NCI-funded centers study new ways to apply telehealth across cancer care
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Nearly 3 years after the COVID-19 pandemic propelled telehealth from the fringes of cancer care to the mainstream, research into the use of this technology across oncology remains limited.
“When the pandemic hit, we watched all of health care flip overnight into using telehealth,” Robin C. Vanderpool, DrPH, chief of the health communication and informatics research branch in the division of cancer control and population sciences at NCI, told Healio | HemOnc Today. “The pandemic really changed the way we deliver cancer-related care.”
Source: University of Pennsylvania.
Now, with the initial urgency of the pandemic in the past, public health agencies including NCI are examining ways to maximize the benefits of telehealth, from cancer screening to survivorship.
NCI’s former director, Norman “Ned” Sharpless, MD, inspired agency officials to undertake a widespread effort to accelerate and optimize use of telehealth, Vanderpool said.
“Dr. Sharpless came to our division and said, ‘We need take advantage of this one silver lining coming out of the pandemic.’” she said. “‘We need to understand what’s happening in the cancer space with telehealth.’”
That advice led to the NCI’s Telehealth Research Centers of Excellence (TRACE), a Cancer Moonshot-supported initiative. NCI issued a request for information in the summer of 2020, and in August of last year awarded $23 million to fund centers at four academic institutions — Memorial Sloan Kettering Cancer, Northwestern University at Chicago, New York University Grossman School of Medicine and University of Pennsylvania. Each center has launched research projects aimed at developing an evidence base on telehealth in cancer care. The projects focus on areas such as disparities and barriers to telehealth access and the policy and payment environment around telehealth.
“The pandemic gave us a real opportunity to put a laser focus on the benefits of telehealth,” Roxanne E. Jensen, PhD, program director of the outcomes research branch in NCI’s division of cancer control and population sciences who oversees the initiative with Vanderpool, told Healio | HemOnc Today. “While we hope there will be great and meaningful research that comes out of this, it’s also about establishing the methods, the networks, the connections and the collaborations that will build the momentum for more work being done in this area in the future.”
Healio | HemOnc Today spoke with leaders of teams at each of the funded telehealth research centers about their projects and the challenges they hope to address.
Understanding ‘digital divide’
The NCI request for information challenged researchers to identify gaps in telehealth implementation and ways to integrate telehealth into cancer care delivery, Jensen said.
“We got a wide range of responses, from patients who emailed their own personal experiences to academic institutions and professional organizations,” she said.
The response helped clarify and prioritize key areas of telehealth research, Jensen said.
“One thing that came out very clearly was the need to understand the digital divide in cancer care, and the real concerns and fears that telehealth could entrench health disparities,” she said.
The creativity of the projects proposed for the four funded research centers impressed Jensen.
“We wanted to find and fund research that could demonstrate what models of care delivery would look like with telehealth added in as an important component,” she said. “At the beginning of the pandemic, it was hard to predict what was possible with telehealth. And it’s really exciting to see the level of nuance, focusing on key cancer-related problems. You feel like you’re seeing something novel that could really help people.”
Addressing modifiable risks
The team at Northwestern’s Scalable TELeheaLth Cancer CARe (STELLAR) Research Center is investigating whether a telehealth-based intervention can help address behavioral risk factors among patients with cancer in Northwestern’s clinical practice network.
“A number of behaviors increase the risk for cancer, and the three we’re focusing on — smoking, physical inactivity and obesity — are the most prevalent and the most consistently demonstrated to be harmful,” Bonnie Spring, PhD, director of the Center for Behavior and Health at Northwestern University’s Feinberg School of Medicine, told Healio | HemOnc Today. “These risk factors typically cluster, and people usually have more than one.”
Historically, treatment has required visits to multiple behavioral modification counselors, Spring said.
“You have to go to one behavioral specialist to treat your smoking, another one to get you physically active, and another one for weight loss,” she said. “This is silly and inefficient, because treatments for all of these risk factors use many of the same behavior change techniques.”
The STELLAR team plans to develop and assess a single tailored, cancer-specific telehealth treatment program for all three behavioral risk factors, which often persist into survivorship.
“If you look at global data on what affects mortality and quality of life in cancer, behavioral and lifestyle factors are a major influence,” she said. “All of the major cancer care guidelines advocate dealing with these risk behaviors, because they probably had a lot to do with why the person got cancer to begin with.”
Moreover, behavioral risk factors can make diagnosis more difficult, interfere with treatment and increase adverse effects and risk for a second cancer and cardiovascular disease, Spring said.
“It’s shortsighted that our current health care system neglects promoting health, alongside treating disease, because making healthy lifestyle changes also can improve the quality of the rest of the patient’s life,” she said. “You usually can’t get health promotion treatment in cancer centers. We’re thrilled to have an opportunity to demonstrate that it’s feasible to make that kind of care accessible, affordable and effective.”
Focusing on lung cancer
University of Pennsylvania’s Telehealth Research Center of Excellence (Penn TRACE) is evaluating lung cancer as an exemplar model for telehealth across the care continuum. The team is using information from communication science and behavioral economics to create and evaluate synchronous telehealth strategies supported by asynchronous components.
“We decided to focus on lung cancer for a few reasons, the first of which is that lung cancer is, by far, the leading cause of cancer death,” Katharine Rendle, PhD, MSW, MPH, assistant professor of family medicine and community health at Perelman School of Medicine and one of the leaders of Penn TRACE, told Healio | HemOnc Today. “Secondly, there are persistent and emergent disparities in lung cancer across the continuum, from incidence to mortality and treatment. These are structural and social barriers that can be modified.”
Rendle and colleagues recognized the potential of telehealth to benefit patients undergoing lung cancer screening and treatment, she said.
“We just need to figure out how to ensure that all patients have access to new technologies,” Rendle added. “We believe that telehealth strategies in lung cancer care might be a pathway by which we can have equitable access to these new technologies.”
Penn TRACE is conducting a large-scale pragmatic trial in which the researchers will test the effectiveness of telehealth in increasing shared decision-making in the context of lung cancer screening, Rendle said. Currently, the annual uptake of lung cancer screening remains low.
“A shared decision-making visit requires a collaborative discussion between a patient and a clinician regarding the risks, benefits and preferences for screening,” Rendle said. “We’ll be testing whether or not this telehealth-based strategy can increase the number of patients who complete this shared decision-making visit, and then make sure patients who are interested in screening get screened.”
Penn TRACE also plans to conduct two pilot studies. The first will evaluate use of a nurse navigator for patients who have undergone complete molecular testing at diagnosis. The second pilot study will evaluate the use of telehealth in follow-up care for lung cancer survivors.
“For a long time, we didn’t have a large number of lung cancer survivors,” Rendle said. “So, to identify what they need and make sure they are receiving care after their active treatment is an exciting area.”
Remote monitoring system
Memorial Sloan Kettering’s telehealth research center, Making Telehealth Delivery of Cancer Care at Home Effective and Safe (MATCHES), will evaluate an expanded model of telehealth called MSK@Home that includes remote treatment and monitoring for patients undergoing systemic therapy for prostate and breast cancer.
“These are the second most common causes of cancer-related deaths in men and women, respectively, in the U.S.,” project leader Michael J. Morris, MD, prostate cancer section head in the division of solid tumor oncology at Memorial Sloan Kettering Cancer Center, told Healio | HemOnc Today. “These are major public health problems and diseases that are very amenable to management via telehealth. Even patients with advanced disease frequently feel well enough to live a normal, functional life, and for them remote management allows for more time to themselves and less spent at the cancer center.”
Many of the medicines these patients require can be delivered orally or via injection, Morris said. “They don’t require a chemotherapy suite,” he said. “So, these are diseases that are very amenable to exploring different models of telehealth delivery.”
In their research, Morris and his colleagues at MATCHES will explore ways to bring certain aspects of cancer care into the patient’s home through telehealth.
“We can arrange for home blood draws and treatment delivery and administration, as well as perform remote vital sign checks and toxicity assessments,” he said. “So, we offer not just communication with the physician, but the actual delivery of care at home, as part of a comprehensive telehealth model.”
Morris said MATCHES will conduct a center-wide analysis at eight regional centers plus the center in Manhattan and compare Memorial Sloan Kettering’s current model with the expanded at-home services model.
“We want to determine which is more satisfying to patients and clinicians,” he said. “Is the expanded model safe and feasible? Also, how much time do we save them from coming into the cancer center by providing these services at home? That is the crux of our research.”
Evaluating social factors
NYU Grossman School of Medicine’s Telehealth Research and Innovation for Veterans with Cancer (THRIVE) is working with the Veterans Health Administration to assess the impact of social factors such as race/ethnicity, poverty and rural residence on the delivery of telehealth for cancer care.
Scott E. Sherman, MD, a professor in the department of population health at NYU Grossman who is affiliated with the VA, said THRIVE researchers will use the entire VA health care system as their clinical practice network.
“I lead a national center on telehealth research at the VA, and we’re doing a large paper looking at the 6 to 9 million people who use the VA,” Sherman told Healio | HemOnc Today. “We saw this as a wonderful opportunity to leverage for the NCI project.”
In addition to being the largest integrated health system in the country, Sherman said, the VA also has the advantage of theoretically being an equal access system.
“Everyone is supposed to have the same access, but at the same time we know there are differences in health care outcomes, and that points to underlying issues,” he said. “So, it seemed like a wonderful opportunity to try to disentangle the problem of why, if everyone is supposed to have the same access, do some people not do as well? And what can we do to mitigate that?”
Sherman added that although telehealth is intended to overcome obstacles to access, it may present a barrier of its own for some patients.
“To access telehealth, you have to have a device — a smartphone, a tablet or a computer,” he said. “You also have to be able to engage with it, not just once, but regularly.”
The national study Sherman and colleagues are conducting involves offering telehealth services to VA centers in 20 primarily rural locations. His co-principal investigators are Danil V. Makarov, MD, a urologist at NYU Langone Health, and Leah L. Zullig, PhD, MPH, a health services researcher in the department of population health at Duke University.
“It’s a great partnership — as a primary care physician, I have been on the prevention side of cancer,” he said. “Dan, as a urologist, is focused on identifying how to best treat prostate cancer, and Leah, as a health services researcher, is focused on survivorship. So, we have the whole spectrum, from prevention to treatment to helping our patients after treatment is over.”
Potential implications
Vanderpool said she expects the four funded research centers to emerge as thought leaders in the field of telehealth.
“There will potentially be policy implications, because they are going to be doing this over the next 5 years,” she said. “During that time, we are going to see changes in telehealth policies, technology and even clinical care guidelines. We are going to see changes in the communication ecosystem we all live and work in. So, we hope to have an impact on the standards of care for telehealth delivery.”
Vanderpool views this project as an excellent opportunity to train the next generation of researchers, students and young investigators in the telehealth space.
“In fact, we asked the centers to talk about that in their applications, because we wanted to set the stage to drive more telehealth research among students, postdocs, junior investigators and community members,” she said. “With this project, we want to bring this whole field along and grow these fields. We wanted to set up a cascading research agenda.”
References:
- NIH. NCI awards $23 million to establish centers of excellence to study telehealth for cancer care (news release). Available at: www.nih.gov/news-events/news-releases/nih-awards-23-million-establish-centers-excellence-study-telehealth-cancer-care. Published Aug. 18, 2022. Accessed Dec. 27, 2022.
- University of Pennsylvania School of Medicine. Penn Medicine awarded $5.7 million NCI grant for new telehealth Research Center of Excellence (news release). Available at: www.pennmedicine.org/news/news-releases/2022/august/penn-wins-nci-grant-for-cancer-telehealth-research. Published Aug. 18, 2022. Accessed Dec. 27, 2022.
For more information:
Roxanne Jensen, PhD, can be reached at National Cancer Institute, 9000 Rockville Pike, Bethesda, MD 20892; email: roxanne.jensen@nih.gov.
Michael J. Morris, MD, can be reached at Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065; email: morrism@mskcc.org.
Katharine Rendle, PhD, MSW, MPH, can be reached at Penn Medicine, 51 N. 39th St., PPMC - Mutch 707, Philadelphia, PA 19104; email: katharine.rendle@pennmedicine.upenn.edu.
Scott E. Sherman, MD, can be reached at NYU Langone Health, 180 Madison Ave., New York, NY 10016; email: scott.sherman@nyulangone.org.
Bonnie Spring, PhD, can be reached at Northwestern Medicine, Suite 1400, 680 Lake Shore Drive, Chicago, IL 60611; email: bspring@northwestern.edu.
Robin C. Vanderpool, DrPH, can be reached at the National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892; email: robin.vanderpool@nih.gov.
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NIH. NCI awards $23 million to establish centers of excellence to study telehealth for cancer care (news release). Available at: www.nih.gov/news-events/news-releases/nih-awards-23-million-establish-centers-excellence-study-telehealth-cancer-care. Published Aug. 18, 2022. Accessed Dec. 27, 2022.
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