Although national guidelines, including ASCO’s palliative care guideline,1 call for the early integration of palliative and oncology care for patients with advanced cancer, only 36% of those with a very poor prognosis and 18% of those with a poor prognosis receive palliative care services.2 The reasons so few patients are able to access this specialized care are many and include a shortage of a trained workforce, public misperception of palliative care as end-of-life care, and reimbursement challenges, among others. However, the results from a recent study comparing the effectiveness of early palliative care delivered via secure video vs in-person clinical visits among patients with advanced non–small cell lung cancer (NSCLC) may help providers and patients overcome these barriers.
Joseph A. Greer, PhD
Jennifer S. Temel, MD, FASCO
The study, conducted by Joseph A. Greer, PhD, and Jennifer S. Temel, MD, FASCO, Co-Directors, Cancer Outcomes Research & Education Program at Massachusetts General Hospital Cancer Center, and their colleagues, included 1,250 patients who were recently diagnosed with advanced NSCLC. The patients were randomly assigned to meet with a palliative care clinician every 4 weeks throughout the course of their disease either via video or in an outpatient clinic. The sessions addressed patient-reported physical and psychological symptoms, including pain, depression, and anxiety; coping skills; perceptions of prognosis; and treatment decisions. The study also compared quality-of-life assessments of 548 caregivers who participated in the study.
The results from the study, presented during the 2024 ASCO Annual Meeting,3 and subsequently published in JAMA,4 showed that after 6 months, both patient groups reported equivalent improvements in their quality of life (adjusted means: 99.7 vs 97.7, P < .04 for equivalence), including better appetite, reduced pain, and clarity in thinking. The two study groups also reported similar improvements in depression and anxiety symptoms, use of coping skills, or perceptions of the goal of treatment and curability of their cancer; and they were equally satisfied with the care they received.3,4 Although caregivers in both groups also expressed similar levels of satisfaction with the care they received, the rate of caregiver participation in early palliative care visits was lower in the telehealth group than in the in-person group, 36.6% vs 49.7%, respectively.3,4
GUEST EDITOR
Janet L. Abrahm, MD, FACP, FAAHPM, FASCO
Dr. Abrahm is Professor of Medicine at Harvard Medical School and former Chief of the Division of Adult Palliative Care, Department of Supportive Oncology, Dana-Farber Cancer Institute, and Division of Palliative Medicine, Brigham and Women’s Hospital. Palliative Care in Oncology addresses the evolving needs of cancer survivors at various stages of their illness.
“Despite the fact that we saw this difference in visit participation between those caregivers in the telehealth group vs the in-person group, it’s not necessarily a bad outcome,” said Dr. Greer. “It may be that video visits give patients and caregivers more autonomy in deciding when to have a joint visit and when not to.”
In a wide-ranging interview with The ASCO Post, Dr. Greer discussed how telemedicine can help increase access to early palliative care services, at less cost, especially to underserved patients with cancer, and why virtual health consultations are garnering bipartisan funding support in Congress.
Adapting to Virtual Palliative Care Consultations
Since receiving a life-threatening diagnosis like advanced lung cancer can be extremely challenging for patients and their families, were you surprised to find that patients were equally satisfied with either video or in-person palliative care sessions?
When we began this trial, in 2018, the use of video visits to deliver palliative care was new, and we definitely found some hesitation among the patients randomly assigned to the video group, because they didn’t know how to use the technology. However, with some minimal training, participants adapted quickly to the technology and came to appreciate the benefits telehealth palliative care visits provided in terms of eliminating the burden of time, travel, and cost to get to their clinic.
We also found when we examined the clinicians’ post-visit summaries, which included information on assessing and managing patients’ symptoms; supporting effective skills for coping with advanced lung cancer; and building and establishing a strong rapport with the family, the clinicians reported discussing these topics at similar rates in both study groups. Moreover, patients’ and caregivers’ level of satisfaction with care was similar for both the video and in-person groups. These results gave us a lot of confidence that clinicians were able to engage in identical conversations with participants regardless of whether they were in person or over video.
When to Provide In-Person vs Virtual Palliative Care
Expanding telehealth services for patients with cancer, especially for those living in rural areas with limited access to cancer care, can increase accessibility to specialized services such as palliative care. However, the needs of patients seeking palliative care treatment for mental health concerns and relief from the physical symptoms of cancer and its treatment are complex. Are there some issues best addressed during in-person clinical visits than with virtual visits?
We need more research to answer that question definitively. However, as I mentioned previously, at least in the topic areas discussed in our study, the level of satisfaction was the same regardless of whether patients received palliative care in person or online. So, that offered reassurance that difficult conversations could happen in both settings.
We do know there were occasions when the clinicians in our study requested some patients in the video group come into the clinic for an in-person visit, and that’s interesting. We don’t know why that happened or whether the request came from the patient or the clinician. We are planning on doing additional analyses and interviews with our study clinicians to find out what the clinical signs were that warranted an in-clinic visit. Having those data would be informative to understand what clinical situations are better addressed in person.
Overcoming the Barriers to Accessing Palliative Care Treatment
Even though the benefits of incorporating early palliative care into routine cancer care are well documented, studies show that fewer than 40% of patients with a poor or very poor prognosis receive palliative care services.2 Please talk about some of the barriers to receiving this care, and how might expanding virtual palliative care services improve its use?
The barriers to receiving this specialized care occur at the patient, physician, and health-care system levels. On the patient level, there is still a misunderstanding of what palliative care is, and the service is often conflated with end-of-life hospice care rather than care that is provided to improve quality of life at any point in the course of disease.
There are also cost and time constraints for patients. As we noted in our study, about 46% of patients reported having to drive over an hour to get to their clinic visits, and that’s a considerable amount of time. The fact that we can offer the benefit of a virtual modality and save patients all that travel time cannot be overstated, especially for older patients who may be frail, immunocompromised, or have comorbidities that make them want to limit going to a clinic for care when possible.
At the physician level, there are only about 6,000 board-certified palliative care specialists in the United States,2 and that’s not enough to meet patient demand. And on the health-system level, the barriers include a lack of resources for referring patients to palliative care and/or a lack of resources to provide palliative care as well as insurance reimbursement policies.
Telehealth can reduce many of these barriers to accessing early palliative care for patients, their caregivers, physicians, and the health-care system by improving time and cost efficiencies. For example, we found in our study, that clinicians saved on average about 10 minutes per virtual visit compared with in-patient clinic visits without compromising the quality or continuity of care, and that’s a significant time and cost benefit.
Building Virtual Palliative Care Models
How can patients receive virtual palliative care services in community settings that don’t have palliative care providers on staff?
There are discussions underway about building models that deliver scalable specialist palliative care in community settings, but without enough palliative care clinicians, this will be difficult to do. One potential model that is being explored, and that we’re researching, is the primary palliative care model in which oncologists undergo training in integrating core palliative care tenets, such as improving quality of life, physical and emotional symptoms, mood, and coping, into standard oncology care.
Other efforts include using prompts embedded in electronic health records to nudge oncology clinicians to discuss illness understanding, goals of care, and values with patients with advanced cancer as part of routine clinical visits.
Eliminating Barriers to Care
The patients enrolled in your study were mostly older than age 65, female, and White. Please talk about the potential of telehealth to bring palliative care medicine to underserved minority patients and to younger patients.
We are conducting subgroup analyses of our study to see how people of different ages, races, and ethnicities responded to telehealth palliative care sessions compared with in-person clinical visits, and some compelling findings are starting to emerge. We are analyzing those data now and will publish the information once that process is completed.
Supporting Medicare Coverage for Telemedicine
Although access to telehealth services increased during the COVID-19 pandemic, there is inconsistency in how telemedicine is covered by insurance companies, and many pandemic-era flexibilities around Medicare coverage expired in December 2024, despite studies showing that telemedicine visits are significantly less expensive to deliver than in-person medical care.5
Congress has passed a 3-month continuing resolution bill to fund the government through March 14, which includes expanded Medicare coverage for telemedicine. Are you optimistic that your study’s findings may help convince policymakers to increase support for telehealth services for palliative care for patients with cancer in funding legislation for fiscal year (FY) 2025?
I am very grateful for the timing of the results of our study. There are decisions being made right now about budget support for Medicare coverage for telemedicine, and I want policymakers to know that data from a very large-scale clinical trial demonstrate it is possible to provide equivalent high-quality palliative care over video compared with in-person clinical care.
I am optimistic that a government funding bill for FY 2025 that includes increased Medicare coverage for telemedicine will be passed, not just because the data from our study will be helpful in informing those policy decisions, but because we are already seeing some positive movement in Congress about the benefits of telehealth in cancer care. There is a lot of bipartisan support for funding for telemedicine, and that gives me hope that we will get a bill approved quickly in March.
DISCLOSURE: Dr. Greer receives consultant fees from BeiGene; research funding from BlueNote Therapeutics; speaking fees from GlaxoSmithKline; and royalties from Oxford University Press.
REFERENCES
1. Sanders JJ, Temin S, Ghoshal A, et al: Palliative care for patients with cancer: ASCO guideline update. J Clin Oncol 42:2336-2357, 2024.
2. Sedhom R, Kamal AH: Is improving the penetration rate of palliative care the right measure? JCO Oncol Pract 18:e1388-e1391, 2022.
4. Greer JA, Temel JS, El-Jawahri A, et al: Telehealth vs in-person early palliative care for patients with advanced lung cancer: A multisite randomized clinical trial. JAMA 332:1153-1164, 2024.
5. Chaiyachati KH, Snider CK, Mitra N, et al: Economics of a health system’s direct-to-consumer telemedicine for its employees. Am J Manag Care 29:284-290, 2023.
