‘We have the technology’: Telehealth increases access to palliative care for cancer
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Key takeaways:
- Quality-of-life scores did not differ for patients who had early palliative care via telehealth compared with in-person visits.
- Caregivers participated more during in-person visits.
CHICAGO — Early palliative care via telehealth had an equivalent impact on quality of life as in-person visits for patients with advanced non-small cell lung cancer, according to study findings presented at ASCO Annual Meeting.
Individuals who had telehealth conferences had similar depression and anxiety symptoms, coping skills and perceptions of prognosis to patients who had in-person therapy, researchers reported.
“As we’re moving into the end of 2024 where Congress is debating the U.S. Telehealth Expansion Act expiration, these data are critical to say, keep going with this. It matters,” Joseph A. Greer, PhD, co-director of the cancer outcomes research and education program and associate professor of psychology at Massachusetts General Hospital, told Healio. “We can do just as high-quality care with telehealth as we can do with in-person care.”
Background and methodology
Palliative and oncologic therapies have shown to improve quality of life in patients with advanced cancer and national guidelines recommend both for care, according to background information researchers provided.
However, limited access and resources and misperceptions about palliative care — which is recommended within 2 to 3 months of diagnosis of a serious illness — often prevents individuals from receiving it, Greer said.
“We find that when patients start to actually meet with the palliative care clinician and overcome some of those preconceived notions [about it impacting treatment], they’re quite grateful that they’ve established that other relationship, in part because they don’t hold the keys to chemotherapy,” Greer said in response to a question following his presentation. “In our prior trials, we have demonstrated that early palliative care delivered in this manner provides no detriment to outcomes with respect to survival; in fact, there has been some evidence to support a survival benefit.”
Researchers investigated whether video services could offer the same level of support as in-person encounters and potentially increase access and use of palliative care.
Greer and colleagues enrolled 1,250 individuals (mean age, 65.5 years; 54% women; 82.1% white) diagnosed with advanced NSCLC in the previous 12 weeks between June 14, 2018 and May 4, 2023, then randomly assigned them to receive telehealth or in-person early palliative care at 22 U.S. cancer centers.
Researchers recorded participant-reported measures every 12 weeks.
They evaluated the equivalence of the two treatment formats on quality of life at week 24 as the study’s primary endpoint. They assessed caregiver participation, depression and anxiety symptoms, coping skills and perceptions of prognosis of both groups as secondary endpoints.
Due to COVID, 3.9% of visits for the in-person cohort occurred over video.
Results and next steps
The telehealth group had a mean of 4.75 visits at week 24 and the in-person cohort had 4.92.
The telehealth arm had a mean quality-of-life score of 99.67 compared with 97.67 for the in-person cohort (P < 0.04 for equivalence).
The groups had equivalent depression and anxiety symptoms, use of coping skills, understanding of their treatment goals and perceptions of curability.
The in-person cohort had higher rates of caregiver participation (49.7% vs. 36.6%), likely due to the need for transportation to appointments, Greer said during his presentation.
Researchers noticed increased acceptance of telehealth during their trial, which started before the pandemic and ended after it.
“Initially, people were hesitant to do telehealth,” Greer told Healio.
“It was unfamiliar for them. They didn’t quite grasp the technology,” he added. “Now, after the pandemic, with all this rapid uptake, patients didn’t want to go back to in-person visits. The convenience factor is huge, and they love the fact they’re able to schedule these at more convenient times.”
However, surveyed clinicians noted certain patient populations could benefit from one modality over another.
“Telehealth is particularly useful for patients who tend to be more frail and have a hard time getting into the clinic, patients who would never go see a palliative care clinician for an extra visit because their lives are just too burdened, also just the transportation, the cost of all that, and certainly patients who live from farther geographic regions,” Greer told Healio. “I would say those are the three big ones.”
In-person visits could benefit those who may have audial or visual impairments or struggle with technology.
“For the most part, this is an older population, and mostly people were able to onboard very easily and do well, but there were some who really did struggle,” Greer told Healio. “Although the video allows for a lot more continuity and efficiency for both the patient and clinician, there were times when [clinicians] couldn’t quite capture how the patient was doing clinically. They felt like they needed an in-person visit just to get a pulse of how they’re doing clinically.”
Future research could further examine which populations benefit the most, he said. Additional studies are also needed to examine telehealth in different cancer types.
“The evidence base is certainly the strongest in advanced lung cancer,” Greer told Healio. “Our team had conducted an efficacy trial several years back both in patients with advanced lung cancer as well as those with non-colorectal advanced GI cancers, and we did not see the same outcomes in that group,” he added. “People are living longer and longer, so say in breast cancer, where patients live a very long time, integrating palliative care from time of diagnosis of that advanced cancer over a disease trajectory that could be years may not make sense.”
Forthcoming studies should determine for whom palliative care delivery via telehealth is most appropriate and when it should be offered, Greer said.
“We see that early palliative care can be delivered successfully, effectively and efficiently using telehealth in patients with advanced lung cancer,” Charu Aggarwal, MD, MPH, FASCO, Leslye M. Heisler associate professor for lung cancer excellence, director of precision oncology innovation at Penn Center for Cancer Care Innovation at the University of Pennsylvania and Healio | HemOnc Today Associate Medical Editor said during a press briefing when discussing the findings.
“Early palliative care is an integral component of delivery for lung cancer care. Now, we have the technology to reduce the burden on patients and use it to our advantage,” she added. “Findings from the study underscore the importance of telehealth in improving access and broad dissemination of palliative care for patients who otherwise may not be able to get it.”
Perspective
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Jorge Nieva, MD
Palliative medicine, more than any other aspect of oncology, really does involve the family and you’re treating the family as much as you’re treating the patients. Telemedicine is great for involving families because multiple people can log in from different locations. There are many anecdotes I can tell you about getting the patient to a goals-of-care area where the patient is comfortable, the patient knows what they want, and then a child who lives on the other coast will suddenly come into the picture toward the end of life and try to change the goals of care and the care plan. The wonderful thing about telemedicine is those people can be involved from the get-go. They can be at work, they can log in for a few minutes for discussion.
Oncology as a field has become more complex. We require additional specialty consultations from our colleagues in many aspects of medicine, and I think often times the patients are overwhelmed with the number of doctors’ visits they have to have. ... So as much as we can make these visits easier and simpler for the patients, this is really a win for patients and their families.
I think that there are so many patients who prefer in-person visits to telehealth visits and ultimately this is going to be something that’s patient directed. It opens the realm of possibilities for palliative care to be now available at institutions and hospitals where it’s not normally available.
Palliative care is still a relatively new specialty. We don't have enough palliative-care physicians in rural areas. We don’t have enough in smaller hospitals and community-based hospitals. Telehealth allows for those types of facilities to essentially contract out the work to places where the palliative-care medicine physicians exist.
You can imagine a world where every hospital now has access to palliative care specialists for their outpatients who require cancer care, knowing that it’s available as a service that can be delivered by telemedicine without a requirement for an onsite person on staff.
The ability for us to take care of patients using telemedicine is entirely dependent on payment structures that reimburse telemedicine at a level comparable to what happens to in-person visits. These regulations are always the subject of congressional appropriations and I think it’s critically important that legislatures and others who can impact Medicare reimbursement schedules understand that telemedicine is something that should very much at the top of the priority list of things that are covered by payers.
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Greer JA, et al. Abstract LBA3. Presented at: ASCO Annual Meeting; May 31-June 4, 2024: Chicago.
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