Telehealth delivery of palliative care an effective alternative to in-person visits for patients with advanced lung cancer

Dr Joseph Greer - Harvard Medical School, Boston, USA

Basically we’ve seen tremendous breakthroughs in cancer therapeutics over the last couple of decades and, at the same time, most patients with advanced cancer will, at some point along their disease trajectory, experience burdensome physical and psychosocial symptoms, questions about what the future might hold, changes in their functioning. To address these unmet needs ASCO and other professional societies have recommended the early integration of palliative care and oncology care from the time of diagnosis of advanced cancer.

Unfortunately, that model of care, whilst evidence based and has been shown to improve patients’ quality of life, their mood symptoms, coping and other key outcomes, as well as outcomes for caregivers, most patients and families do not receive it. The primary reason is that there’s a limited workforce of specialty-trained palliative care clinicians to provide that care. In addition, there are just logistical barriers for patients for accessing supportive care.

So our team, who have been conducting decades-worth of research in demonstrating the efficacy of early palliative care, was trying to conceive of a way to improve access to that model and to allow patients and families to be able to meet with palliative care clinicians. So one idea that we had, and this was well prior to the pandemic, was to use video visits as a method for enhancing access, particularly for patients who may be frail or live a geographic distance away from the clinic.

So we decided to develop a comprehensive comparative effectiveness trial to test the delivery of early integrative palliative care either via video visits or in-person visits. The in-person visits is what we had tested in the past and shown to be efficacious.

For that trial we enrolled 1,250 patients with advanced non-small cell lung cancer and 548 caregivers and they were randomly assigned in a 1:1 fashion either to receive video visit early palliative care or in-person early palliative care. The patients followed the same protocol in terms of the frequency of meeting with the palliative care clinicians of meeting at least once every four weeks. In addition to that both patients and caregivers completed self-report measures of their quality of life, their satisfaction with care, their mood symptoms as well as coping and other key outcomes. The primary outcome that we were most interested in, and this was based on our prior research, was patient-reported quality of life on the Functional Assessment of Cancer Therapy Lung scale or the FACT-L.

So the timepoint that we were measuring for that primary outcome was 24 weeks post-randomisation. Patients completed those surveys at randomisation and then again subsequently every 12 weeks up until week 48. What we found was that patients in the video visit arm reported improvements in quality of life that were equivalent to those in the in-person arm. So study groups demonstrated the equivalence of the two modalities in delivering early palliative care for patient-reported quality of life. In addition to that, the two study groups did not differ with respect to patient and caregiver reported satisfaction with care and they also did not differ with respect to the patient and caregiver reported mood symptoms.

One difference we did observe is that there was a higher rate of caregiver attendance in the in-person palliative care visits compared to the video visits. We surmise that the reason for that was likely due to the fact that for many patients they do need assistance to get to clinic appointments. So if a friend or family member was helping with transportation they often also attend the video visits.

But overall we were incredibly pleased to demonstrate the equivalence of these two modalities and see how, both for patients and caregivers, there were relatively no differences in their outcomes whether the care was delivered by a video or in person. This has tremendous importance, especially now as policy makers are debating whether to continue the expansion of telehealth services for both coverage and access for patients.

In addition to that, for those who are particularly frail or have comorbid conditions or are immune compromised, as many of these patients are, coming into clinic can be quite a burden. So having this care, especially for those vulnerable populations, not to mention those who have to travel a great distance, is quite meaningful. We did observe in our study that approximately 46% or so have to travel about an hour or more to get to the cancer clinic which is significant. So this would obviously reduce that burden as well. So we were very pleased to demonstrate those findings and are hoping that these will inform future decision making regarding the rolling coverage of telehealth in the US.