Telehealth has proved to be a valuable way to expand access to care and ensure patients continue receiving healthcare services, especially amid the COVID-19 pandemic, but it's not a one-size-fits-all solution across specialties.
Scott Michael Schuetze, MD, PhD, professor of medical oncology and internal medicine at the University of Michigan in Ann Arbor, shared what telehealth's emerging role looks like in cancer care, and potential strategies that may be used in the future to advance access in the oncology field.
Editor's note: Responses have been lightly edited for clarity and length.
Question: COVID-19 has had a significant impact on cancer care, causing people to delay treatment and screenings. How might telehealth's role in the oncology space address that?
Dr. Scott Schuetze: Telehealth with video visits may be used to assess patient treatment and potential adverse effects of chemotherapy before each cycle of treatment to review the patient’s progress and determine if adjustments in chemotherapy doses are needed, and if additional supportive care measures are required to address or treat adverse effects. Telehealth is well suited for patients receiving oral chemotherapy.
It's also useful for patients seeking treatment recommendations for rare cancers if expertise is not available through their local providers or medical centers. Additionally, it can be used for second opinions regarding cancer diagnosis.
Telehealth may be helpful in evaluating patients following curative therapy for surveillance of cancer recurrence, monitoring for longer-term complications of cancer treatment, and discussion of measures to prevent the development of cardiovascular and other diseases of which cancer survivors may be at higher risk following cancer therapy.
Cancer screening often requires in-person testing such as mammography, colonoscopy, lung screening with CT and Pap smears. However, telehealth visits can be useful in reminding patients of the importance of cancer screening for at-risk individuals. Skin cancer screening may be suitable for telehealth with photography and innovative algorithms to evaluate digital images.
Q: How does telehealth in cancer care differ from its use in other areas of care?
SS: Care of cancer patients is highly dependent on the cancer pathology and findings on advanced imaging studies such as CT, MR and PET. Often, review of the pathology and imaging by experts is critical in order to provide the best recommendations for the patient. This usually requires review of pathology and imaging by experts and may incur additional costs.
Assessment of patients’ overall health condition and performance status is critical to determine whether chemotherapy treatment may be beneficial or detrimental to patients. Many times it is difficult to assess the suitability of a treatment for a patient without seeing the patient in person.
Q: What does telehealth's role in oncology look like now and where is it going?
SS: Telehealth is being used to limit patient travel and exposure during the COVID-19 pandemic, but it has additional benefits we can utilize for years to come. Virtual care platforms like Summus Global are helping oncologists provide expert second opinions for patients with rare cancers and initial exploration of patients seeking clinical trial opportunities. Additionally, there is an opportunity for telehealth to assist with cancer survivor evaluation and monitoring, but partnering with community physicians and primary care providers is essential.
Q: What is the biggest challenge or barrier for oncologists working to enhance telehealth offerings?
SS: Insurance coverage of telehealth visits is a big barrier. Issues regarding state medical licensing requirements and malpractice coverage when providing telehealth evaluations for patients who live out of the state of the practicing physician significantly reduce physician incentive to provide telehealth. Telehealth may also require more time per visit because of technology-related problems such as low bandwidth and internet interruptions. Physician access to radiology images and laboratory/pathology results to review is widely variable. Lack of access to imaging and results greatly affects proper assessment of a patient’s condition and appropriate recommendations. Another problem affecting telehealth is difficulty in ordering radiology and laboratory results to be done in the patient’s community.
When confusing or difficult news is delivered, patients receiving the information via telehealth do not have immediate access to nursing support or medical social worker support, which are valuable in helping patients process the information, discussing next steps in care and comforting patients.
Patients seeking treatment on clinical trials are required to be evaluated and provide consent for screening. Often, this needs to be done in person per FDA and government regulations. The treatment then needs to be delivered in-person at the site approved to conduct the clinical trial.
Q: While telehealth is aimed at expanding care access, there are some challenges for patients with lack of access to reliable internet or smartphones. How may those disparities be addressed?
SS: There has been discussion of establishing community kiosks in community libraries or other public centers, or mobile centers with good internet connection for underserved patients to use for telehealth visits. In places previously underserved by advanced radiology imaging such as MRI or PET, mobile radiology trucks/centers have proven very useful in bringing this service to rural areas. A similar approach could be considered to bring video/communication/computer to areas with limited technology and internet resources.
For these solutions to be viable, technology assistance needs to be available on-site to help patients who are not familiar with computer software or hardware technology. It would also be ideal if trained staff/counselors are available to help with lay understanding of the information provided during the telehealth encounter, similar to nursing and medical social work that is available in medical clinics. Another limitation of current telehealth encounters is that written documentation of assessment and recommendations in lay language are difficult to provide to patients who may not have access to an electronic medical record via an electronic portal.