not only plays a crucial role in treatment planning but also that the provision of real-time feedback to patients may effectively contribute to cancer pain relief.

The duration of interventions varied across studies, ranging from 1 week in one study, 2 weeks in one study, 4 weeks in two studies, and 8 weeks in one study. In all cases, the intervention group demonstrated significant improvement compared to the control group. The frequency of symptom reporting via telecommunication devices was documented as “daily” in four studies and “twice a week” in one study. However, the patient input rate was not specified in any study and remains unknown. When examining studies that assessed the time-series effect of telemedicine interventions, it was difficult to establish a direct relationship between the duration of the intervention and pain relief. However, it is hypothesized that a higher frequency of intervention—such as daily reporting—may lead to more efficacious outcomes. Furthermore, three studies (24-26) supported the effectiveness of long-term or multifaceted interventions such as PEPs or individualized education. These approaches, which combine symptom monitoring, self-management training, and relaxation guidance, demonstrated statistically significant reductions in pain intensity and time to pain control.

According to the findings of Kim et al. (19), the results 1 week after baseline (immediately following the conclusion of the intervention) demonstrated a significant decrease in the mean pain score for the intervention group that received pain management education and telemonitoring, compared to the control group that received conventional pain management education. However, 2 months after the intervention had concluded, no significant difference was observed in the mean pain scores between the intervention and control groups. This finding suggests that interventions incorporating real-time pain monitoring, patient interviews, and personalized advice may provide more immediate benefits in pain relief compared to long-term pain management strategies. This short-term effectiveness highlights the potential utility of integrating interventions, such as adjuncts to conventional treatments, particularly in the early phases of pain escalation.

Previous systematic reviews have shown that the effectiveness of telemedicine interventions in cancer pain management is more pronounced when the intervention period is extended from 3 to 6 months (29). Included patients with treatment-related pain associated with surgery, unlike the present study, which focused on pain caused by advanced cancer. While postoperative pain may show long-term effects as the wound heals, further research is needed to determine the long-term effectiveness of telemedicine in treating pain caused by advanced cancer.

A review of previous studies found that hybrid models of telemedicine and face-to-face care provide flexible, patient-centered care and high satisfaction with pain management in patients with cancer. Taken together, these results suggest that a combination of telemedicine and face-to-face care may be effective in enhancing overall treatment outcomes (13).

This review identified three types of telemedicine interventions for cancer pain: medication-based pain management by pharmacists, telemonitoring interventions by nurses, and active medical interventions by physicians. However, the differential effects of these intervention types remain unclear and warrant further investigation.

Conversely, some studies on telemedicine-based symptom management in cancer patients have suggested that the implementation of patient education programs, along with interventions extending beyond 12 weeks, may have a beneficial impact on symptom alleviation (10). Nevertheless, further research is required to elucidate the effects of telemedicine interventions on cancer pain management, including the optimal duration and frequency of interventions, as well as the role of different healthcare professionals in delivering these services.

A significant proportion of the studies included in this review utilized communication technologies such as smartphones and tablets. This trend likely reflects the rapid proliferation and widespread adoption of these technologies across diverse age groups in recent years.

In developed countries, mobile phone adoption (measured as the number of subscribers per 100 population) reached 85% in 2005. However, by 2020, this figure exceeded 100%, indicating that, on average, each individual possessed at least one mobile phone. In contrast, emerging countries exhibited a substantially lower mobile phone adoption rate, with an average of 22.9% in 2005. Nevertheless, this rate experienced a significant surge, surpassing 100% by 2018–2019. This increase can be attributed, at least in part, to the widespread proliferation of mobile phones. Additionally, the possibility that some individuals own multiple devices may have further contributed to this growth.

Mobile broadband—defined as wireless communication technology that utilizes cellular infrastructure, including smartphones and their associated services—underwent substantial growth in adoption between 2010 and 2020 (30). Previous studies have indicated that tele-intervention via telephone calls remains a common modality (10,11,31). However, research also suggests that system-based consultations involving direct input through digital platforms are more readily accepted by patients than traditional telephone consultations. According to previous reviews, the spread of mobile phones has led to an increase in interventions using apps (13,29). These findings suggest that the future of telemedicine will likely be increasingly characterized by web-based and communication device-based interventions, such as smartphone applications, which enhance both accessibility and patient engagement.

A notable limitation of this review is the high risk of bias inherent in the selected studies. Due to the challenges associated with blinding, outcome evaluators relied on patient self-assessment, making the results inherently subjective—particularly in the context of cancer pain. This subjectivity introduces potential bias in outcome evaluation. There are some differences between the results of previous review studies and the results of risk of bias assessments, but this is thought to be due to differences in the tools used (29). In any case, to address these concerns, the incorporation of objective indicators, such as biological data, alongside patient-reported outcomes may enhance the quality of evidence and improve the accuracy of cancer pain assessment.

Furthermore, the scope of this review is limited to countries and populations where communication devices are widely available. The implementation of ePRO systems requires not only access to electronic devices such as smartphones and tablets but also a stable communication infrastructure to support real-time monitoring. Consequently, in regions with underdeveloped telecommunication infrastructure, the adoption of these technologies may be challenging, potentially leading to disparities in access to telemedicine-based pain management.

Conclusions

This study on the use of telecommunication technologies, including ePROs by healthcare professionals, for the alleviation of cancer pain in patients with advanced cancer suggests that providing real-time feedback to patients may be an effective pain management strategy. However, the heterogeneity of intervention durations, the involvement of various types of healthcare professionals, and the diversity of intervention methods collectively complicate the development of a comprehensive and integrated synthesis. Therefore, further research is essential to validate these findings and to establish more standardized approaches.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-25-33/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-33/prf

Funding: This study was supported by the Japan Society for the Promotion of Science (JSPS KAKENHI) (grant No. 23K16432).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-33/coif). M.M. serves as an unpaid editorial board member of Annals of Palliative Medicine from February 2024 to January 2026. S.Y. reports a pending patent application related to a “Pain Monitoring Device, Method, and Program”, which is entirely unrelated to the content presented in this paper. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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