Bridging the Gap: Telehealth Expands Access to Essential Palliative Care
Joseph Greer, PhD, discussed a study evaluating in-person vs telehealth modalities of early integrated palliative care for patients with advanced lung cancer.
Joseph Greer, PhD
Palliative care plays a crucial role in improving the quality of life for patients with cancer and has proven benefits for patients and their caregivers, especially when integrated early in the treatment course.
“There are a lot of misperceptions when we use the term ‘palliative care’ that we are only talking about end-of-life care,” said Joseph Greer, PhD, in an interview with Targeted OncologyTM. “When we are talking about early integrated palliative care, we are talking about a team of clinicians who are dedicated to improving a patient's care experiences, their quality of life, and their symptoms.”
However, issues with widespread access can make achieving early palliative care integration into cancer treatment challenging. The featured plenary abstract from this year’s American Society of Clinical Oncology (ASCO) Annual Meeting focused on whether palliative care could be delivered with comparably effectiveness as an in-person or telehealth model. The findings suggest that telehealth can be a valuable tool for expanding access to palliative care, particularly for patients with advanced cancer who may face barriers to in-person care.
In the interview, Greer, primary investigator of the study and codirector of the cancer outcomes research and education program at Massachusetts General Hospital in Boston, Massachusetts, discussed the trial and the importance of its findings.
Targeted Oncology: What are some of the unmet needs among patients with advanced lung cancer, specifically regarding mental, social, and emotional needs?
Greer: We have been fortunate to see tremendous breakthroughs over the last couple of decades in novel therapeutics for lung cancer. But nonetheless, for most patients with advanced lung cancer, at some point along the disease trajectory, they are going to experience a range of physical and psychological symptoms, namely things like pain or fatigue, anxiety or depression, worries about what the future might hold, concerns about changes in functioning, and worries about how their care and their cancer may affect their loved ones. All these unmet needs can certainly exacerbate poor quality of life.
What were you evaluating in your study?
Given these unmet needs, ASCO has put forth guidelines to integrate palliative care from the time of diagnosis of advanced cancer to support patient coping and improve their quality of life in which patients would meet with a palliative care clinician in tandem with their oncology care over their course of illness. Palliative care is really dedicated to improving the care experience and the quality of life of patients with advanced cancer and their loved ones. We have been testing the integration of palliative care now for almost 2 decades, and various efficacy trials have shown that when palliative care does meet with the patient, along with oncology care, it improves patient's quality of life and improves their mood symptoms, their coping skills, as well as the quality of their care.
Unfortunately, most patients do not receive this evidence-based care per ASCO guidelines, because of the one major obstacle being the limited availability of trained specialty palliative care clinicians, in addition to practical barriers of seeking additional care. So, when we were conceiving of this study, we were trying to think of different ways to improve access to palliative care, particularly for [patients] who may be frailer or live in rural areas. And at the time—this was before the [COVID-19] pandemic—we were thinking about the use of telemedicine to improve access.
The goal of this study, which is funded by the Patient-Centered Outcomes Research Institute, was to evaluate delivering early integrated palliative care, this evidence-based model that we have been studying for the last couple of decades, was equivalent as in-person modality vs video based.We wanted to enroll [patients]and randomly assign them to meet with a palliative care clinician from the time of diagnosis with the same frequency, having similar conversations, with the only difference being whether they would receive that care in person in clinic or over video.
We enrolled 1250 patients with advanced non–small cell lung cancer. They could also identify caregivers, most often a family member, to participate. They completed self-report measures of quality of life,mood, symptoms, coping, perceptions of prognosis, and satisfaction with care upon randomization. Then, they completed those measures again at 12, 24, 36, and 48 weeks. If[the patient] did elect to have a caregiver involved, the caregiver would also complete self-report measures that were very similar. Then, we followed [the patients] over the course of their illness.
We were pleased to find that patients in the video visit group reported equivalent quality of life scores on our primary outcome measure as the patients who received in-person palliative care, thereby really confirming our primary hypothesis that these modalities for delivering early palliative care were equivalent. We also found that in terms of the other outcome measures like satisfaction with care or patient or caregiver mood symptoms also did not differ between study groups. Whether patients receive this care either in the video modality or the in-person modality, we found that their reported outcomes were quite similar across a range of measures, which was exciting.
Taking into consideration the practical limitations of palliative care, especially community settings, what do you consider to be the implications for oncologists?
I think it is a key point that we are struggling with a couple of different issues. There is the access issue, particularly for patients who may not be able to get to clinic or may not be even willing to see another provider, given just all the burdens of the medical appointments with cancer care. Video-based early palliative care is an easier way to access that care, a much lower burden, a lower touch point, and would in some ways allow [patients] ease into that care in a way that is much more patient-centered.
From one level, it is about encouraging oncology clinicians to work with their patients to help them understand the value and benefit of palliative care, because I think that is an obstacle. Sometimes [patients]have misperceptions about the role of palliative care.
We clinician-scientists have to continue to think about how we tailor these services in a way that meets patient's needs.As patients are living longer with advanced disease, and we must triage services, what are the other ways that we are considering improving access? So other things that we are considering are, how do we introduce palliative care early on, but then intensify the frequency of visits based on a patient’s needs?Maybe when there's a change in treatment, or perhaps when their quality-of-life declines. Targeting the power of care and frequency relative to what their needs are is another way that we are evaluating the benefit of these models.
What is the role of palliative care in oncology as a whole?
There are a lot of misperceptions when we use the term “palliative care” that we are only talking about end-of-life care. I do want to distinguish early integrated palliative care from hospice, which is a specialized form of end-of-life care. When we are talking about early integrated palliative care, we are talking about a team of clinicians who are dedicated to improving a patient's care experiences, their quality of life, and their symptoms. This could be for any serious illness, whether it is curable or not, at any point along the disease trajectory. This type of service is not about end-of-life care, but really about living well for as long as possible.That is why we believe that integrating this early on really matters. Even if that means first establishing a relationship with a palliative care clinician, and then titrating the frequency more over time as the needs increase. Those are also reasonable models that we are also evaluating.
Nonetheless, developing a strong relationship with that palliative care clinician clearly demonstrates that when patients have that combined comprehensive care, their outcomes across a whole host of self-reported measures are improved.We believe that that not only improves that that longitudinal trajectory of their care, but then when or if the person does need to then transition to end-of-life care, we have also found that that helps benefit them at that time as well and making sure that that the type of care that they received at the end of life is one that is in accordance with their goals and wishes.
