Scalable Telehealth Cancer Care: integrated healthy lifestyle program to live well after cancer treatment

Abstract

Northwestern University’s Center for Scalable Telehealth Cancer Care (STELLAR) is 1 of 4 Cancer Moonshot Telehealth Research Centers of Excellence programs funded by the National Cancer Institute to establish an evidence base for telehealth in cancer care. STELLAR is grounded in the Institute of Medicine’s vision that quality cancer care includes not only disease treatment but also promotion of long-term health and quality of life (QOL). Cigarette smoking, insufficient physical activity, and overweight and obesity often co-occur and are associated with poorer treatment response, heightened recurrence risk, decreased longevity, diminished QOL, and increased treatment cost for many cancers. These risk behaviors are prevalent in cancer survivors, but their treatment is not routinely integrated into oncology care. STELLAR aims to foster patients’ long-term health and QOL by designing, implementing, and sustaining a novel telehealth treatment program for multiple risk behaviors to be integrated into standard cancer care. Telehealth delivery is evidence-based for health behavior change treatment and is well suited to overcome access and workflow barriers that can otherwise impede treatment receipt. This paper describes STELLAR’s 2-arm randomized parallel group pragmatic clinical trial comparing telehealth-delivered, coach-facilitated multiple risk behavior treatment vs self-guided usual care for the outcomes of reach, effectiveness, and cost among 3000 cancer survivors who have completed curative intent treatment. This paper also discusses several challenges encountered by the STELLAR investigative team and the adaptations developed to move the research forward.

Early detection and treatment advances continue to multiply the number of cancer survivors in the United States, which is expected to reach 22.5 million by 2032 (1). Survivorship highlights the necessity for quality cancer care to include disease treatment and morbidity prevention plus promotion of long-term health and quality of life (QOL) (2-5). Prevalent behavioral risk factors—insufficient activity, obesity, and smoking—heighten survivors’ odds of new cancers, recurrences, cardiometabolic comorbidities, premature mortality, diminished QOL, and increased medical costs (6,7). National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology recommend positive diet and activity changes and smoking cessation for cancer survivors (8-10), a majority of whom say they want health promotion as part of survivorship care (11,12). However, cancer survivors cannot readily access treatment for modifiable risk behaviors (health promotion) because it is not integrated into usual cancer care. Telehealth (providing health care remotely by telephone or audiovisual technology) offers advantages to deliver health promotion. Even before the pandemic, telehealth-delivered risk behavior treatment was established as effective as face-to-face outcomes (5,13,14).

Techquity is the strategic development and use of technology, such as telehealth, to advance health equity (15). One well-recognized “digital divide” is underresourced patients’ lack of access to mobile technologies, although this gap is closing. With relatively little variation among racial or ethnic groups, 85% of US adults own a smartphone. Ownership rises to 96% for those aged 18-49 years. Fewer (61%) older adults own a smartphone, but ownership is increasing rapidly (16), with 90% owning a computer and using the internet (17). Insufficient technological skills and attitudes needed to benefit fully from digital tools create another potential digital divide. Although some patients can reduce behavioral risks using technology alone, more commonly, there is minimal change without human support. Coupling human support with digital tools yields clinically meaningful risk factor improvement more reliably (18,19).

Northwestern University’s Scalable Telehealth Cancer Care (STELLAR) Center builds on techquity’s premise that telehealth can help mitigate health disparities and connect cancer survivors with the health-care system to engage with its different sectors. STELLAR is 1 of 4 National Cancer Institute and Cancer Moonshot–supported Telehealth Research Centers of Excellence, designed to study telehealth’s utility across the entire cancer care continuum (20). Grounded in the ecological model (21) and sociotechnical systems frameworks (22), STELLAR examines whether telehealth treatment of multiple risk behaviors can be integrated equitably, affordably, and scalably throughout Northwestern Medicine’s 11 hospitals and 52 oncology clinics to improve cancer survivors’ health outcomes and QOL.

Multiple risk behavior change

Risk behaviors are leading modifiable contributors to the global cancer burden (23). Despite their adverse health effects, behavioral risk factors are prevalent among adult cancer survivors: 69% are overweight or obese, 34% engage in no physical activity, and up to 14% smoke (24). Moreover, 52% exhibit 2 or more behavioral risk factors, and the odds of adverse health events rise as the number increases (25,26). Patients with low socioeconomic status also have more risk behaviors and lower odds of being offered preventive care (27). Behavioral counseling is gold standard treatment for physical inactivity, obesity, and (in combination with cessation pharmacotherapy) smoking (13,14,28,29).

Despite debate about the best way to target multiple risk behaviors, evidence suggests few or no adverse effects, and possibly benefits, from addressing up to 4 behaviors simultaneously (30,31). Simultaneous treatment is also more efficient (32). However, no validated protocols exist to treat co-occurring obesity, insufficient activity, and smoking simultaneously, particularly among cancer survivors. Also, it is unusual for a single health professional to have expertise treating more than 1 risk behavior. An unfortunate consequence is that survivors who seek treatment for multiple risk behaviors usually need to see specialists at different clinics.

Recognizing the inefficiency of delivering a different treatment for each of several comorbid disorders, Barlow et al. introduced the unified treatment protocol (33). A unified protocol integrates treatment techniques that address shared psychosocial mechanisms underlying diverse behavioral phenotypes (33). Smoking, overeating, and excess sedentary use of screen-based media are all behaviors triggered by environmental cues and are sometimes used to self-administer pleasure. Accordingly, we designed STELLAR’s facilitated treatment to apply effective behavior change techniques (motivational interviewing, goal setting, realistic outcome expectations, self-monitoring, feedback, self-efficacy, problem solving, support, accountability) applicable to all 3 behaviors to help individuals learn more adaptive self-regulatory skills (34). STELLAR’s facilitated treatment integrates 3 evidence-based interventions, each effective in treating a single risk behavior, into a telehealth-delivered unified protocol that addresses 2-3 co-occurring risk behaviors simultaneously (18,35-37).

Multilevel, sociotechnical framework

From an ecological perspective, most evidence-based treatments to change health risk behaviors target individual level (intrapersonal) determinants (eg, motivation, knowledge, skills). However, barriers and facilitators inherent in life contexts are increasingly recognized as determinants of health habits people acquire and their success in changing them. Interventions attributing responsibility for change primarily to the individual can worsen disparities by blaming marginalized people for attaining less success than those who are better resourced (38). Intervening at more than 1 determinant level redistributes agency for change, balancing it across influences that can be leveraged more equitably. Accordingly, we planned STELLAR’s active intervention to take a multilevel, ecological approach (22). In addition to targeting intrapersonal behavioral determinants, we included interpersonal-level (eg, social support) and institutional-level (eg, health-care delivery system) components.

Figure 1 shows how we conceptualized multilevel ecological influences for the STELLAR program. We posited that the intervention would help survivors lessen their cancer risk behaviors by bolstering their underlying intrapersonal self-regulatory capabilities. We planned for a bachelor-level health promotionist, trained in behavior change coaching and digital technologies, to provide interpersonal support and accountability by delivering an active, technology-supported coaching intervention accessibly via telehealth. Finally, we designed the intervention to use the care delivery system’s institutional technologies to identify survivors with multiple risk behaviors and invite program enrollment. We intended for remote telehealth treatment delivery to maximize patient convenience and minimize interference with clinical workflows and for electronic health record (EHR) communication to digitally elicit support for patient progress from the clinical team.

Figure 1.

Scalable Telehealth Cancer Care (STELLAR) Intervention’s Multilevel Sociotechnical Model. STELLAR’s multilevel intervention combines components that target individual (ie, wireless feedback system), interpersonal (health promotionist, clinician communication), and system levels (electronic health record [EHR] integration). The wireless feedback system reinforces self-regulation. The system transmits data to a health promotionist who provides warm technical support and coaching and conveys patient progress to the clinical team via the EHR.

We used sociotechnical systems theory to conceptualize STELLAR’s implementation (39). The theory posits that productivity and constituent well-being in a multilevel program are best attained by jointly optimizing the system’s human and technical components. The 3 actors STELLAR needs to connect effectively are cancer survivors, health promotionists, and oncology clinical teams who navigate across 2 institutions—one clinical (Northwestern Medicine [NM]) and one academic (Northwestern University) (Figure 1).

STELLAR center aims and organization

The center has 3 aims: 1) implement an integrated telehealth risk behavior assessment and treatment program for cancer survivors across an 11-hospital system; 2) evaluate the reach, effectiveness, and care costs of a telehealth-delivered multiple risk behavior treatment program for cancer survivors compared with enhanced usual care in a 2-arm randomized parallel group pragmatic trial; and 3) disseminate findings and resources (eg, unified treatment protocol, digital tools, lessons learned).

Figure 2 diagrams the center’s organization. To progress toward STELLAR’s pragmatic trial, we launched 3 pre-implementation activities: 1) planning, 2) Rapid Cycle Pilot 1 with survivors, and 3) Rapid Cycle Pilot 2 with clinical team members. Below, we describe challenges encountered and adaptations made across the 3 phases.

Figure 2.

Center organization. Three cores support STELLAR’s Pragmatic Trial: Administrative Core, Research Methods Core, and Clinical Practice Network. The Administrative Core coordinates input from multiconstituent advisory groups: internal, external and community advisory boards, policy advisory group, and equity committee. These groups suggest strategies to increase STELLAR’s acceptability, equity, and sustainability at Northwestern Medicine (NM) and scalability beyond NM. The Administrative Core also accelerates dissemination and facilitates engagement opportunities for trainees and early stage investigators interested in telehealth cancer care. The Research Methods Core oversees development and maintenance of the Unified Protocol, electronic health record and mobile technology system tools, and algorithms that pull data from NM’s Enterprise Data Warehouse, a clinical repository of all NM patients that is updated nightly. Clinical Practice Network facilitates pragmatic trial implementation throughout NM’s 11 hospitals. Clinical Practice Network leaders advise on how to customize health promotion treatment delivery for cancer-specific care workflows at each setting. STELLAR’s Clinical Practice Network leverages a network developed between 2018 and 2020 for a Moonshot initiative to deliver smoking cessation services to cancer patients (47). The Pragmatic Trial is preceded by 2 Rapid Cycle Pilots and a Field Trial and is followed by a Dissemination Pilot.

 

Planning

Initial discussions concerned 2 challenges related to 1) identifying and recruiting eligible survivors, and 2) providing clinical teams with additional human assets needed to deliver telehealth coaching for risk behavior change.

Acquiring actionable information about risk behaviors

The 3 risk behaviors differed in the survivors’ EHR documentation. Survivors with overweight or obesity could reliably be identified based on routine body mass index recording at clinical encounters. Smokers usually were identifiable either because the physician added smoking to their EHR problem list or because the patient self-reported smoking on a screening questionnaire. In contrast, physical activity information was not available. To close that gap, physical activity assessments are being added to the patient’s previsit screener. The more complete risk behavior documentation will provide 3 ways to identify survivors with multiple risk behaviors: 1) patient report via previsit screener, 2) electronic data warehouse search, and 3) clinician referral.

The current absence of complete risk behavior information in the EHR has had 2 implications for STELLAR’s research design. First, the planned trial will only qualify as maximally pragmatic by Pragmatic Explanatory Continuum Indicator Summary 2 (40) criteria once the functionality to find and enroll those who need risk behavior treatment becomes usual cancer care (a sustainable policy we hope STELLAR will establish at NM). Second, the inability to identify those with multiple risk behaviors from the EHR obligates prerandom assignment consent rather than the more usual postrandom assignment consent in pragmatic trials. Trials that can determine patient eligibility from EHR data can randomly assign patients to active intervention or control and obtain consent only from those in the active treatment arm (reducing expense and staff patient burden). Control patients continue with usual care and may remain unaware of trial participation. Outcome data for patients in both arms can be obtained from the EHR.

Scalable, sustainable system assets for risk behavior change

Research indicates that oncologists want health promotion services for their patients but lack time, expertise, and resources to counsel about risk behavior change (41,42). Assigning responsibility for health promotion to existing clinical team members might seem ideal but, at existing compensation levels, would be unsustainable by third-party payments. STELLAR bolsters physician resources and survivor engagement by adding human (ie, health promotionists) and technology resources (ie, telehealth, digital tools).

Health promotionists, the added human resource, are salaried comparably with community health workers. They are trained in telehealth behavior change coaching and supervised by licensed clinical health psychologists. Working outside clinic space, they provide audio or audiovisual telehealth coaching affordably at current reimbursement rates without disrupting workflow. Health promotionists also provide technical support to help patients overcome digital literacy barriers that could otherwise impede their comfort using telehealth or the wireless feedback system integral to STELLAR’s active treatment (36).

The wireless feedback system, an added technical resource, includes a custom-built native application (app) that participants download to a smartphone or tablet to aid in self-monitoring and self-regulating their behavior. The app gives survivors personalized feedback about progress in changing their targeted risk behaviors and sends the health promotionist real-time data via a custom dashboard. We have used the wireless feedback system to connect health promotionist and participant in prior studies to change weight, dietary intake, physical activity, and smoking (35,36,43). STELLAR adds clinical teams to the connective information flow. Rapid Cycle Pilot 1 informed that expansion.

Rapid Cycle Pilot 1—oncology clinical team

The first pilot study enrolled clinicians, based on the belief that their endorsement of STELLAR will impact survivors’ enrollment and retention. In 17 semistructured interviews, we asked oncologists and other care team members to appraise planned study features. Discussion focused on how to construct the wireless feedback system’s connective link that transmits data from the app and health promotionist’s sessions to clinical teams. We initially planned to convey those data directly into the EHR, where they would autogenerate and transmit patient progress reports to the clinical team. However, the EHR could not presently integrate data from our custom-designed app.

Conveying behavior change data to the clinical team

To find a workaround, we interviewed oncologists and clinic staff about preferred presentation formats and channels to receive patient progress information. Of the shared prototypes, clinicians preferred written reports over sensor data and text about patients’ behavior change over infographics. Reports were considered more actionable during clinical encounters. Although they appreciated historical data, clinicians worried about having insufficient time to review it during a patient visit.

Among the written reports, they preferred a short option (Figure 3) because of its simplicity and ease of interpretation. They could quickly grasp whether patients usually met their behavioral goals (achieving) or did not (not meeting goal) and valued the pithy communication prompts. Most clinicians wished to receive the progress report by an EHR in-basket message 1 or 2 days before a clinic visit. Fortunately, this less technically sophisticated communication strategy was acceptable relative to the fully EHR-integrated tools originally planned. It matched physician preferences and was consistent with health system guidelines for EHR integration of patient-generated data.

Figure 3.

InBasket progress report message to clinical team. Message sent by the health promotionist reports usual success in meeting behavioral goals. Provides prompts for tailored clinician-patient communication.

Heightening clinician buy-in and study engagement

The STELLAR internal advisory board and pilot 1 interviewees recommended adding study features to engage oncologists. Oncologists requested 2 EHR modifications: 1) an EHR referral to STELLAR and 2) the addition of physical activity to the existing screener that assesses smoking.

Equipoise between trial arms

We planned to randomly assign survivors to either active telehealth treatment (STELLAR) or assessment-only control (enhanced usual care) in STELLAR’s pragmatic trial. However, our external advisory board and clinical practice network leaders were concerned that STELLAR treatment was more desirable than usual care (albeit enhanced). Several oncologists voiced hesitancy to advise patients to enroll in a study with 50% odds of getting what one oncologist called “nothing.” To prevent lack of equipoise from augmenting control arm attrition, we renamed the arms facilitated (active treatment) and self-guided (control). We also added an educational orientation session and informational handouts to the control arm.

Navigating between institutions

Some challenges to integration persist. To limit potential liability, the hospital restricts full EHR access privileges to hospital employees who are insured under NM’s coverage. Hence, STELLAR research staff can only access partial EHR functionalities to communicate with NM clinical teams. Fortunately, we planned and are implementing backup strategies. This issue highlights the importance of planning for staff supervisory and regulatory lines of authority when research requires study personnel to work across institutions. Our contracted EHR research builds have at times been delayed, understandably, to prioritize clinical over research needs. Nevertheless, the new tools are being integrated in the pragmatic trial as their programming finishes.

Rapid Cycle Pilot 2—survivors

Patient vs clinician framing—words matter

Early discussions with our cancer center’s patient and family advisory board and pilot 2 participants surfaced strong preferences about vocabulary used to describe STELLAR’s intervention goals. Survivors greatly disliked terminology referencing “risk behaviors” or “changing unhealthful behaviors.” They felt such wording hinted at “blame,” implying their lifestyle choices may have heightened their cancer susceptibility. They strongly preferred STELLAR to use positive language emphasizing survivors’ motivation to regain control over their health after cancer and advocated calling the intervention “health promotion” rather than “risk behavior change.” We scripted patient-facing portions of intervention materials (ie, lessons, health promotionist scripts) according to those principles.

In contrast, oncologists made clear that risk behavior terminology better captured their attention, motivating them to take action to promote patients’ behavior change. As one oncologist stated: “‘Risk behaviors’ mean I need to do something. ‘health promotion’ means the psychologist needs to do something.’” Accordingly, provider-facing materials use risk behavior terminology.

Cancer survivor survey

To verify the feasibility and acceptability of study plans, we surveyed 274 cancer survivors from NM’s central (Chicago) region who had completed curative intent treatment. Results confirmed the presence of cancer survivors with co-occurring risk behaviors: 31% reported 2 or all 3 of smoking, obesity or overweight, and insufficient physical activity, and 26% reported no risk behavior. More than 95% reported ownership and comfort using a smartphone, computer, and internet. Comparable proportions of survivors expressed willingness to meet with a health promotionist by telehealth, share their digital tracking data, and have their behavior change progress shared with their clinical oncology team. These encouraging findings prompted launching the field trial.

Field trial

The short field trial rehearses procedures for the pragmatic trial. A total of 30 NM central region survivors who have 2 or more of STELLAR’s targeted risk behaviors undergo a 2-week version of the facilitated or self-guided arms. The field trial enables verification that the recruitment pathways, random assignment procedure, and wireless feedback system (including app, coach dashboard, and feedback transmission to clinicians) function well, and participants find the intervention and assessment materials acceptable.

Pragmatic trial

Figure 4 displays the pragmatic trial design. To enhance inclusivity and generalizability, the pragmatic trial design has minimal exclusion criteria. Current NM adult patients who have completed curative intent treatment for any cancer (other than nonmelanoma skin cancers) are identified primarily via the electronic data warehouse. We enroll only those with the heightened risk conveyed by 2-3 targeted risk behaviors because STELLAR only has the capacity to enroll 3000 of the NM network’s 70 000 established and 15 000 annual new oncology patients. After screening and informed consent, we randomly assign survivors to the facilitated or self-guided study arm. Main outcomes are reach (primary), health outcomes, and health-care costs, measured by blinded assessors at months 3, 6 (primary end point), 9, and 12 months.

Figure 4.

Patient flow through Pragmatic Trial. Eligible patients are identified via the electronic data warehouse, patient report of risk behaviors via the patient portal, or physician referral via the electronic health system. After screening, consent, and baseline assessment, patients are randomly assigned to either the facilitated or self-guided treatment and complete follow-up assessments. EDW = electronic data warehouse; PRO = Patient Reported risk behavior Outcome; NCCN = National Comprehensive Cancer Network Clinical.

Facilitated treatment

Facilitated treatment consists of 1) videoconference orientation; 2) access to website with 12 lessons (seventh grade literacy level, adjusted for cultural sensitivity) providing strategies for effective behavior change; 3) wireless feedback system; and 4) 16 semiscripted telehealth health promotion sessions (phone or videoconference per patient preference). Treatment also includes health promotionist messages to the oncology team about patient progress toward health behavior change goals, with prompts for clinician-patient communication. Telehealth sessions, averaging 10-20 minutes, occur every other week for 6 months. Between months 6 and 12, a total of 4 unscripted maintenance sessions occur monthly, then bimonthly.

Self-guided treatment

Control self-guided treatment also begins with a videoconference orientation. Then, survivors are asked to read 3 informational handouts: 1) National Comprehensive Cancer Network Clinical Health Promotion Guidelines, 2) curated information and recommendations about the survivor’s risk behaviors, and 3) tailored public and private community resources that support health. Assessments occur on the same schedule as facilitated treatment.

Dissemination pilot

A dissemination pilot study will be launched in the Pragmatic Trial’s final year. The pilot will examine how to successfully implement STELLAR’s health promotion program in more diverse, less well-resourced settings (eg, federally qualified health centers in Chicago) that use similar EHR technology.

Toward techquity: mitigating disparities, bridging digital divides

Telehealth holds the potential to equalize care access and quality for marginalized patients by overcoming geographic and logistical barriers. But, without thoughtful design, technology can create barriers that further marginalize the already underserved. Accordingly, STELLAR’s health promotionists play a critical role. Health promotionists adapt behavioral recommendations to the survivor’s environment and sociocultural context while supporting and holding them accountable to achieve goals. Health promotionists also provide “warm technical support”: reliable, friendly, patient-centered support in the survivor’s native language. Health promotionists offer a bridge across the digital divide for elderly, low-resourced, or non-English speaking patients who are intimidated by digital tools. STELLAR’s health promotionists, fluent in English and Spanish, fill a unique niche that is new to health-care staffing and much needed by patients who use telehealth. By pairing motivational interviewing with digital training, the health promotionist helps patients clarify how technology can help them achieve value-concordant goals. By comfortably modeling use of digital tools, health promotionists credibly convey confidence in patients’ abilities to master them. Given positive expectations, our experience is that virtually all patients master using mobile tools for self-monitoring (44-46).

The impact of equipping patients with digital tools and training is limited in environments lacking socioecological supports for health equity. Marginalized patients who mistrust the health-care system may not engage fully with technologies the hospital disseminates. Even motivated, lower-income racial and ethnic minority survivors may not be referred for health promotion services by clinicians whose unconscious biases leave them skeptical about such patients’ readiness and ability to change. To mitigate inequitable access, STELLAR uses the EHR’s digital tools. Proactive, unbiased recruitment of eligible patients algorithmically identified through the electronic data warehouse allows STELLAR to offer health promotion to the whole patient population, particularly the underserved.

Conclusions

The STELLAR Telehealth Research Center addresses a critical gap in cancer care. Its intent is to improve survivorship care by integrating telehealth-based, comprehensive treatment for multiple cancer risk behaviors. Leveraging telehealth and sociotechnical systems theory, the program seeks to optimize intervention delivery and enhance patient outcomes. The program’s 3 aims (implementation, evaluation, and dissemination) reflect commitment to advancing feasible, evidence-based interventions and sharing resources and lessons learned. STELLAR’s organizational structure is designed to support its ambitious goals. Advisory board involvement, including health-care professionals, researchers, and cancer survivors, elicits diverse perspectives that enrich the program. Launching the project also has highlighted real-world implementation challenges. We described these, hoping that future researchers benefit from our lessons learned and the adaptations we developed to move forward. STELLAR aims to reach and engage a broad population of cancer survivors, effect positive behavior changes, and disseminate its novel approach to health promotion within cancer care. Patient-generated data integration into the EHR and telehealth coaching by health promotionists could serve as a model for future interventions to foster whole health in cancer survivorship care.

Data availability

Data can be made available by sending a manuscript proposal and a data use agreement to the corresponding author, bspring@northwestern.edu.

Author contributions

Bonnie Spring, PhD (Conceptualization; Data curation; Funding acquisition; Investigation; Methodology; Project administration; Supervision; Validation; Writing—original draft; Writing—review & editing), Sofia Garcia, PhD (Conceptualization; Data curation; Funding acquisition; Investigation; Methodology; Project administration; Supervision; Validation; Writing—original draft; Writing—review & editing), Elyse Daly, BA (Investigation; Project administration; Supervision; Writing—review & editing), Maia Jacobs, PhD (Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing—review & editing), Monisola Jayeoba, MS (Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing—review & editing), Neil Jordan, PhD (Conceptualization; Methodology; Supervision; Writing—review & editing), Sheetal Kircher, MD, PhD (Conceptualization; Data curation; Investigation; Methodology; Project administration; Resources; Writing—review & editing), Masha Kocherginsky, PhD (Data curation; Formal analysis; Methodology; Validation; Visualization), Rana Mazzetta, MSW (Investigation; Project administration; Supervision; Writing—review & editing), Teresa Pollack, MS, CPHQ (Project administration; Supervision; Writing—review & editing), Laura Scanlan, MS (Investigation; Project administration; Supervision; Writing—review & editing), Courtney Scherr, PhD (Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing—review & editing), Brian Hitsman, PhD (Conceptualization; Funding acquisition; Investigation; Methodology; Project administration; Supervision; Validation; Writing—original draft; Writing—review & editing), and Siobhan Phillips, PhD (Conceptualization; Data curation; Funding acquisition; Investigation; Methodology; Project administration; Supervision; Validation; Writing—original draft; Writing—review & editing).

Funding

This work was supported by the National Cancer Institute (P50CA271353, PI Spring, MPIs: Garcia, Hitsman, and Phillips).

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

The authors have no conflicts of interest to disclose. National Comprehensive Cancer Network Clinical makes no warranties of any kind regarding the content, use, or application of their guidelines and disclaims any responsibility for their application or use in any way.