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by Linda Wang
The use of telehealth in cancer care surged during the COVID-19 pandemic, when, for a period of time, in-person medical care was limited and many visits to the doctor went virtual. Despite some recent pullbacks in telehealth flexibilities, many experts believe that telehealth will continue to have a role in cancer care.
But how well does telehealth perform when it comes to delivering palliative care for people with cancer, which can rely on a deeper level of connection between patients and providers than may be possible with a virtual visit?
A study of 1,250 people with advanced lung cancer has now provided some insights into that question. The study found that virtual and in-person palliative care were similarly effective in improving patients’ quality of life and other important measures of well-being, according to findings published September 11 in JAMA. It also found benefits for caregivers.
The results show that “we can successfully deliver … high-quality [palliative] care in person and virtually,” said Joseph A. Greer, Ph.D., of Massachusetts General Hospital, who led the study.
The study results also have implications for the accessibility of palliative care, Dr. Greer noted. Telehealth provides a way for people with cancer who live in rural areas where there may not be many palliative care providers or who don’t have reliable transportation to receive palliative care.
“Many of us see the potential that telehealth can have, and studies like this go a long way to help provide the evidence” needed to demonstrate that it can be used effectively as part of something as complex as palliative care, said Roxanne Jensen, Ph.D., of NCI’s Healthcare Delivery Research Program, who was not involved in the study.
Delivering cancer palliative care by video
Palliative care, which should be a part of all cancer treatment, can be given to people at any stage of their disease to help manage their physical symptoms and emotional issues.
However, in the past, palliative care tended to be provided only to people nearing the end of life. Recent studies have shown that incorporating palliative care earlier in the treatment of cancer, such as when a patient is first diagnosed with advanced disease, can help improve their quality of life.
Expert guidelines for cancer care recommend that palliative care should be included as part of the standard of care for people with advanced cancer. But because people with advanced cancer are living longer, and the number of doctors specializing in palliative care is limited, it’s been challenging for some hospitals, particularly smaller community hospitals and those in rural areas, to keep up with the increased need for palliative care, Dr. Greer said.
Many oncology practices and hospitals now regularly use telehealth to deliver some forms of care, often routine follow-up visits. Dr. Greer and his colleagues wanted to investigate whether palliative care, which involves more complicated care like assessing and managing symptoms and mental health issues, could also be delivered virtually and as effectively as when it’s delivered in person.
No differences in quality of life
In their study, the researchers enrolled 1,250 adults recently diagnosed with advanced non-small cell lung cancer who were being treated at one of 22 cancer centers in the United States.
Participants were randomly assigned to receive, at least once a month, either video palliative care or in-person palliative care. Participants in the video group attended the initial meeting with their care team in person and all subsequent meetings by video. The 138 palliative care providers in the study served both groups.
Patients completed questionnaires at enrollment and every 3 months for the next year. The questionnaires asked about their quality of life, including their physical, emotional, and social and functional well-being, as well as satisfaction with their palliative care.
After 6 months, patients in both groups reported similar improvements in quality of life, such as improved appetite, reduced pain, and clarity in thinking. Patients in both groups were also equally satisfied with the care they received.
Psychological symptoms, such as anxiety and depression, improved to a similar degree between the two groups. The average number of palliative care sessions in each group was also similar, 4.7 in the video group and 4.9 in the in-person group, indicating that the groups received a similar amount of interaction with their providers. Palliative care doctors reported having discussed similar topics in both video and in-person sessions.
The study also included 548 caregivers, the majority of whom were spouses or partners of the patients. Caregiver participation in the video group was lower than in the in-person group, 37% compared with 50%. But caregivers in both groups expressed similar levels of satisfaction with the care.
Dr. Greer suggested that because caregivers often accompany patients to the clinic, that may have led to their higher participation in person.
Striking the right balance
The results of this study are “practice changing” and contribute to the body of knowledge about how to make palliative care happen, said Eduardo Bruera, M.D., of the University of Texas MD Anderson Cancer Center in an editorial.
“These findings should be reassuring for both clinicians and patients who prefer video palliative care whenever possible,” he said.
Dr. Greer noted that more research is needed to determine the types of issues that are better addressed in person than over video. Additional research is also needed to find out whether the impact of telehealth varies by factors such as a patient’s age, education level, or level of experience with technology.
That will be important, Dr. Jensen said, because there are people for whom telehealth remains a challenge, such as those with limited or no internet access, language barriers, and visual and hearing impairments.
“As we all become more comfortable with video and telehealth, we need to make sure that the people who aren’t comfortable with [or lack access to] the technology are getting the care they need,” she said.
Dr. Greer hopes that the study’s findings help provide the evidence needed by policymakers to continue supporting expanded access to telehealth services for palliative care even as some insurance coverage for telehealth implemented during the pandemic expires.
It’s clear that delivering palliative care via video visits can offer patients many benefits, Dr. Jensen said, including greater comfort from being at home and easier scheduling. In fact, a recent study on the benefits of telehealth in cancer care showed that video visits save patients a substantial amount of time, travel, and money.
But it doesn’t have to be one or the other, Dr. Bruera said. “A hybrid and flexible model for care, capable of rapidly changing from an in-person to video visit or vice versa should be standard,” he said.
Dr. Jensen agreed: “I hope that people can look at this study and take heart that they can get just as much out of either of these types of visits and do what’s best for them and their family.”
