Transforming patient-centered cancer care using telehealth: the MATCHES Center

Abstract

Modern cancer care is costly and logistically burdensome for patients and their families despite an expansion of technology and medical advances that create the opportunity for novel approaches to care. Therefore, there is a growing appreciation for the need to leverage these innovations to make cancer care more patient centered and convenient. The Memorial Sloan Kettering Making Telehealth Delivery of Cancer Care at Home Efficient and Safe Telehealth Research Center is a National Cancer Institute–designated and funded Telehealth Research Center of Excellence poised to generate the evidence necessary to inform the appropriate use of telehealth as a strategy to improve access to cancer services that are convenient for patients. The center will evaluate telehealth as a strategy to personalize cancer care delivery to ensure that it is not only safe and effective but also convenient and efficient. In this article, we outline this new center’s research strategy, as well as highlight challenges that exist in further integrating telehealth into standard oncology practice based on early experiences.

Over the past 3 decades, the landscape of cancer care delivery has undergone a consequential transition from predominantly inpatient care to a more outpatient-focused approach (1,2). This shift has been driven by several factors including advancements in medical technology, the expansion of oral and injectable treatments, targeted therapies with larger therapeutic indices, improved supportive care, and a growing emphasis on patient-centered care. The emergence of telehealth as a cancer care delivery strategy now presents an opportunity for yet another transformation—the potential for a broader spectrum of cancer care to be administered at home. Individuals with cancer typically dedicate an average of 16 hours per month over a 4- to 5-day period to engage in activities related to their anticancer treatment (3). Cancer care is time consuming, demanding considerable social support, scheduling flexibility, and financial resources (4). As therapeutic options have expanded, patients are requiring extended courses of treatment, which augment the importance of these burdens. As a result, evaluating strategies such as telehealth that may support patients’ ability to tolerate longitudinal care becomes more important.

Following the onset of the COVID-19 pandemic, the utilization of telehealth services surged from less than 1% of all Medicare outpatient encounters (5) to comprising 29% of care in 2022 (6). Although previous studies have illustrated the effectiveness of telehealth in areas like genetic counseling (7-13), survivorship (14,15), and cancer risk reduction, such as smoking cessation (16), there are limited data on the impact of telehealth in the field of cancer medicine (17), which is distinguished by high acuity levels and complex needs. In response to this gap, the American Society of Clinical Oncology has, in its interim position statement on telehealth, called for research to determine the efficacy of emerging telehealth models in clinical care (18). Consequently, the Memorial Sloan Kettering (MSK) Making Telehealth Delivery of Cancer Care at Home Efficient and Safe (MATCHES) Telehealth Research Center, designated as a National Institute of Health (NCI) Telehealth Research Center of Excellence (TRACE) supported by the Cancer Moonshot initiative, has set out to identify the role of telehealth in oncology care and establish best practices for its implementation (Figure 1). The TRACE initiative aims to fund multiple centers focused on: rapidly developing the evidence necessary to inform equitable telehealth use across the cancer care continuum, creating innovative approaches to improve cancer care delivery, and evaluating and guiding policy.

Figure 1.

Conceptual diagram of the MATCHES Telehealth Research Center. MATCH-IO = MAking Telehealth- delivery of Cancer care at Home Effective and Safe- Immunotherapy; MATCH-UP = MAking Telehealth- delivery of Cancer care at Home Effective and Safe- Upscaled services Protocol.

MATCHES is primarily focused on examining the use of telehealth for patients undergoing active cancer treatment. The challenges unique to cancer care—stemming from the severity and morbidity of the disease; the considerable toxicity potential of treatments- and the frequent need for intense psychosocial discussions regarding prognosis, goals of care, and end-of-life priorities—make the study of telehealth in this context crucial. Despite the widespread adoption of telehealth during the pandemic (5), there is still considerable debate about the most suitable setting for delivering cancer care along with multiple barriers hindering its sustained and expanded use for cancer patients (19-23). American Society of Clinical Oncology’s telehealth in oncology standards and practice recommendations suggest that certain types of visits may be better suited to telehealth, such as medication management, pretherapy evaluations, and discussions of results. However, delivering a new cancer diagnosis or treatment plan may be more effectively done in person (24). This sentiment is shared by oncologists who express openness to integrating telehealth into specific aspects of patient care. Still, concerns linger regarding visits that require a strong patient-clinician connection (25,26) and the absence of a physical exam (19,23,25,26). Despite these potential risks, telehealth provides an opportunity to alleviate the burden on patients and their families, who often face the impact of frequent, time-intensive visits to health-care facilities (3,27), along with associated hidden costs like travel, possible overnight stays, parking fees, and lost work productivity (28-30).

The mission of the MATCHES Telehealth Research Center is to advance the science of precision care delivery by tailoring various aspects of telehealth, including but not limited to the type, location, and timing of visits to individual patients based on their specific needs and circumstances.

Our goal is to develop analytic approaches that support personalized care, employing advanced methods in data science and machine learning. Additionally, we strategically design pragmatic trials to test innovative approaches to home-based care. We aim to leverage these findings to advocate for increased access to telehealth and other interventions that promote home-based care, particularly as Health and Human Services considers policies for payment of telehealth services beyond December 31, 2024 (31). In this article, we outline our center’s strategy and shed light on challenges in further integrating telehealth into standard oncology practice based on our early experiences.

MATCHES center overview

Below we describe 4 main components of the center: MATCH-BOX, MATCH-UP (MAking Telehealth- delivery of Cancer care at Home Effective and Safe- Upscaled services Protocol), MATCH-IO (MAking Telehealth- delivery of Cancer care at Home Effective and Safe- Immunotherapy), and MATCH-LIGHT.

MATCH-BOX: a research commons for creating telehealth data

To establish telehealth best practices in oncology, we are creating MATCH-BOX, a comprehensive data analytic environment. The platform incorporates diverse patient, disease-related, and encounter-level data to facilitate research. Our focus includes identifying biomarkers for cancer care delivery and determining when remote telehealth or in-person care is safer and preferable based on patient and disease factors. We will assess indicators for telehealth effectiveness, acceptability, adoption, and sustainability. MATCH-BOX will also address systematic bias in telehealth service use, ensuring equitable access for diverse patient groups. Our goal is to utilize MATCH-BOX data to identify and overcome barriers and systemic obstacles in cancer care. This includes developing tools such as implementation guides for telehealth interventions, oncology-at-home programs, best practices, and outcome measurement tools. Furthermore, although not part of the initial MATCHES’ primary aims, the robust data collected retrospectively and prospectively will help investigators conduct necessary cost-effectiveness analyses of various telehealth approaches. These analyses will be critical in informing policy and developing sustainable care delivery programs. Although MATCH-BOX is a research commons developed and maintained by the MATCHES center, it will be available on request to other researchers with relevant research questions as approved by our data use and publication committee.

MATCH-UP: a cluster-randomized pragmatic trial of MSK@home for patients with prostate or breast cancer receiving hormone therapy or select oral chemotherapies

The current care model requires regular clinic visits for monitoring, laboratory testing, imaging, and treatment leading to substantial time and financial burdens. To address this, we will initiate an unblinded hybrid type I cluster-randomized pragmatic trial to compare MSK@Home with usual care for patients with prostate and breast cancer receiving hormone therapy. MSK@Home integrates enhanced services including 1) access to telehealth appointments, 2) home-based labs, 3) treatment at home, and 4) vital sign monitoring at home. Treatment at home involves the provision of self-administered medications supported by nurse-to-patient telehealth visits. The goal of this project is to overcome a key telehealth challenge by reducing reliance on cancer centers for routine clinical needs. Although telehealth facilitates audiovisual communication between patients and clinicians, in-person visits to clinics remain central because of on-site requirements for services like bloodwork and vital sign monitoring. The hypothesis is that MSK@Home is efficient, effective, safe, and equitable and can provide patients and their care teams with the resources required for productive interactions that achieve shared goals. MATCH-UP will measure patient and clinician telehealth experiences during active treatment, offering insights on care quality, addressing barriers, illuminating opportunities for refinement, and identifying predictors of success or failure. To launch this institution-wide pragmatic trial, we are actively pilot testing each hybrid service within the MKS@Home portfolio, ensuring we gather preliminary data on service context and patient and clinician perspectives regarding the appropriateness and acceptability of each service, as well as the global feasibility. We will modify each hybrid service as necessary prior to final launch of the pragmatic trial.

MATCH-IO: a single-arm pilot trial of MSK@home for patients receiving pembrolizumab immunotherapy for solid tumors

Typically, single-agent immunotherapy involving pembrolizumab is administered through outpatient infusions every 3 weeks (32). However, the US Food and Drug Administration has recently granted accelerated approval for a less frequent dosing schedule, extending the interval to every 6 weeks (33). This adjustment aims to reduce the number of visits to infusion centers, minimizing the time and financial burden on patients and decreasing health-care costs for cancer centers. Despite this approval, the adoption of the extended interval dosing remains low, accounting for less than 40% of all infusions, as clinicians prefer the 3-week monitoring to identify and manage potential toxicity early (34).

Presently, the MATCH-IO study is investigating the safety and efficacy of in-person immunotherapy visits every 6 weeks, supplemented by interim telehealth toxicity assessments, compared with the standard 3-week infusion during in-person visits. The study incorporates enhanced telehealth delivery components, including the use of remote monitoring devices and at-home phlebotomy services as clinically indicated. The outcomes are evaluated based on the Institute of Medicine’s dimensions of care quality, with the primary focus on efficiency, measured as the proportion of face-to-face clinic visits per year. Additionally, safety, effectiveness, equity, and preferences of patients and clinicians are considered.

MATCH-LIGHT: a training unit to equip MSK investigators from diverse backgrounds with resources, skills, and mentorship to conduct telehealth research

The monthly MATCH-LIGHT seminars and study design workshops center around telehealth and related research themes. Annually, we invite external speakers to participate in 5-10 sessions including members from other NCI P50-TRACE centers. For example this year’s seminars have delved into topics such as oncology hospital-at-home interventions, decentralized clinical trials, and digital health equity and access. Furthermore, we are dedicated to training multidisciplinary researchers equipping them with the skills necessary to continually advance the field of precision care delivery.

Telehealth implementation challenges: early lessons learned

The MATCHES research program presents a comprehensive, multidisciplinary initiative to deepen our understanding of how telehealth influences cancer treatment. Additionally, we aim to devise and test new strategies that utilize telehealth and remote monitoring technologies, ultimately enriching the patient-centered aspects of oncology care. Despite the promise of telehealth, ongoing barriers impede its seamless integration as a pivotal component in care delivery and the pursuit of our research goals. Our targeted research efforts will pinpoint areas necessitating policy intervention and refine guidelines to successfully implement telehealth approaches thereby fostering more effective cancer treatment.

Below are 3 narratives derived from our collective experiences, based on real-life situations. These vignettes have been selected to illuminate the complex challenges and insights acquired through the integration of advanced telehealth practices into clinical settings, with a particular focus on infrastructure, equitable access, and the obstacles related to policy and reimbursement barriers.

Scenario 1: Need for dedicated resources for digital navigation support

Patient scenario: Mr D, a man aged 67 years, is undergoing treatment for castration-sensitive metastatic prostate cancer with continuous androgen deprivation therapy in addition to abiraterone and prednisone. Notably, he serves as the primary caretaker for his wife, who has multiple sclerosis and requires frequent office appointments. This caregiving responsibility makes it challenging for Mr D to attend onsite visits to the clinic. He opted to participate in the MATCH-UP pilot, offering him the convenience of receiving most of his care at home. In the initial weeks of the pilot study after multiple video calls to set up and orient Mr D to the device, he noted that his home blood pressure readings were higher than the values usually recorded during his clinic visits. The clinical staff were uncertain about the accuracy of the blood pressure readings from the home device. Ultimately, Mr D had to visit the clinic, revealing that the cuff that came with the home blood pressure monitoring device was too small for accurate blood pressure measurements. A digital navigation team knowledgeable about home monitoring devices could have hastened the resolution of the issue, lightened the workload on the clinical staff, and possibly prevented the need for the patient to travel on-site.

Telehealth faces many constraints primarily due to the absence of an optimized infrastructure to support it. In contrast to in-person clinic visits, telehealth sessions require additional resources to assist patients in setting up calls and troubleshooting potential issues. As such, clinical staff may find themselves assuming the role of an information technology professional. Similar challenges arise when implementing remote monitoring devices to collect vital sign measurements from patients’ homes. Early on, we identified 3 critical issues: 1) the absence of a dedicated team at MSK to provide optimal support for patients and clinical teams in using remote monitoring devices, 2) the substantial efforts needed to train (and retrain) staff and patients on the correct utilization of these devices, and 3) the frequent necessity for in-person visits to set up patients and clinical teams for success with telehealth and remote monitoring initiatives.

To address this, we formed a team of clinical staff and informaticians crucial for developing a strategy to onboard and train patients and staff on device usage and troubleshoot technical problems. Challenges arose in developing this team, as nonexempt research lacked research staff support, and this work fell outside standard clinical care, limiting access to resources. Although ongoing exploration is essential for refining recommendations, clinics must have physical and financial resources for the successful implementation of telehealth initiatives. Support structures may involve adopting a facility-fee model, aiding clinicians in deploying and maintaining telehealth platforms, or contracting with external vendors. Smaller, community-based, or rural oncology clinics may require substantial grants or government-based support to facilitate the integration of telehealth. Finally, we believe it is critical to share our center’s learnings around telehealth and the implementation of digital care innovations among not only the oncology community but also other fields, such as cardiology and nephrology, that additionally require close patient monitoring to benefit all patients and continue to move all health-care delivery forward.

Scenario 2: Equity and access

Patient scenario: Ms P is a woman aged 82 years with recurrent lung adenocarcinoma with a high tumor mutational burden. She has limited support at home and is interested in participating in the MATCH-IO pilot as it will reduce the number of visits to the cancer center while also providing her with essential services at home, including home phlebotomy and vital sign monitoring. The MATCH-IO care plan appeals to her; however, she is hesitant about enrolling as she lacks a digital device to enable participation in the televisits and patient-reported outcome assessments. After discussing the situation with her adult daughter, she has decided to participate in MATCH-IO with her support. She has committed to being present at the telehealth visits and to assist her with the patient-reported outcome assessments. A member of the MATCHES team coordinated care with the patient’s daughter to provide education on the intervention and the technology components. The daughter expressed appreciation for the intervention because even though she has committed to attend televisits, it still requires less time than accompanying her to in-person clinic visits.

Although telehealth holds the promise of mitigating geographic, physical, and socioeconomic barriers faced by many patients attending in-person clinics, studies suggest it might exacerbate disparities (35). Access to technology and broadband internet is not the sole requirement; patients must also possess the sensory and technical skills for executing telehealth encounters, contributing to what has been termed the digital divide (36-38). This divide can have profound consequences for patients with limited socioeconomic resources (39) and physical and cognitive disabilities (40,41) and for non-English speakers (42,43), who already confront challenges in participating in cancer care. For our pilot study initiatives, we have proactively provided multiple loaner devices, specifically iPads, to patients who might otherwise lack access to telehealth and our research initiatives. Notably, the participation of these patients has yielded invaluable insights, emphasizing the need for in-person support during onboarding. In response, we are integrating in-person support for patients and caregivers to provide the necessary technology education, ultimately empowering them for future success with telehealth-based care. There has been a call for health systems to consider a formal role of a patient-facing digital navigator to serve functions such as providing culturally competent patient and caregiver education on the operation of the technology and addressing patient barriers in access to the technologies (44).

Notably, the new 2024 Medicare fee schedule proposal has included reimbursement for patient navigation services, creating the opportunity to similarly fund critical digital navigation programs (45). Additionally, Medicare has already put forth a reimbursement framework for remote monitoring, which, if used appropriately, could provide the necessary funds to support remote monitoring programs and to assist patients with limited access to or ability to use technology (46). However, payers may need to reconsider their current reimbursement rates because current levels inadequately provide for the services necessary to sustain digital navigation for patients with limited access to technology. This challenge is likely greater in the community where there might not be the scale necessary to compensate for those patients needing extra time and support for digital efforts. Public-private partnerships with not-for-profit community organizations with expertise in digital navigation in underrepresented communities might be another means of achieving improved access. Furthermore, valid concerns persist regarding clinicians’ ability to deliver high-quality culturally competent care through telehealth, especially during impactful or sensitive clinical conversations. As such, our MATCH-LIGHT seminar series is dedicated to developing training programs that not only assist clinicians and researchers in delivering culturally competent care via telehealth but also actively train the next generation to take on this responsibility.

Scenario 3: Policy and reimbursement barriers

Patient scenario: Mr Z, a man aged 71 years, diagnosed with very high-risk localized prostate cancer, is undergoing a treatment plan that includes 2 years of androgen deprivation therapy augmented with abiraterone and prednisone complementing curative intent radiation therapy. Residing in Pennsylvania, approximately 2 hours away from the MSK clinic in New Jersey, Mr Z faces complications such as transaminitis and hypertension, both common side effects of abiraterone. His frequent need for lab checks (every 2 weeks) and vital sign monitoring (weekly) makes him an ideal candidate for the MATCH-UP pilot. Despite his suitability, state-licensure restrictions prevent his clinician, who is licensed in New Jersey, from providing him care via telehealth in Pennsylvania. Fortunately, a member of the research team secured a Pennsylvania clinical license, although at a considerable cost in terms of money and time required to complete the required licensure.

The policies enacted by the Centers for Medicare and Medicaid Services that relaxed state medical licensure requirements and ensured parity of reimbursement for remote visits have facilitated the adoption of telehealth. A recent omnibus bill passed by the US Congress in December 2022 extends these telehealth provisions for an additional 2 years, although it leaves uncertainty regarding interstate licensing requirements and reimbursement (47). Currently, states exhibit varying restrictions on telehealth practices with a majority of states limiting access to providers with state-issued licenses. Further complicating interstate clinical visits is the lack of clarity from some medical liability providers regarding coverage for telehealth services across state lines (48). Consequently, patients and clinicians across state borders are limited in their ability to conduct telehealth visits. Our MATCH-IO and MATCH-UP pilot projects underscore that these restrictions particularly affect patients facing significant geographic barriers to care, for whom telehealth could offer sizable benefits. Furthermore, the future of telehealth remains uncertain, as additional legislation will be required by December 2024 to sustain current access to telehealth for patients nationwide. The results generated from the MATCHES research center will be used to advocate for state and national policies that increase access to telehealth and cancer at-home initiatives, including legislation that allows for Medicare patients to receive care across state lines.

Telehealth presents an opportunity to enhance cancer care and make it feasible for patients to tolerate the longitudinal treatments that have been shown to improve survival in clinical trials. This collaborative center will investigate whether telehealth can be harnessed to make it feasible and safe to deliver a larger proportion of cancer care in the convenience of patients’ homes. This work aligns with the recently released National Cancer Plan and priorities noted by patient and community-based stakeholders (47). The National Cancer Plan prioritizes delivery of optimal and equitable care to all patients by addressing the time and cost barriers that often prevent the delivery of ideal care to individuals from underresourced or marginalized communities (49). The MATCHES Telehealth Research Center, supported by the NCI TRACE initiative, strives to redefine the realm of cancer care delivery leveraging novel research methods, data science, and pragmatic clinical trials to define the role of telehealth in personalized cancer care delivery. Our program will develop protocols and research initiatives that explore the use of telehealth throughout the spectrum of cancer care including patients of various demographics, diseases, and stages. The center provides essential data to support policy and infrastructure changes necessary for the effective sustainability of novel care initiatives.

Data availability

No new data were generated or analyzed for this manuscript.

Author contributions

Katherine Panageas, DrPH (Conceptualization; Data curation; Funding acquisition; Investigation; Methodology; Project administration; Supervision; Writing—original draft; Writing—review & editing), Peter Stetson, MD, MA (Conceptualization; Funding acquisition; Investigation; Methodology; Project administration; Resources; Writing—review & editing), Susan Chimonas, PhD (Writing—review & editing), Yuan Chen, PhD (Writing—review & editing), Yasin Khadem Charvadeh, PhD (Writing—review & editing), Camila Bernal, MPH (Project administration; Resources; Writing—original draft; Writing—review & editing), Kiana Chan, MPH (Investigation; Project administration; Writing—review & editing), Deborah Schrag, MD, MPH (Conceptualization; Funding acquisition; Investigation; Methodology; Project administration; Resources; Writing—review & editing), Kristina Stevanovic, BS (Project administration; Writing—review & editing), Chris Liebertz, NP (Investigation; Project administration; Resources; Writing—review & editing), Fernanda Polubriaginof, MD PhD (Conceptualization; Funding acquisition; Project administration; Resources; Writing—review & editing), Gilad Kuperman, MD PhD (Conceptualization; Data curation; Funding acquisition; Project administration; Writing—review & editing), Allison Lipitz-Snyderman, PhD (Conceptualization; Data curation; Funding acquisition; Writing—original draft; Writing—review & editing), Bobby Daly, MD, MBA (Conceptualization; Data curation; Formal analysis; Funding acquisition; Supervision; Writing—original draft; Writing—review & editing), Erin Bange, MD MSCE (Conceptualization; Data curation; Methodology; Project administration; Supervision; Writing—original draft; Writing—review & editing), Sahil Doshi, MD (Data curation; Investigation; Project administration; Writing—review & editing), and Michael Morris, MD (Conceptualization; Funding acquisition; Investigation; Project administration; Supervision; Writing—original draft; Writing—review & editing).

Funding

This study was supported in part by the National Institutes of Health and National Cancer Institute Cancer Center Support Grant P30 CA008748; MATCHES P50 CA271357 and T32 CA275764 (SDD).

Monograph sponsorship

This article appears as part of the monograph “Integrating Telehealth into Cancer Care Delivery: Advancing a National Research Agenda,” supported by the National Cancer Institute.

Conflicts of interest

MM reported receiving personal fees from Lantheus, AstraZeneca, Amgen, Daiichi, Convergent Therapeutics, Pfizer, ITM Isotope Technologies, Clarity Pharmaceuticals, Blue Earth Diagnostics, POINT Biopharma, Telix, Progenics, and Z-Alpha. He receives salary support from the National Cancer Institute.

EB disclosed consulting fees from Flatiron Health.

DS disclosures research funding from Grail to Dana Farber Cancer Institute; personal fees for editorial services from JAMA.

RD discloses grant support from the National Institutes of Health; participation on a data safety monitoring board or advisory board with Varian Medical Systems; and stock or stock options in Roche.

All of the other authors disclose no potential conflicts of interest.