Telemedicine stepped up to the plate when the COVID-19 pandemic swept the globe. Oncology providers—and practitioners in all specialties—had to rapidly adapt to a telemedicine format when face-to-face visits were severely limited. This scenario had its benefits for both patients and providers (and some aspects of this format will undoubtedly stay in place post pandemic), but it also had its drawbacks. Notably, existing disparities were magnified by the necessity for telemedicine, and many patients without access to the necessary technology—or lacking the digital literacy to use it—missed out on care.
At the 2022 Summit on Cancer Health Disparities in Seattle, Howard (Jack) West, MD, and Joy Feliciano, MD, discussed the changing landscape of cancer care since the onset of the COVID-19 pandemic, the rapid adaptation to telemedicine in oncology, and strategies to mitigate disparities exacerbated by telemedicine.1
Howard (Jack) West, MD
Joy Feliciano, MD
“Telemedicine didn’t start with the pandemic,” said Dr. West, Associate Clinical Professor in Medical Oncology at City of Hope Comprehensive Cancer Center, Duarte, California. “We had the bandwidth, and we had the hardware, we just didn’t have much of a will for it.”
Prior to the COVID-19 pandemic, less than 1% of oncology visits were conducted via telemedicine. But in March 2020, when in-person visits dropped exponentially, telemedicine visits jumped significantly. The shift was rapid, with some cancer centers establishing virtual care programs only days or weeks after the declaration of the pandemic. Now, in-person visits have picked back up, and telemedicine visits have leveled out, but at a higher level than before the pandemic.2
During this time, what became increasingly clear was that telemedicine is well suited for some situations and patients and poorly suited for others, noted Dr. West.
Advantages of Telemedicine Visits
A survey of more than 1,000 oncologists from National Comprehensive Cancer Network (NCCN) institutions3 revealed that over 90% of respondents found no adverse issues associated with telehealth, but they did acknowledge certain situations were better suited for it—such as reviewing benign findings and following up with patients on maintenance therapy. However, visits to assess complications of therapy or to establish a personal connection were not deemed appropriate for telemedicine.
Dr. West pointed out that even high-stakes discussions conducted via telemedicine during the pandemic were effectively conducted and well received. A study from Dana-Farber Cancer Institute showed that even when patients with cancer were discussing end-of-life issues and preferences for going on a ventilator during a time when hospital care was extremely limited, the telemedicine experience was found to be favorable—in some cases more so than live visits.4 Multidisciplinary teams (eg, including interpreters, social workers, nurses, pharmacists) participated in these conversations, and they found that documenting goals of care was “easier than they anticipated” and often even initiated by patients.
In addition, there seemed to be a significant increase in discussions about end-of-life care in April 2020. Dr. West noted these findings could be interpreted as slightly artificial, since the pandemic created a sense of urgency to discuss goals of care. However, providers received training on conducting these visits over the phone or via video, and patients seemed relatively comfortable to discuss these issues, they reported.
Barriers to Telemedicine
Although telemedicine may have been a success in many ways, it wasn’t without its barriers. “We’ve replaced some old disparities with new disparities, and it’s become clear there are certainly people for whom video-based visits are pretty elusive,” commented Dr. West. Issues and lack of confidence with using the technology created frustrations for both providers and patients (especially older patients), whereas lack of access to it entirely impeded some people from receiving care during the pandemic, widening disparities between the “haves” and “have-nots.”
A study on “telemedicine unreadiness” revealed that older patients, minorities, unmarried patients, less-educated patients, lower-income patients, and less-healthy patients were least able to avail themselves of the potential benefits of telemedicine.5
From a provider standpoint, insufficient or uncertain reimbursement (despite a change in policy by the Centers for Medicare & Medicaid Services [CMS]), questions about the quality of patient care, language barriers, licensing issues (though strides are being made through the Interstate Medical Licensure Compact [IMLC]), and liability all created additional hurdles.6 To lower some of these barriers, ASCO’s Position Statement on Telemedicine in Cancer Care supports continuing CMS provisions for cancer care telemedicine beyond the pandemic, favors the participation of all states in the IMLC, and supports medical liability insurance coverage of telemedicine. Dr. West emphasized reimbursement issues and predicted that reimbursement will dictate the future role of telemedicine.
When asked what patients think of telemedicine, Dr. West said it depends on who you talk to. Surveys have revealed that patients have individualized perspectives on whether telemedicine is an advancement in care or a poor substitute.7
However, according to Dr. West, these issues can be improved upon, adding that “patient stories shouldn’t be about tech challenges.” Bedside manner has been honed over centuries, but “webside manner” is a new concept. Taking small steps to improve the patient experience can make a big difference in making patients feel more comfortable; such steps include making sure sound, camera, and lighting are well adjusted (with an appropriate, uncluttered background); making eye contact with the camera; and acknowledging the new/odd nature of video visits with patients.8
“It’s important to recognize that telemedicine isn’t intended to be—nor should it be—a replacement for all patients in all settings,” noted Dr. West. “Smartphones didn’t replace computers; each tool is well suited to different tasks. Telemedicine is a complement to live clinic visits, and a tool that should be integrated in our workflows over time.”
Addressing ‘Techquity’
According to Dr. Feliciano, Associate Professor of Oncology at Johns Hopkins University School of Medicine, Baltimore, telemedicine has the potential to exacerbate as many disparities as it reduces, but its many benefits and success stories should not go unnoticed.
According to Dr. Feliciano, telemedicine can improve communication between resource-rich and resource-poor cancer centers, provide access to subspecialty care that may not be available in local institutions, increase access to clinical trials, and reduce travel and expenses for patients and their families. It also allows for the inclusion of family and caregivers who may not be in immediate proximity to the patient, increased access to supportive care, and virtual education opportunities for both patients and clinicians.
However, telemedicine can also highlight disparities, particularly when it is rapidly adopted among unprepared populations. For instance, a cross-sectional analysis of Medicare-enrolled cancer survivors revealed a digital divide: Certain demographic factors such as place of residence, age ≥ 75, or race (being Black or Hispanic) were associated with lower odds of either technology ownership, Internet access and/or use, or overall telehealth availability.9
Telehealth Disparities and Clinical Outcomes
“Many investigators have demonstrated that telehealth disparities exist for certain patient populations,” noted Dr. Feliciano. “But, at our institution, we wanted to explore whether or not these disparities are associated with inferior clinical outcomes.”
Dr. Feliciano and colleagues performed a retrospective study of patients treated at their cancer center between March and July 2020 (in press, JAMA Network Open). The study included 759 patients, with a total of 2,106 visits (679 in-person and 1,352 telehealth).
They found that race, insurance status, zip code, and marital status were associated with unsuccessful telehealth visits, and that these unsuccessful telehealth visits may be associated with poorer outcomes. Patients with all successful telehealth visits (compared with those who had mixed or no success) had lower odds of both death and emergency department visits, and these findings were statistically significant.
“This is hypothesis-generating,” stated Dr. Feliciano. “But I think it’s important to realize that not only do disparities exist, but there might also be an actual association with clinical outcomes.”
To work toward mitigating these disparities, Dr. Feliciano points to the ASCO Standardization and Practice Recommendations for Telehealth in Oncology. Among other recommendations, these guidelines include identifying appropriate circumstances for telehealth, providing orientation for all patients and providers to ensure adequate access, and offering external tech support for telehealth visits.
Recommendations for thoughtful implementation of telehealth in cancer care are constantly evolving, Dr. Feliciano added. Actionable policy recommendations—such as establishing coverage and payment parity at federal and state levels, as well as investing in high-speed broadband infrastructure in underserved communities—will hopefully improve the equitable implementation of telehealth in the future.10
DISCLOSURE: Dr. West has received honoraria from and served as a consultant or advisor to Amgen, AstraZeneca, Daiichi Sankyo, Genentech/Roche, Merck, Mirati, Regeneron, and Takeda; and has participated in speakers bureaus for Amgen, AstraZeneca, and Merck. Dr. Feliciano reported no conflicts of interest.
REFERENCES
1. West J, Feliciano J: Technology and cancer disparities Session. 2022 Summit on Cancer Health Disparities. Presented April 30, 2022.
2. Patel SY, Mehrotra A, Huskamp HA, et al: Trends in outpatient care delivery and telemedicine during the COVID-19 pandemic in the US. JAMA Intern Med 181:388-391, 2021.
3. Tevaarwerk AJ, Chandereng T, Osterman T, et al: Oncologist perspectives on telemedicine for patients with cancer: A National Comprehensive Cancer Network survey. JCO Oncol Pract 17:e1318-e1326, 2021.
4. Lally K, Kematick BS, Gorman D, et al: Rapid conversion of a palliative care outpatient clinic to telehealth. JCO Oncol Pract 17:e62-e67, 2021.
5. Lam K, Lu AD, Shi Y, et al: Assessing telemedicine unreadiness among older adults in the United States during the COVID-19 pandemic. JAMA Intern Med 180:1389-1391, 2020.
6. Chang JE, Lai AY, Gupta A, et al: Rapid transition to telehealth and the digital divide: Implications for primary care access and equity in a post-COVID era. Milbank Q 99:340-368, 2021.
7. Granberg RE, Heyer A, Rising KL, et al: Medical oncology patient perceptions of telehealth video visits. JCO Oncol Pract 17:e1333-e1343, 2021.
8. Webside Manner: Helping clinicians achieve perfect patient communications in the telehealth era. Available at https://websidemanner.net/. Accessed June 3, 2022.
9. Lama Y, Davidoff AJ, Vanderpool RC, et al: Telehealth availability and use of related technologies Among Medicare-enrolled cancer survivors: Cross-sectional findings from the onset of the COVID-19 pandemic. J Med Internet Res 24:e34616, 2022.
10. Kircher S, Braccio N, Gallagher K, et al: Meeting patients where they are: Policy platform for telehealth and cancer care delivery. J Natl Compr Canc Netw 19:1470-1474, 2021.
