Telemedicine in the cancer continuum: the two digital dimensions of Continuity of Care

The second phase of the Sharing Progress in Cancer Care (SPCC) project on Telemedicine in Cancer Care started with the “Telemedicine in Cancer Care Continuum: implementation and integration”, an on-line conference which took place on 6-7 May 2022 with the participation of world-renowned experts. Held in collaboration with the American Society of Clinical Oncology (ASCO), the second phase of the project focused on how to overcome both barriers and limitation in order to create the best conditions to implement and integrate Telemedicine models and applications over the Cancer Care Continuum. This to have a real and effecting improvement on the cancer care pathway, first of all, for patients and their relatives, but also for the whole health system, in terms of cost-effectiveness, efficiency and sustainability.

In this “continuum” of the cancer care pathway, one of the critical issues (and opportunity) is represented by the continuity of care since it is concerned with quality of care over time. But there are two important dimensions on this. Traditionally, continuity of care is idealized in the patient’s experience as a ‘continuous caring relationship’ with an identified health care professional team composed by different providers who, through integration, coordination, and the sharing of information, are cooperatively involved in ongoing health care management process toward the shared goal of high quality, cost-effective medical care. Continuity of care may, therefore, be viewed from the perspective of either patient or provider. In the second, continuity in the experience of care relates conceptually to patients’ satisfaction with both the interpersonal aspects of care and the coordination of that care.

In the first dimension, Telemedicine solutions can address the limitations imposed by the conventional modes of care delivery, namely, time and space, and have a positive impact on cancer care efficiency and integrate processes and models of care management.

The pandemic itself has proved the critical importance of digital health solutions to improve and to advance care and helping to increase access in the constraints that were presented by the pandemic, ensuring continuity of care and safety for patients and for the workforce. And we have seen rapid deployment and expanded use of telemedicine and remote monitoring of symptoms during routine cancer care practices as well, as underlined by Andreas Charalambous, Associate Professor of oncology and palliative care at the Cyprus University of Technology, Adjunct Professor at the University of Turku in Finland, and President of the European Cancer Organization, during the opening of the second day of the conference.

Traditionally we have measured Patient-Reported Outcomes with paper questionnaires but now the time has come to use wider in common clinical practice remote monitoring, allowing the patient to use a mobile phone, computer, or other devices. The flow of information coming from the patient and that in real-time can be implemented in the Electronic Health Record and can generate alerts that can be managed by the nurses and by oncologists to manage the problems, the symptoms referred by the patient. So, this is not only a way to improve the quality of care and quality of life for the patient, but also to improve thee management of cancer patients among the health providers.

However, as Massimo Di Maio, medical oncologist at the University of Turin, Italy, showed in his presentation, this kind of clinical technological management approach has many challenges not only from a technical point of view but also, in terms of physicians’ involvement and awareness, and in terms of lack of awareness by hospital management of the importance of incorporating ePROs into medical health records. And, last but not least, the need for education of patients and caregivers to fill in the questionnaires and the ePROs, and the need of education for clinicians on how to manage patients’ questionnaires, patients’ answers, as Remote patient monitoring can be also an important tool to ensure continuity of care for patients after the phase of active treatment, for example, and it provides a cost-effective means of ensuring the person’s needs are being identified and addressed when they no longer have frequent interactions with the cancer care team. And that’s why patient-reported outcome measures and data can be really helpful to support care decisions and to make sure that patients feel looked after in the long-term without those frequent interactions.

Digital solutions and the use of patient-generated data in continuity of care can really help with a learning cycle of the system, improving efficiency of cancer care through cost saving on wastage and through opportunities to prevent overtreatment, as presented by Alex Filicevas, President of All.Can International and Executive Director of the World Bladder Cancer Patient Coalition, during his presentation on efficiency and telemedicine in cancer care. Regular monitoring of patients using patient-reported outcomes can really help the team make the necessary adjustments to treatment plans or cease given treatment, thus benefitting both the patient and the healthcare system. And we can really utilize these data to improve the efficiency of systems, the efficiency in care, and especially the outcomes for patients.

The second dimension of the continuity of care relates to patients’ satisfaction experience with both interpersonal aspects of care and coordination of that care, some ethical issues arise from the use of telemedicine. So that’s why the new patient-doctor digital relationship has to be assessed also from an ethical perspective in order to have the better option of care and setting for patients and their health providers, considering the importance of empathy and mutual trust between them. How to deal with the “human side of telemedicine” has been the core of presentation by one of the chairs of the conference, Sana Al Sukhun, Medical Oncologist, Director of Al Hayat oncology practise in Amman, Jordan. Currently chair of the International Affairs Committee of the American Society of Clinical Oncology, ASCO. Sharing informed decision-making process and appropriate recommendations improve patient outcome, and usually, this can be achieved through communication, direct communication, history taking, and physical examination is very important to establish this relationship appropriately and help patients improve their outcomes. Nevertheless, through digital communication platforms, even in the best setting where the infrastructure for telehealth is established, for some activities or phases of continuity of care there are potential concerns to be aware of in order to set and manage them in a proper way. For example, the challenge when giving a telehealth counselling opinion. How can clinicians explain critical issues to patients, especially if they do not have a previous relationship with those patients? They can only provide help to deal with their complaints, control their pain, reduce their nausea, keeping them comfortable, but unfortunately, are unable to provide treatment that could prolong life. That would be quite difficult to discuss in a telehealth visit, if the clinician does not have a previous strong relationship, and a mutual understanding with his patients. It’s very hard for physicians to recommend not to do anything and just go on supportive care from a distance, that can be discussed empathetically, with our patients in a face-to-face visit, especially if surrounded by their caregivers. But from a distance, especially for a second opinion or consult most clinicians find it hard to face patients and just tell them there isn’t much more to be done to prolong their life. And that’s why many societies, including the American Society of Clinical Oncology, in their recommendations when discussing telehealth and oncology emphasize that in-person consultations are preferred for initial consultations to build mutual trust, important whenever we are delivering key-information, diagnosis, treatment plan, when we are changing the treatment plan in cases of relapse or progression, or whenever we are making critical decisions such as to stop cancer treatment and go only with supportive care to palliate symptoms and help patients through end of life decisions. Despite all these challenges, telemedicine is a necessity. We have witnessed its importance and it’s helped in the last couple of years during the pandemic. And probably, it is here to stay. That’s why we need, as Sana Al Sukhun said at the end of her presentation, to define a morally justifiable trade-off between a less satisfactory relationship between physician and patients and improved availability and access to medical care, also in terms of its continuity.