Abstract
Background
Before the coronavirus disease 2019 (COVID-19) pandemic, telehealth was rarely used for breast cancer management at tertiary care centers. We sought to examine patient satisfaction, experiences, preferences, and perceived effectiveness and technical quality of telehealth visits in follow-up patients receiving routine outpatient care in the breast medical oncology practice at The University of Texas MD Anderson Cancer Center.
Methods
We administered a survey to 60 follow-up patients for a duration of 9 months (January 5, 2021 to October 27, 2021) who had at least one telehealth consultation during the COVID-19 pandemic, from April 10, 2020 to October 21, 2021. Descriptive statistics were then generated for each question, each domain, and overall survey scores. Subgroup comparisons within patient populations were done using the chi-square or t-test when appropriate.
Results
Among the 60 participants, 49 (82%) were undergoing standard follow-up during active treatment for either early-stage or metastatic breast cancer. Telehealth and in-person office visits were considered equivalent in terms of quality of communication by 43 participants (72%). Most participants (n = 49, 82%) felt equally cared for during telehealth and in-person visits, and 40 participants (67%) reported feeling connected to their healthcare professional during both telehealth and in-person visits. In addition, 28 participants (47%) felt that the duration of telehealth visits was similar to in-person visits, 46 (77%) found both telehealth and in-person visits equally comfortable for discussing sensitive topics, 39 (65%) considered telehealth visits convenient, and 42 (70%) perceived the overall quality of care for telehealth to be similar to that of in-person visits. Participants expressed high satisfaction with telehealth appointments, with 42 (70%) rating their experience as very satisfying. Most participants (n = 44, 73%) expressed a strong likelihood of participating in telehealth appointments for breast cancer follow-up care in the future.
Conclusions
Our results indicate that telehealth can serve as an effective and satisfactory approach for delivering healthcare services to patients with breast cancer requiring follow-up care. The positive experiences and willingness to continue using telehealth indicate its potential for improving access to care and patient outcomes.
Keywords: telehealth, COVID-19, breast cancer, chemotherapy
It is unclear which patients with cancer are best suited for telehealth. The objective of the current study was to assess patient satisfaction, experiences, preferences, perceived effectiveness, and attitudes on the technical quality of telehealth visits in patients receiving routine outpatient care in the breast oncology practice at The University of Texas MD Anderson Cancer Center.
Implications for practice.
The study’s findings suggest that telehealth can effectively and satisfactorily deliver healthcare services to patients with breast cancer during follow-up care. Patients reported high satisfaction levels with telehealth visits, indicating its potential for increased utilization in routine outpatient settings. This positive experience, coupled with patients’ willingness to continue using telehealth, implies improved access to care and suggests that telehealth can maintain or even enhance the quality of healthcare provided to patients with breast cancer. Overall, the study supports the integration of telehealth into breast cancer management practices to improve patient outcomes and satisfaction.
Introduction
The coronavirus disease 2019 (COVID-19) pandemic has led to the rapid implementation and expansion of telehealth services across a broad spectrum of healthcare settings. Before the pandemic, the rationale for the proposed expansion of telehealth in oncology included a predicted shortage of oncologists in the US, the aging of the US population, and the mounting mismatch between the healthcare workforce and population geographic demands.1-3 Furthermore, the digitization of health records and availability of familiarity with videoconferencing platforms (like Zoom) has long held promise for the better exchange of health information, with telehealth fitting this paradigm. Telehealth may offer a sustainable and innovative way to improve the coordination of care and efficiency of care delivery while providing time savings, increased access to care and education, and provision of better individualized care.
Telehealth aligns with the needs and preferences of patients with breast cancer by offering convenience, reducing travel-related stress, enabling regular follow-ups, providing access to specialists regardless of geographical barriers, and allowing for more comfortable discussions about sensitive topics.4
Meta-analyses have shown that telehealth interventions are beneficial in non-oncology fields, including cardiac rehabilitation for coronary artery disease, glycemic control for type 2 diabetes, and adherence to management plans for patients with several chronic diseases.5-7 However, studies have also highlighted concerns that patients have about telemedicine. Investigators at the University of Michigan conducted a “National Poll on Healthy Aging” to explore the opinions of older patients about telemedicine; In that study, older adults were concerned about providers being unable to perform a physical examination, and they questioned the overall quality of care of telehealth visits.8 Additionally, several respondents had concerns about privacy, not feeling connected to their provider during their telehealth visits, and technology use.
In oncology, there has been an increasing focus on telehealth in the past few years, with various studies exploring several different aspects of telehealth. A study done in Israel9 examined cancer patients’ views on telemedicine, revealing it as a secure and effective method that does not hinder patient-doctor relationships. It is particularly beneficial for post-treatment surveillance, emphasizing the necessity of communication training for physicians to optimize telemedicine integration during crises like COVID-19. Delivery of telehealth services by an academic-based oncology team to rural sites was found to have both clinical and cost-effectiveness.10 A meta-analysis of 20 randomized controlled trials that included a telehealth intervention for patients with breast cancer revealed that compared with usual care, telehealth led to an improvement in several psychosocial outcomes, such as quality of life, depression, and stress.11 Since then, many others have further confirmed the efficacy of telehealth in cancer care through high levels of patient satisfaction and improved access to services.12-14
Some of the unique considerations and challenges in implementing telehealth in breast oncology include the need for multidisciplinary care coordination, handling sensitive discussions effectively, limitations in physical examinations, ensuring technological accessibility, and complying with legal and regulatory standards.15 Facilitators include convenience, reduced travel-related stress, and regular follow-ups.16
However, given the diversity patients with cancer experiences across the trajectory of the disease, it is unclear which patients are best suited for telehealth. The objective of the current study was to assess patient satisfaction, experiences, preferences, perceived effectiveness, and attitudes on the technical quality of telehealth visits in patients receiving routine outpatient care in the breast oncology practice at The University of Texas MD Anderson Cancer Center.
Patients and methods
Inclusion criteria
We conducted screenings, approached individuals, and obtained their consent from established medical oncology patients receiving their follow-up care from January 5, 2021 to October 27, 2021 in the Nelle B. Connally Breast Center at The University of Texas MD Anderson Cancer Center. Patients were required to have completed at least one virtual visit since April 10, 2020.
Eligible patients needed to speak, read, and understand English and were identified by their oncology care providers to be appropriate for a telehealth visit.
Study setting and telemedicine
Starting April 10, 2020, breast medical oncologists at MD Anderson offered established patients the option for their follow-up visits to be converted to telehealth visits, based on the provider’s professional assessment of the suitability of the mode of visit for the individual patient’s situation (eg, patients could communicate effectively in this mode, physical examination was not critical to the visit). Because of the pandemic, the providers conferred with the schedulers about patients who could be asked if a telehealth appointment would be suitable. We reviewed each physician provider template in EPIC for the day and sorted out telehealth visits. From that list, we randomly selected patients. However, not every patient was approached, mainly due to limited coordinator resources dedicated to the trial. Zoom was the virtual meeting platform that was integrated with the electronic medical record system to connect patients and providers during these video visits. Before the telehealth visit, participating patients received education, instruction, and phone-based technology support and testing for installation of the visit software via a phone call from the clinic.
In the current study, willing patients from a pool of 21 providers of telehealth visits were asked to complete a survey 1-2 weeks after their telehealth visit. Patient informed consent was obtained remotely prior to study participation. The summary of the process for remote consenting involved sending the patient an email with the consent form beforehand, allowing ample time for them to review and ask questions. Once their queries were addressed through email or phone, the consent document was sent via EPIC to the patient’s phone through text or email (as per their preference) for remote signing. The remaining steps and standards of the consent process mirrored those in a clinic setting. The iCONSENT application in EPIC was used, with ongoing phone support provided during signing to troubleshoot any issues. Alternatively, patients could opt to receive a copy via MyChart if they wished to consider the study further. All written communication, including sending every patient a copy of their informed consent, was exclusively done through EPIC MyChart. These telehealth visits were predominantly conducted shortly after a call with the health care provider (nurse/MD) responsible for mediating and interacting with the patients. Virtual care patients were identified using modifier codes in the electronic medical record indicating enrollment in the virtual visit program. The study received approval from the MD Anderson institutional review board (IRB-2020-0661).
Survey methods and data collection
Surveys are a common method for assessing patient-reported outcomes and are widely used in telehealth research. We developed a patient questionnaire, adapted from previous peer-reviewed studies of surveys evaluating telehealth platforms. The survey was developed by the principal investigator, a Breast Medical Oncologist at MD Anderson, with support and input from collaborating faculty members with expertise in breast cancer and health services research. Surveys comprised 2 sections: a set of multiple-choice background questions related to demographics and care status (eg, active treatment, surveillance, etc.), and a set of Likert scale questions to assess patient satisfaction, experiences, and preferences. The multiple-choice demographic questions included basic information on diagnosis and treatment. We included selected patient experience measures developed by the University of Michigan, University of Pittsburgh, and the Agency of Healthcare Research and Quality, further augmented with items developed specifically for oncology.8,17,18 Key domains included patient satisfaction, patient experience, and quality of the technology and communication.
To protect patient privacy, we deidentified all surveys. Participants completed surveys electronically and the data were subsequently entered into REDCap (Research Electronic Data Capture).19 REDCap is a secure, web-based application designed to support data capture for research studies. All data was stored and recorded in REDCap. During the study, the research team also collected information about the patient age, sex, race, education, marital status, cancer history, and other health conditions from the electronic medical record.
Statistical analysis
We recruited 60 patients. Descriptive statistics (including mean, standard deviation, median, and range) were used to summarize patient characteristics. Frequencies and percentages were used to summarize categorical variables as appropriate. Likert scale responses were converted to numerical values. Using subsequent integer scaling reflective of the Likert scale score, we generated domain scores and an overall score for each respondent’s survey. Descriptive statistics were then generated for each question, each domain, and overall survey scores. Outcome variables of incidence were estimated along with 95% CIs. Subgroup comparisons within patient populations were done using the chi-square or t-test when appropriate.
Results
Patient characteristics
The survey was conducted among patients receiving care at our breast center between April 10, 2020, and October 27, 2021. A total of 81 individuals were approached for potential participation in the study, and 60 patients provided consent to participate; an additional 21 individuals either withdrew their consent or did not qualify based on the eligibility screening process.
Among the participants who completed the study, all 60 were female patients who primarily used video visits for symptom management and ongoing care. Among the 60 participants, 7 had breast cancer in addition to other cancers, and the remaining 53 participants solely had breast cancer. Table 1 depicts patient characteristics. The participant age range was 34-72 (median 55) years at the time of the survey, with a median age of 49 years at metastasis for those with advanced disease. Most patients were non-Hispanic White (n = 49, 82%), and 47 (78%) were married. The primary tumor was hormone receptor-positive and HER2-negative, a favorable biomarker, in 37 patients (62%). At the time of analysis, 52 participants were alive and 8 had died.
Table 1.
Characteristics of the survey participants (n = 60).
| Characteristic | No. (%) |
|---|---|
| Race | |
| White or Caucasian | 49 (82) |
| Black or African American | 5 (8) |
| Asian | 3 (5) |
| Other | 3 (5) |
| Ethnicity | |
| Hispanic or Latino | 12 (20) |
| Not Hispanic or Latino | 48 (80) |
| Age at metastasis | |
| 18-40 years | 16 (27) |
| 41-60 years | 38 (63) |
| 61-75 years | 6 (10) |
| Marital status | |
| Single | 6 (10) |
| Divorced | 3 (5) |
| Legally separated | 1 (2) |
| Married | 47 (78) |
| Significant other | 1 (2) |
| Widowed | 2 (3) |
| Family history of breast cancer | |
| First-degree relatives | 11 (18) |
| Second-degree relatives | 26 (43) |
| Stage of breast cancer* | |
| Early stage | 23 (38) |
| Metastatic | 26 (43) |
| Grade of primary breast cancer | |
| I | 2 (3) |
| II | 40 (67) |
| III | 18 (30) |
| Receptor status | |
| HR+ HER2- | 37 (62) |
| Triple-negative | 10 (17) |
| HER2+ | 13 (22) |
| Survival status | |
| Alive | 52 (87) |
| Deceased | 8 (13) |
*For those receiving active treatment (11 patients were not receiving active treatment at the time of survey).
Among the participants, 25 had received or were receiving neoadjuvant treatment, 40 had received or were receiving adjuvant treatment, and 27 had undergone or were undergoing treatment for metastatic disease. A total of 23 patients were receiving active treatment for early-stage breast cancer (stages I, II, or III, confined to the breast or lymph nodes), and 26 patients were receiving active treatment for metastatic breast cancer. Among the 49 participants receiving active treatment, 19 (39%) were receiving intravenous chemotherapy or targeted therapy, 24 (49%) were receiving oral chemotherapy or targeted therapy, and 12 (24%) were taking endocrine therapy.
In terms of telehealth use, 34 participants (57%) had engaged in a telehealth medical appointment outside of MD Anderson since the declaration of COVID-19 as a pandemic by the World Health Organization (WHO) on April 10, 2020, and 26 (43%) had not. However, 59 of the 60 participants had already participated in a telehealth medical appointment with MD Anderson for their breast cancer care since April 10, 2020. The number of prior telehealth visits (excluding the current one) reported at the time of survey administration was distributed as follows: A total of 21 participants reported having 1 to 3 visits, with 8 participants reporting 1 visit, 9 participants reporting 2 visits, and 4 participants reporting 3 visits. Additionally, 24 participants reported having 4 to 6 visits, 11 participants had 4 visits, 7 participants had 5 visits, and 6 participants had 6 visits. Furthermore, 9 participants indicated having 7 to 10 visits, including 3 participants with 7 visits, 2 participants with 8 visits, and 4 participants with 10 visits. Finally, 6 participants reported having 12 or more visits, with 2 participants having 12 visits and 4 participants reporting more than 20 visits (Figure 1). The presence of participants with multiple visits indicates that telehealth was used for ongoing follow-ups or management, highlighting its potential significance in long-term patient care.
Figure 1.
Distribution of previous telehealth visits (excluding current) during survey administration
Figure 2 shows participant interest in discussing various health topics during their telehealth visit for those receiving active treatment for early-stage breast cancer. Most participants were extremely interested in discussing the side effects of chemotherapy, targeted therapy, or hormonal therapy. Participants were also extremely interested in discussing follow-up for routine surveillance, advance directives, and genetic counseling during their telehealth visits.
Figure 2.
Participant interest in discussing health topics during their telehealth visit for those receiving active treatment for early-stage breast cancer (n = 23).
Figure 3 shows participant interest in discussing various health topics during their telehealth visit for those receiving active treatment for metastatic breast cancer. Most participants were extremely interested in discussing the side effects of chemotherapy, targeted therapy, hormonal therapy, or clinical trial treatments. Participants were also extremely interested in reviewing staging scans and discussing advance directives and genetic counseling during their telehealth visit.
Figure 3.
Participant interest in discussing health topics during their telehealth visit for those receiving active treatment for metastatic breast cancer (n = 26).
Patient satisfaction
Most participants expressed high satisfaction levels with their telehealth care for breast cancer at MD Anderson. Specifically, 42 participants (70%) rated their experience as very satisfying, and 9 participants (15%) considered it somewhat satisfying. However, 4 participants (7%) expressed being very dissatisfied, and 2 participants (3%) reported feeling somewhat dissatisfied. A small portion, 3 participants (5%), had a neutral stance.
Participants showed a positive inclination for future telehealth appointments for breast cancer or follow-up care if their provider offered it. Specifically, 44 participants (73%) stated that they were very likely to participate, and 7 participants (12%) indicated that they were likely to participate. Only 1 participant (2%) expressed a strong unlikelihood of participating, and 3 participants (5%) felt that they were unlikely to participate. There were also 5 participants (8%) who maintained a neutral stance. We notified the providers if one of their patients expressed strong dissatisfaction.
Patient experience
Table 2 shows participant opinions on how telehealth visits compare to in-person visits in terms of the relationship and interaction with healthcare professionals. Most participants (n = 43, 72%) reported that telehealth and in-person office visits were equivalent in terms of communication with their healthcare professionals. Similarly, 49 participants (82%) found both methods to be equally effective in terms of feeling cared for. In terms of feeling connected to their healthcare professional, 40 participants (67%) felt that telehealth and in-person office visits were on par.
Table 2.
Participant opinions on how breast cancer telehealth visits compare to in-person office visits (n = 60).
| Factor | No. (%) | ||
|---|---|---|---|
| Telehealth visits better | In-person office visit better | Telehealth and in-person office visits about the same | |
| Communicating with your healthcare professional | 4 (7) | 13 (22) | 43 (72) |
| Feeling cared for by your healthcare professional | 3 (5) | 8 (13) | 49 (82) |
| Feeling connected to your healthcare professional | 3 (5) | 17 (28) | 40 (67) |
| Duration of the entire visit | 24 (40) | 8 (13) | 28 (47) |
| Comfort discussing sensitive topics | 4 (7) | 10 (17) | 46 (77) |
| Amount of time spent with the healthcare professional | 8 (13) | 13 (22) | 39 (65) |
| Involving family members or support system | 21 (35) | 9 (15) | 30 (50) |
| Overall convenience | 39 (65) | 6 (10) | 15 (25) |
| Overall quality of care | 5 (8) | 13 (22) | 42 (70) |
Regarding the duration of the entire visit, 28 participants (47%) felt that telehealth and in-person office visits took about the same amount of time. In addition, 46 participants (77%) found both methods equally comfortable for discussing sensitive topics. When it came to involving family members or support systems, 30 participants (50%) felt that telehealth and in-person office visits were equally effective.
For overall convenience, 39 participants (65%) considered telehealth visits to be satisfactory, and 42 participants (70%) perceived the overall quality of care to be similar between telehealth and in-person office visits.
Technology and communication quality
Table 3 shows participant concerns about interactions with healthcare professionals during telehealth visits. Most participants lacked concern regarding interactions with healthcare professionals during telehealth visits. Most participants (n = 53, 88%) expressed no worries about privacy. Likewise, 45 participants (75%) had no worries about the difficulty in seeing or hearing the healthcare professional during the telehealth visits. Furthermore, 35 participants (58%) reported no worries about encountering technical difficulties when using the technology.
Table 3.
Participant concerns about interaction with healthcare professionals during telehealth visits for breast cancer care (n = 60).
| Concern | No. (%) | |||
|---|---|---|---|---|
| Not at all worried | Somewhat worried | Very worried | Unsure | |
| Privacy | 53 (88) | 4 (7) | 0 (0) | 3 (5) |
| Difficulty seeing or hearing the healthcare professional | 45 (75) | 12 (20) | 2 (3) | 1 (2) |
| Technical difficulties using the technology | 35 (58) | 21 (35) | 3 (5) | 1 (2) |
| Not feeling personally connected to the healthcare professional | 45 (75) | 12 (20) | 3 (5) | 0 (0) |
| Healthcare professional not being able to perform a physical examination | 26 (43) | 22 (37) | 11 (18) | 1 (2) |
| Not having enough time during the encounter | 48 (80) | 8 (13) | 4 (7) | 0 (0) |
| Quality of care not being as good as an in-person visit | 38 (63) | 17 (28) | 4 (7) | 1 (2) |
The participants also indicated a lack of concern about personal connection with their healthcare professional, with 45 participants (75%) expressing no worries in this regard. Additionally, 26 participants (43%) reported no worries about the healthcare professional’s inability to conduct a physical examination. Furthermore, 48 participants (80%) reported no worries about the encounter time being insufficient and 38 participants (63%) had no worries about the quality of care being inferior to that of an in-person visit.
Table 4 details participant opinions about the usability of telehealth visits. Participants found telehealth to be convenient; 57 participants (95%) had a signified agreement that telehealth saved time by eliminating the need to travel to the hospital or specialist. Additionally, 46 participants (77%) signified agreement that telehealth effectively met their healthcare needs. Furthermore, 51 participants (85%) had a signified agreement that the telehealth system was easy to use, and 44 participants (73%) had a signified agreement that they could be productive and enjoyed using the telehealth system.
Table 4.
Participant opinions about the usability of telehealth visits for breast cancer care (n = 60).
| Factor | No. (%) | ||||
|---|---|---|---|---|---|
| Strongly disagree | Disagree | Neutral | Agree | Strongly agree | |
| Telehealth saves me time traveling to a hospital or specialist | 1 (2) | 0 (0) | 2 (3) | 13 (22) | 44 (73) |
| Telehealth provides for my healthcare needs | 1 (2) | 3 (5) | 10 (17) | 13 (22) | 33 (55) |
| It is easy to use the system | 2 (3) | 1 (2) | 3 (5) | 21 (35) | 33 (55) |
| It was easy to learn to use the system | 2 (3) | 2 (3) | 5 (8) | 19 (32) | 32 (53) |
| I believe I could become productive using this system | 3 (5) | 1 (2) | 12 (20) | 12 (20) | 32 (53) |
| I like using the system | 4 (7) | 1 (2) | 11 (18) | 14 (23) | 30 (50) |
| The system is simple and easy to understand | 1 (2) | 3 (5) | 9 (15) | 18 (30) | 29 (48) |
| This system is able to do everything I would want to be able to do | 2 (3) | 8 (13) | 11 (18) | 11 (18) | 28 (47) |
| I could easily talk to the clinician using the telehealth system | 2 (3) | 3 (5) | 6 (10) | 14 (23) | 35 (58) |
| I could hear the clinician clearly using the telehealth system | 3 (5) | 2 (3) | 4 (7) | 19 (32) | 32 (53) |
| I felt I was able to express myself effectively | 1 (2) | 3 (5) | 3 (5) | 20 (33) | 33 (55) |
| Using the telehealth system, I can see the clinician as well as if we met in person | 5 (8) | 8 (13) | 3 (5) | 15 (25) | 29 (48) |
| I think the visits provided over the telehealth system are the same as in-person visits | 7 (12) | 10 (17) | 12 (20) | 10 (17) | 21 (35) |
| I was provided with adequate support on how to use the telehealth system before it began | 2 (3) | 1 (2) | 4 (7) | 20 (33) | 33 (55) |
| Whenever I made a mistake using the system, I could recover easily and quickly | 2 (3) | 4 (7) | 16 (27) | 15 (25) | 23 (38) |
| The system gave error messages that clearly instructed me on how to fix problems | 3 (5) | 4 (7) | 25 (42) | 15 (25) | 13 (22) |
| I feel comfortable communicating with the clinician using the telehealth system | 1 (2) | 3 (5) | 4 (7) | 17 (28) | 35 (58) |
| Telehealth is an acceptable way to receive healthcare services | 5 (8) | 4 (7) | 5 (8) | 20 (33) | 26 (43) |
| I would use telehealth services again | 4 (7) | 2 (3) | 2 (3) | 16 (27) | 36 (60) |
| Overall, I am satisfied with this telehealth system | 3 (5) | 2 (3) | 4 (7) | 19 (32) | 32 (53) |
In terms of user experience, 47 participants (78%) had signified agreement that the system was simple and easy to understand and 39 participants (65%) had signified agreement that the telehealth system was able to fulfill their desired purposes.
Participants also expressed positive views on communication aspects. Most participants (n = 49, 81%) had a signified agreement that they could easily converse with the clinician using the telehealth system and 51 participants (85%) signified agreement that they could clearly hear the clinician. Additionally, 53 participants (88%) signified agreement that they were able to effectively express themselves using the telehealth system. Furthermore, 44 participants (73%) signified agreement that the visits conducted via telehealth were equivalent to in-person visits.
Regarding system support and functionality, 53 participants (88%) signified agreement that they received adequate support on how to use the telehealth system before its implementation. In addition, 38 participants (63%) signified agreement that they could easily and quickly recover from any mistakes made while using the system. However, 25 participants (42%) expressed a neutral stance regarding whether the system provided clear error messages for problem resolution.
In terms of comfort and satisfaction, 52 participants (86%) signified agreement that they felt comfortable communicating with the clinician using the telehealth system. Additionally, 46 participants (76%) signified agreement that telehealth was an acceptable method of receiving health care services. Furthermore, 52 participants (87%) strongly agreed that they would choose to use telehealth services again, and 51 participants (85%) expressed overall satisfaction with their telehealth system.
We assessed the effect of age on responses related to telehealth experiences specifically in usability aspect given the technology issues and preferences for cancer care. We found no significant effect of age on patient satisfaction with telehealth; most Likert scale responses were not influenced by age, indicating that telehealth can be a viable option across different age groups.
During subgroup analyses, we examined the active treatment patients and categorized them based on their reported treatment groups. This categorization included oral chemotherapy or targeted therapy, hormonal therapy, and intravenous chemotherapy or targeted therapy. In addition, we investigated both early-stage and metastatic patients. Our findings revealed no significant effect, indicating that responses did not differ by treatment type for either group.
Additionally, we examined the duration of each telehealth visit, and Supplementary Figure S1 illustrates the median distribution of visit durations among all patients with 27 patients receiving moderate to long visits (15-30 minutes) covering a range of patient-related aspects, 12 patients receiving long visits (31-50 minutes) indicating comprehensive discussions, and 9 patients receiving very long visits (51 minutes and above) involving highly detailed consultations and addressing significant medical complexities or patient concerns. Very short durations ≤5min were due to technical issues and an aborted teleconsultation.
Discussion
Our findings suggest that telehealth has demonstrated effectiveness and satisfaction as a viable approach for providing healthcare services, particularly in the case of follow-up care required by breast cancer patients.
Telehealth in the context of breast cancer has been the focus of research aimed at exploring its potential benefits and impact on various aspects of care. Several studies have been conducted to examine the impact of telehealth in the context of breast cancer. These studies shed light on various aspects of telehealth care, including teleconsultation, quality of life, psychological outcomes, and the overall benefits of telemedicine for patients with breast cancer. One study highlighted the increasing preference for teleconsultation among patients undergoing intravenous chemotherapies for early-stage breast cancer and those receiving other systemic treatments. This expert consensus favored teleconsultation as a viable option for such patients, offering convenience and reducing the need for frequent in-person visits.20 Another meta-analysis investigated the effect of telehealth interventions on the quality of life and psychological outcomes of breast cancer patients. The results of that study indicated a positive impact, with telehealth interventions significantly improving patients’ quality of life and psychological well-being.21 Furthermore, another study emphasized the promise of telemedicine in improving both the physical and mental health detriments associated with breast cancer and its treatments. Telemedicine was found to offer benefits for providers as well as breast cancer survivors, providing opportunities for monitoring, support, and the development of healthy habits to reduce the risk of recurrence.22 Our findings are consistent with these previous findings, indicating that telemedicine can be effective in breast cancer care.
Both previous studies and the current study collectively highlight the potential of telehealth in breast cancer care, with the possibility of reducing in-person visits and improving patients’ quality of life and psychological well-being. Another study focused on qualitative evidence, aiming to synthesize women’s experiences with telehealth during breast cancer treatment and follow-up. That research highlighted that telehealth could ensure continuity of care, particularly in distant locations. It also explored how telehealth contributes to the overall patient experience and helps address the challenges associated with distance and accessibility.23 Furthermore, specific research projects have been conducted to develop telemedicine systems tailored to providing treatment plans for patients with breast cancer. These projects aim to enhance the delivery of care and ensure the continuity of treatment.24
At our large breast medical oncology practice, telehealth services were quickly adopted for visits that could be completed outside of the clinic, to limit patient exposure to SARS-CoV-2. These services consisted of video-based telehealth visits through the electronic medical system. These visits were typically 15-30 minutes long, with patient-assessed symptoms (when indicated), limited physical examination based on visual inspection, and patient and provider-based discussion of the patient’s oncologic status and care. These services replaced nonessential in-person visits but did not replace essential visits required for physical examinations, laboratory checks, chemotherapy, or other treatment administration. Any concerns that could not be addressed via telehealth required the scheduling of an in-person visit. These processes allowed rapid implementation of telehealth services without any interruption in the continuity of care for our cancer patients.
A strength of the current study was that we were able to stratify patients receiving active treatment by treatment type and continuity of care—ie, oral chemotherapy, hormonal therapy, or targeted therapy versus intravenous chemotherapy or targeted therapy leading to better management of their conditions. A limitation of the current study is that we could not assess clinical and long-term outcomes, which would require greater follow-up length. The implementation of telehealth in breast cancer care faces challenges such as limited access to technology and digital literacy, the necessity of physical exams, privacy concerns, and disparities in internet access.25 Although both the current study and previous studies have demonstrated the potential benefits of telehealth in breast cancer care, further research is needed to fully understand its implications.
Nevertheless, telehealth currently serves as a valuable adjunct to traditional care, improving access to health care services, reducing travel burdens, and enhancing overall patient experience in the management of breast cancer. Future research and improvements in telehealth-supported care for breast cancer management should focus on several key areas. It is important to note that the disadvantages of telehealth can be mitigated by assessing the long-term effectiveness of telehealth interventions, including a hybrid model that combines both in-person and remote care, optimizing technological infrastructure, and ensuring equitable access to services. Additionally, regular evaluation and feedback from patients and healthcare providers can help identify and address any challenges or limitations associated with telehealth in breast cancer care such as whether telehealth is as good (or better) for patients to understand their diagnosis and treatment plan where information conveyed effectively, or more or less accurately. Integrating multidisciplinary care seamlessly, evaluating the cost-effectiveness of telehealth compared to traditional care models, and exploring telehealth’s role in survivorship care and psychosocial support for breast cancer survivors. Ultimately, improving the quality and reporting of this research is essential to improve our understanding of how various models of telehealth-supported care impact specific groups of patients.
Supplementary material
Supplementary material is available at The Oncologist online.
Acknowledgments
This study was supported by the National Institutes of Health/National Cancer Institute through a Cancer Center Support Grant to The University of Texas MD Anderson Cancer Center (P30CA016672) and the biostatistics core group. The authors would like to acknowledge Erica Goodoff in MD Anderson’s Research Medical Library for editing the article.
Contributor Information
Akshara Singareeka Raghavendra, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
Kristofer Jennings, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
Gil Guerra, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
Debu Tripathy, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
Meghan S Karuturi, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
Author contributions
Akshara S. Raghavendra (Conceptualization, Data curation, Formal Analysis, Project administration, Writing—original draft, Writing—review & editing), Kristofer Jennings (Formal Analysis, Writing—review & editing), Gil Guerra (Project administration, Writing—review & editing), Debu Tripathy (Conceptualization, Investigation, Supervision, Writing—review & editing), Meghan Karuturi (Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing—review & editing)
Conflicts of interest
The authors declare no financial conflicts of interest.
Data availability
The data that support the findings of this study are available upon reasonable request to the corresponding author. The data are not publicly available to protect the privacy of study participants.
References
- 1. Hortobagyi GN; American Society of Clinical Oncology. A shortage of oncologists? The American Society of Clinical Oncology workforce study. J Clin Oncol. 2007;25(12):1468-1469. 10.1200/JCO.2007.10.9397 [DOI] [PubMed] [Google Scholar]
- 2. Association AM. American Medical Association (AMA) Physician Masterfile. Medical Marketing Service; 2015. Accessed May 13, 2015. Archived by WebCite® at http://www.webcitation.org/6YVGcl0ku [Google Scholar]
- 3. Sirintrapun SJ, Lopez AM. Telemedicine in cancer care. Am Soc Clin Oncol Educ Book. 2018;38:540-545. 10.1200/EDBK_200141 [DOI] [PubMed] [Google Scholar]
- 4. Shaverdian N, Gillespie EF, Cha E, et al. Impact of telemedicine on patient satisfaction and perceptions of care quality in radiation oncology. J Natl Compr Cancer Netw. 2021;19(10):1174-1180. 10.6004/jnccn.2020.7687 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Huang K, Liu W, He D, et al. Telehealth interventions versus center-based cardiac rehabilitation of coronary artery disease: a systematic review and meta-analysis. Eur J Prev Cardiol. 2015;22(8):959-971. 10.1177/2047487314561168 [DOI] [PubMed] [Google Scholar]
- 6. Liang X, Wang Q, Yang X, et al. Effect of mobile phone intervention for diabetes on glycaemic control: a meta‐analysis. Diabet Med. 2011;28(4):455-463. 10.1111/j.1464-5491.2010.03180.x [DOI] [PubMed] [Google Scholar]
- 7. Hamine S, Gerth-Guyette E, Faulx D, Green BB, Ginsburg AS. Impact of mHealth chronic disease management on treatment adherence and patient outcomes: a systematic review. J Med Internet Res. 2015;17(2):e52. 10.2196/jmir.3951 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Kurlander J, Kullgren J, Singer D, et al. National poll on healthy aging: virtual visits: telehealth and older adults. October 1, 2019. Available from: http://hdl.handle.net/2027.42/151376 [Google Scholar]
- 9. Hasson SP, Waissengrin B, Shachar E, et al. Rapid implementation of telemedicine during the COVID-19 pandemic: perspectives and preferences of patients with cancer. Oncologist. 2021;26(4):e679-e685. 10.1002/onco.13676 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Doolittle G, Allen A, Wittman C, et al. Oncology care for rural Kansans via telemedicine: The establishment of a tele-oncology practice. Proc Am Soc Clin Oncol. 1996;15:326. [Google Scholar]
- 11. Chen Y-Y, Guan B-S, Li Z-K, Li X-Y. Effect of telehealth intervention on breast cancer patients’ quality of life and psychological outcomes: a meta-analysis. J Telemed Telecare. 2018;24(3):157-167. 10.1177/1357633X16686777 [DOI] [PubMed] [Google Scholar]
- 12. Thaker DA, Monypenny R, Olver I, Sabesan S. Cost savings from a telemedicine model of care in northern Queensland, Australia. Med J Aust. 2013;199(6):414-417. 10.5694/mja12.11781 [DOI] [PubMed] [Google Scholar]
- 13. Doolittle G, Harmon A, Williams A, et al. A cost analysis of a tele-oncology practice. J Telemed Telecare. 1997;3(1):20-22. [DOI] [PubMed] [Google Scholar]
- 14. Doolittle GC, Allen A. Practising oncology via telemedicine. J Telemed Telecare. 1997;3(2):63-70. 10.1258/1357633971930869 [DOI] [PubMed] [Google Scholar]
- 15. Turner K, Bobonis Babilonia M, Naso C, et al. Health care providers’ and professionals’ experiences with telehealth oncology implementation during the COVID-19 pandemic: a qualitative study. J Med Internet Res. 2022;24(1):e29635. 10.2196/29635 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Breen KE, Tuman M, Bertelsen CE, et al. Factors influencing patient preferences for telehealth cancer genetic counseling during the COVID-19 pandemic. JCO Oncol Pract. 2022;18(4):e462-e471. 10.1200/OP.21.00301 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Parmanto B, Lewis AN Jr, Graham KM, et al. Development of the telehealth usability questionnaire (TUQ). Int J Telerehabilitation. 2016;8(3):3-10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Cleary PD, Crofton C, Hays RD, Horner R. Advances from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) project. Introduction. Med Care. 2012;50(Suppl):S1. 10.1097/MLR.0b013e31826ec0cb [DOI] [PubMed] [Google Scholar]
- 19. Becevic M, Boren S, Mutrux R, Shah Z, Banerjee S. User satisfaction with telehealth: study of patients, providers, and coordinators. Health Care Manag (Frederick). 2015;34(4):337-349. 10.1097/HCM.0000000000000081 [DOI] [PubMed] [Google Scholar]
- 20. Bizot A, Karimi M, Rassy E, et al. Multicenter evaluation of breast cancer patients’ satisfaction and experience with oncology telemedicine visits during the COVID-19 pandemic. Br J Cancer. 2021;125(11):1486-1493. 10.1038/s41416-021-01555-y [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Snoswell CL, Chelberg G, De Guzman KR, et al. The clinical effectiveness of telehealth: a systematic review of meta-analyses from 2010 to 2019. J Telemed Telecare. 2021;27(4):204-213. [DOI] [PubMed] [Google Scholar]
- 22. Kruse CS, Pacheco GJ, Vargas B, et al. Leveraging telehealth for the management of breast cancer: a systematic review. Healthcare (Basel). 2022;10(10):2015. https://doi.org/10.3390%2Fhealthcare10102015 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Meneses AFP, Pimentel FF, da Cruz JPF, Candido dos Reis FJ. Experiences of women with breast cancer using telehealth: a qualitative systematic review. Clin Breast Cancer. 2023;23(2):101-107. 10.1016/j.clbc.2022.11.001 [DOI] [PubMed] [Google Scholar]
- 24. Khodaveisi T, Sadoughi F, Novin K, Hosseiniravandi M, Dehnad A. Development and evaluation of a teleoncology system for breast cancer during the COVID-19 pandemic. Future Oncol. 2022;18(12):1437-1448. 10.2217/fon-2021-0822 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Klee D, Pyne D, Kroll J, James W, Hirko KA. Rural patient and provider perceptions of telehealth implemented during the COVID-19 pandemic. BMC Health Serv Res. 2023;23(1):981. 10.1186/s12913-023-09994-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that support the findings of this study are available upon reasonable request to the corresponding author. The data are not publicly available to protect the privacy of study participants.