Highlights of the E2C2 Trial
The Electronic Health Record-Facilitated Symptom Surveillance and Collaborative Care (E2C2) trial represents a landmark shift in how we manage the multifaceted symptoms of cancer. Key highlights include:
- EHR-facilitated collaborative care (ECC) significantly reduced the population-level burden of SPPADE symptoms (sleep, pain, physical function, anxiety, depression, and energy/fatigue) compared to usual care.
- The trial demonstrated a notable impact on psychological symptoms, specifically anxiety and depression, as well as fatigue.
- 85% of the study population reported at least one clinically actionable symptom (score ≥4/10), highlighting the immense unmet need in oncology care.
- The pragmatic, stepped-wedge design allowed for a real-world assessment across 15 medical oncology and haematology clusters, involving over 50,000 patients.
The Challenge of Symptom Management in Oncology
Cancer patients frequently experience a cluster of debilitating symptoms collectively known by the acronym SPPADE: sleep interference, pain, impaired physical function, anxiety, depression, and energy deficit (fatigue). While patient-reported outcome measures (PROMs) have long been recognized as the gold standard for identifying these issues, the transition from screening to effective intervention has remained a significant bottleneck. Traditional collaborative care models, which involve care managers and specialist oversight, are effective but often prohibitively resource-intensive for large-scale implementation.
The E2C2 trial addressed this challenge by leveraging the Electronic Health Record (EHR) to automate surveillance and facilitate care management. By using the Epic EHR system, the researchers aimed to determine if technology could bridge the gap between symptom detection and clinical action without overwhelming human resources.
Study Design: A Pragmatic, Stepped-Wedge Approach
The E2C2 trial was a cohort cluster-randomized, unblinded, stepped-wedge, pragmatic trial. This design is particularly well-suited for evaluating interventions in real-world clinical settings where a traditional randomized controlled trial might be difficult to implement. The researchers randomly assigned 15 clusters of medical oncology and haematology clinics within a US multi-state health system to five different sequences.
The intervention (ECC) consisted of remotely delivered electronic PROM (ePROM) symptom surveillance combined with EHR-facilitated collaborative care management. This was compared against usual care (UC), which involved ePROM surveillance alone. Every eight months, sequences transitioned from the control state to the intervention state. The study included adult patients across all cancer types and stages, excluding only those in hospice or with acute leukaemia. Symptoms were measured on a 0–10 numerical rating scale during clinical encounters.
Key Findings: Reducing the Population Symptom Burden
Between 2019 and 2023, the study enrolled 50,207 patients. The primary analysis focused on a cohort of 24,874 participants who completed at least two ePROMs. The results were striking in their breadth and statistical significance.
Impact on Global Symptom Burden
The multivariate analysis showed that the mean population joint SPPADE symptom burden significantly favored the ECC intervention periods (p=0.0055). This indicates that the collaborative care model, when facilitated by the EHR, effectively lowered the overall ‘volume’ of symptoms experienced by the patient population.
Specific Symptom Improvements
The benefits of the ECC intervention were most pronounced in the domains of mental health and vitality. The adjusted mean differences favored ECC for several key areas:
- Anxiety: -0.12 (95% CI -0.19 to -0.05)
- Depression: -0.08 (95% CI -0.15 to -0.01)
- Fatigue: -0.06 (95% CI -0.16 to 0.03)
When looking specifically at ‘actionable’ scores (those ≥4/10), the benefit of ECC was even more statistically robust (p<0.0001). For patients reporting significant distress, the intervention provided a measurable reduction in anxiety, depression, and fatigue scores.
Clinical Interpretation and Mechanistic Insights
The success of the E2C2 trial lies in its ability to move beyond passive data collection. In the usual care group, symptoms were identified through ePROMs, but the responsibility for acting on that data rested entirely on the primary oncology team, who are often stretched thin. In the ECC group, the EHR-facilitated system ensured that when a symptom reached a certain threshold, a collaborative care framework was triggered.
This model likely works by increasing the frequency and specificity of symptom-focused interventions. By centralizing management, the system ensures that evidence-based protocols for depression, anxiety, and fatigue are consistently applied. The fact that pain and physical function scores showed less significant improvement suggests that these domains may require more intensive, in-person physical interventions (such as physical therapy or complex medication titration) that are harder to deliver through a remote, EHR-facilitated model.
Expert Commentary and Limitations
Health policy experts and clinical oncologists view E2C2 as a proof-of-concept for the ‘learning health system.’ It demonstrates that the EHR can be more than a digital filing cabinet; it can be an active participant in care delivery. However, some limitations must be noted. The study population was 95-96% White, which raises questions about the generalizability of these findings to more diverse patient populations who may face different barriers to accessing digital health tools.
Furthermore, while the reductions in symptom scores were statistically significant, the absolute differences (e.g., -0.12 for anxiety) are small. From a population health perspective, these small shifts across thousands of patients represent a major reduction in morbidity, but for an individual patient, the change may feel subtle. Future research should focus on identifying which patient subgroups derive the greatest clinical benefit from this model.
Conclusion: A New Standard for Symptom Surveillance?
The E2C2 trial provides compelling evidence that centralized, EHR-facilitated collaborative care is superior to symptom surveillance alone. As oncology moves toward more personalized and data-driven care, the integration of PROMs into actionable clinical workflows will be essential. This study offers a scalable blueprint for health systems to improve the quality of life for cancer patients by ensuring that once a symptom is reported, it is systematically addressed.
Funding and ClinicalTrials.gov
This study was funded by the US National Institutes of Health (NIH). The trial is registered at ClinicalTrials.gov under the identifier NCT03892967.
References
Cheville AL, Herrin J, Pachman DR, et al. Electronic health record-facilitated symptom surveillance and collaborative care intervention in oncology (E2C2): a cluster-randomised, population-level, stepped-wedge, pragmatic trial. Lancet Oncol. 2025;S1470-2045(25)00526-1. doi:10.1016/S1470-2045(25)00526-1.
