Telemedicine Takes the Lead in Cancer Care Strategy During the COVID-19 Outbreak

H. Jack West, MD

H. Jack West, MD

Telemedicine has been implemented in medical practices across the country in response to “stay at home” orders and social distancing recommendations from local governments and health authorities. For some practices, telemedicine was already an extension of their day-to-day operations. For other practices, conducting patient visits via telephone or internet is a novel concept.

Oncology practices especially have to take careful steps for deciding which patient cases can be managed through telemedicine and which require in-person visits. Some examples of individuals who may be ideal for telemedicine visits are those who are finished treatment and only require surveillance. Other patients who may be cleared for telemedicine are those who have been responding to their treatment long-term.

“Telemedicine expanded greatly in a short time out of necessity, but with that we have seen how valuable it can be as an alternative to live visits for some patients. I believe that we will continue to employ telemedicine far beyond these acute issues,” H. Jack West, MD, toldTargeted Oncology.

At the City of Hope, restrictions were heightened in response to the spread of the novel coronavirus disease 2019 (COVID-19) in the United States (US). Telemedicine is 1 of the ways the center is continuing to care for its patients while limiting potential exposure to COVID-19 and keep patients safe.

In an interview withTargeted Oncology, West, executive director, AccessHope and associate clinical professor, City of Hope Comprehensive Cancer Center, discussed the role telemedicine has taken to support the treatment and post-treatment surveillance of patients with cancer during the COVID-19 pandemic.

TARGETED ONCOLOGY:In the face of COVID-19, what has been revealed about the way oncology practices have been operating? What factors play a part in some oncology practices continuing to thrive during this time while others have hardship?

West: I would say that 1 practical issue is that there is a lot of variability in how different areas of the country and different institutions are affected just by the magnitude of COVID-19 exposures and serious infections. Certain areas like New York that have been very hard hit have had a greater impact in terms of people being able to safely come into a clinic or have a procedure performed with access to operating rooms and ventilators at this time with competing needs for managing acute issues around COVID-19.

What we have seen is that the threat and the challenge of [optimizing] coronavirus infection around our patients with cancer has forced us to look carefully at our practices and be as judicious as possible about clarifying if patients need to come now or can be postponed to a longer interval. Can we repeat a scan and review it with them if they've been stable on treatment for a long period of time? Increasingly, we consider whether we can use a telemedicine visit as an alternative to them coming into the clinic. That is an attractive option for some patient, but not everyone is ideally suited for them. That may be because they need to come in to get an infusion or because they have a more acute issue that needs to be evaluated with a [physical] examination or because they don't have the internet access or technologic confidence to participate in a telemedicine visit.

This is something that I think will improve over time, but right now, telemedicine has rapidly become a tool for the job in some, but not all, cases. Many places have been adapting to this [shift], some not as much.

TARGETED ONCOLOGY:Telemedicine is important right now. How is telemedicine being used at your institution?

West: I have personally been eager to pursue more telemedicine as an efficient platform for delivering cancer care. Oncology is in many ways well-suited for telemedicine or at least for second opinions because it is certainly a serious issue that requires consideration of the options but is not so serious that it requires immediate input without being planned and scheduled in advance.

A lot of the decisions we make are more cognitive. They're based on the value of a pathology finding or imaging, talking with the patient about their symptoms, and then coming up with a comprehensive plan together.

City of Hope is integrating telemedicine in a number of ways. One way has really catalyzed our expansion of telemedicine in our outpatient clinic where we have patients who may be able to go over a scan, check in on how they're tolerating a treatment, or just have a follow-up to consider subsequent management options. All of these factors contribute to the remote discussion. Both the physicians who have been doing this more often and the vast majority of patients have found this to be a convenient and useful platform that we are likely to continue to use regularly outside of social distancing by necessity.

The other way that we are using telemedicine is through our remote consult service where we have historically had patients fly in or drive in from a distance to see several doctors over the course of a day as consult on our campus. That is a more challenging strategy right now considering our current environment. Having an enhanced virtual visit that includes that same series of consult with several specialists in a day can be done in a video-based platform.

TARGETED ONCOLOGY: Based on your experience, what are the benefits of using telemedicine? What challenges have been experienced by both providers and patients?

West: We have found that it is often efficient. It's not that live visits aren't of benefit, but being able to use telemedicine as an alternative for the right situation has shown physicians that we can still have an interpersonal connection with patients, and even with their families. We are able to preserve the best aspects of communicating as if we were in person, except we mitigate the experience of being in the waiting room or potential exposures from having multiple people in the same place.

It's a safe alternative that has proven to be feasible. The challenge is that we have been communicating in person for decades and have become very accustomed to how to optimize communication between the patient and the physician and have had less opportunity to communicate through a screen.

We have to take practical steps like making sure the light and sound are good on both sides, both the physician and patients have the technologic confidence to get into the same space together, and making sure that we have spaces that are conducive to a telemedicine visit on both sides.

TARGETED ONCOLOGY: There is some belief that the use of telemedicine today is an eye opener because providers are realizing that some patients don’t necessarily need an office visit. As an oncologist can you give an example of a patient case for which telemedicine may be more ideal and, why is that?

West: There are a wide range of patients. One is a patient who is coming in for a surveillance visit that may have preceded by a scan to assess how they're doing 6 months or even 2 years after receiving treatment for their cancer. It may be assessing how they've been feeling. For many of these routine visits, we can review the same information through a telemedicine visit.

For patients who are doing well with ongoing treatment, particularly something like a targeted therapy or hormone therapy that is orally administered and for whom we have regularly scheduled follow-up, we can do these visits through telemedicine. This saves patients from the time and difficulty of coming into the clinic.

Telemedicine is also useful for patients who have recently started a treatment and are concerned about how well their tolerating the drug and whether they're eating and drinking as needed at home. We can do a telemedicine visit to clarify whether they need to come in for more support, fluids, etc.

TARGETED ONCOLOGY: Communication with other providers inside and outside of your institution has likely been impacted COVID-19 as well. How are virtual meetings effecting patient care? What are the pros and cons?

West: One of the new issues we're dealing with is that a lot of our cancer meetings are being rapidly converted to virtual meetings. I'm confident that we will find that they can be very efficient for conveying the information of new reports. We will need to see how much we lose in translation from the actual interactions and conversation that happen when you're in the same place.

We are doing a lot more virtual meetings. This is not just in terms of large conferences but group of colleagues getting to together for informal symposia sharing. By doing this, we get information about the management of our clinics, managing patients with COVID-19 exposure, and even serious illness from COVID-19.

The benefit is that telemedicine can bridge distance instantly. It's not the same as being there, and overall there are advantages and disadvantages of these virtual formats compared with their in-person communication.

At City of Hope we've even had virtual social hours to enforce a sense of camaraderie and help gratify us as a global medical community to remind us that we're in this together. We're not just sharing our information with colleagues in different parts of the US, but also with colleagues in Asia, Italy, Spain, and various other part of the world. It unites us and galvanizes us against this common enemy. 

I would say that once things are back to normal and we don't have enforced social distancing, we will continue to see value in virtual meetings and probably use them more than we had previously.

TARGETED ONCOLOGY:In your expert opinion, what does all of this mean for the future in terms of how oncology practices should operate? For your institution, what newly implemented practice do you think is important to keep after COVID?

West: Telemedicine is here to stay at City of Hope and many institutions throughout the US and around the world. Telemedicine expanded greatly in a short time out of necessity, but with that we have seen how valuable it can be as an alternative to live visits for some patients. I believe that we will continue to employ telemedicine far beyond these acute issues. I also think it will become routine to have our practice be a combination of live visits and telemedicine visits. Realizing the utility of telemedicine will be one small lasting benefit of all of these challenges that we're facing. It will make cancer care and medical care overall more efficient long after this time.