Enhancing Cancer Supportive Care: Integrating Psychosocial Support, Nutrition, and Physical Activity Using Telehealth Solutions

Abstract

This review explores current guidelines for integrating psychosocial support, nutrition, and physical activity into cancer care and examines the resources available to deliver comprehensive care effectively and equitably, with a focus on telehealth solutions. A review of current guidelines related to psychosocial support, nutrition, and exercise in oncology published between the years 2020 and 2024 was conducted. Additionally, relevant articles from the authors' personal archives were included. Current guidelines emphasize routine psychosocial distress screening, nutritional assessment, and tailored physical activity interventions for patients with cancer. The National Comprehensive Cancer Network and ASCO highlight the need for regular psychosocial evaluations and the management of common psychiatric disorders. The American Cancer Society and the Academy of Nutrition and Dietetics recommend nutritional screening, personalized counseling, and exercise to improve treatment tolerance and overall quality of life. Despite these recommendations, challenges such as resource limitations, time constraints, and financial barriers hinder their implementation. Integrating psychosocial support, medical nutrition therapy, and physical activity into cancer care is essential to enhancing patients' quality of life. Telehealth offers a viable solution to overcome barriers by providing remote access to supportive services, facilitating comprehensive care, and promoting patient engagement. The effectiveness of telehealth in delivering psychosocial, nutritional, and physical activity support highlights its potential to improve patient outcomes and overcome barriers to care. Telehealth technologies hold high potential to optimize cancer care delivery, ensuring personalized support for patients throughout their cancer journey.

BACKGROUND

Cancer treatment has evolved significantly, with a growing recognition that high-quality care extends beyond treating the disease alone. Multiple guidelines emphasize the need for comprehensive person-centric care, including psychosocial, nutritional, and physical activity interventions before, during, and after cancer treatment. These components are critical for improving outcomes and overall quality of life. This paper summarizes the recommendations from established guidelines regarding the standard of care for assessing supportive care needs in patients with cancer and discusses available resources, particularly telehealth, to deliver comprehensive care effectively and equitably (Table 1).

TABLE 1.

Summary of Recommendations Made by Current Guidelines

Recommendation	Description
Psychosocial
1	Provide information and resources on depression and anxiety to all patients and caregivers
2	Use a stepped-care model for treatment based on symptom severity and other variables
3	Use manualized, empirically supported psychological and psychosocial interventions
4	Facilitate patient follow-through for referrals to psychological care
5	Prioritize treatment of depressive symptoms or use a unified protocol for both depression and anxiety
6	Regularly assess treatment response for psychological treatments
7	Regularly assess symptom relief, side effects, and satisfaction for pharmacologic treatments
8	Adjust treatment regimen if there is little improvement after 8 weeks
Nutritional
1	Screen for malnutrition risk using validated tools and begin personalized nutritional counseling if at risk. Monitor interventions at regular intervals as part of a multidisciplinary team care plan
2	Follow a healthy diet pattern with adequate macronutrients and micronutrients, prefer plant-based diets, and avoid overuse of dietary supplements. Adhere to food safety procedures
Physical activity
1	Aerobic and resistance exercise during active treatment to improve quality of life and mitigate side effects (eg, fatigue, cardiorespiratory fitness, physical functioning, strength, anxiety, depression)
2	Preoperative exercise for lung cancer surgery patients to reduce hospital stay and complications

CURRENT GUIDELINES AND RECOMMENDATIONS

Psychosocial

Organizations like the National Comprehensive Cancer Network (NCCN) and ASCO recommend routine psychosocial distress screening for all patients with cancer.^1,2 The NCCN guideline emphasizes the importance of identifying patients' needs to develop effective management plans. However, due to a lack of available supportive care services and programs, along with time constraints and stigma, discussions about psychiatric and psychological needs are often omitted in routine clinical practice.¹ The guidelines also outline the evaluation and treatment of common psychiatric disorders in patients with cancer, emphasizing the importance of mental health support to address disparities in access to care and treatment outcomes, and improve overall care.¹

ASCO updated its guidelines in 2023 to address the management of anxiety and depression in adult cancer survivors.² These guidelines highlight the heightened prevalence of psychological disorders in patients with cancer compared with the general population, emphasizing the importance of timely recognition and treatment. They recommend routine screening using validated measures and a stepped-care model tailored to symptom severity, psychiatric history, and other individual factors. Treatment encompasses evidence-based psychological interventions, such as cognitive behavioral therapy and mindfulness-based stress reduction (MBSR), and pharmacologic approaches when necessary.² The guidelines also emphasize the importance of culturally informed care and the need for health care providers to tackle barriers for accessing mental health services.

Nutrition and Physical Activity

The American Cancer Society and the Academy of Nutrition and Dietetics emphasize the importance of early and regular nutritional assessment and intervention.^3,4 This involves screenings for malnutrition (both over- and undernutrition), personalized counseling, and multidisciplinary monitoring. A healthy, plant-based diet with adequate nutrients is recommended, along with avoiding overuse of dietary supplements and adhering to food safety procedures. Following these guidelines, along with recommendations for preventing other chronic diseases, can minimize treatment-related side effects and enhance long-term survival and health outcomes for cancer survivors.^3,4

The American College of Sports Medicine's guideline recommends 150 minutes per week of moderate dynamic exercise for patients with cancer.^5,6 Exercise during and after treatment improves functionality, manages side effects, and enhances treatment outcomes. Aerobic and resistance training are particularly beneficial for managing anxiety, depression, physical function, and lymphedema. Cancer survivors should follow tailored exercise and nutrition plans to improve tolerance and overall quality of life.^5,6

Likewise, ASCO guidelines recommend that oncology providers encourage aerobic and resistance exercise during active cancer treatment to mitigate side effects such as fatigue, improve physical functioning, and enhance quality of life, with a particular emphasis on preoperative exercise for patients with lung cancer to reduce hospital stays and postoperative complications.⁴ ASCO highlights the current lack of evidence for specific support dietary interventions or intentional weight loss during treatment and discourages neutropenic diets for infection prevention.⁴ Further research into diet and weight management strategies during cancer treatment is needed, while discussion about healthy diet and weight should continue between clinicians and patients.

IMPROVING QUALITY OF LIFE THROUGH COMPREHENSIVE SUPPORTIVE CARE

Incorporating psychosocial, nutritional, and physical activity recommendations into cancer treatment is crucial for enhancing the overall quality of life of patients.^1-6 Psychosocial care helps to mitigate anxiety, depression, and other psychological symptoms.⁷ Providing patients and their caregivers with information and resources about mental health, using evidence-based psychological interventions, and ensuring follow-up and patient satisfaction can significantly improve patients' mental well-being.⁷ Prioritizing psychosocial care can lead to better adherence to treatment plans and a more holistic approach to cancer care, ultimately fostering a supportive environment that recognizes the psychological burdens of cancer.⁷

Medical nutrition therapy is another vital component in the management of patients with cancer. Proper nutrition can help maintain body weight, reduce treatment-related side effects, and improve overall treatment outcomes.⁴ Routine screening for malnutrition is crucial for timely intervention.^8,9 As patients conclude treatment, a post-treatment nutrition plan can reduce the risk of cancer recurrence and long-term side effects. Emphasizing a balanced diet, managing symptoms that affect nutrition, and considering additional nutritional support strategies when necessary can help maintain strength and energy levels crucial for their recovery. Improved medical nutrition therapy can also enhance treatment tolerance and reduce symptoms.⁹

Physical activity is equally important in the comprehensive care. Regular exercise improves physical functioning, reduces fatigue, and enhances quality of life during and after treatment.^5,10,11 Tailored exercise programs on the basis of the patient's condition, type of cancer, and treatment stage provide significant benefits. Encouraging even small amounts of regular physical activity can help maintain independence and improve overall health outcomes.^4,5 Early and ongoing promotion of physical activity is essential for the whole care of patients with cancer.

Despite their clear benefits, implementing these comprehensive care recommendations poses several challenges. The integration of psychosocial, nutritional, and physical activity interventions into standard cancer care requires multidisciplinary collaboration and adequate resources. Many health care settings face limitations in access to trained professionals, such as dietitians, certified exercise trainers, and mental health practitioners, and may struggle with time constraints and financial barriers.^12,13 Additionally, individualizing care plans to meet the unique needs of each patient requires continuous assessment and adaptation, which can be resource-intensive. Addressing these challenges is essential for the successful implementation of guidelines, ensuring that all patients can benefit from comprehensive care that supports their physical, emotional, and nutritional health.

LEVERAGING TELEHEALTH FOR PROVIDING COMPREHENSIVE SUPPORTIVE CARE

Telehealth has emerged as a valuable tool in delivering comprehensive supportive care, especially after the COVID-19 pandemic highlighted the usefulness of remote health care solutions (Fig 1). Notably, telehealth overcomes geographical barriers, providing access to specialized care for patients in remote or underserved areas. Government organizations worldwide are increasingly transitioning in-person activities to web-based platforms, a shift that has highlighted the numerous advantages of digital technology.¹⁴ This has also been recognized by the WHO as feasible, acceptable, and effective approaches to providing supportive care.¹⁵

FIG 1.

Telehealth has emerged as a valuable tool in delivering comprehensive supportive care.

For psychosocial support, telehealth enables virtual counseling sessions, support groups, and follow-ups, ensuring patients have timely access to mental health professionals. This is particularly beneficial for those facing mobility issues or residing in remote areas.^16,17 Telehealth can facilitate consistent monitoring and management of anxiety and depression, ensuring that patients receive the emotional and psychological support they need throughout their cancer journey.

Systematic reviews and meta-analyses have shown that telemedicine can improve quality of life and mitigate anxiety, distress, and depression among patients with cancer.^18,19 Other studies have also noted improvements in sleep disorders, sexual function, and fear of cancer recurrence.¹⁸ Data from low- and middle-income countries suggest that telehealth is feasible and effective in providing supportive and palliative care for patients, regardless of their age and disease stage.^20-23 In addition, app-based interventions can be an effective strategy for delivering standard of care supportive care to patients with cancer. For example, a recent study suggests that an app-based MBSR program improved physical and emotional symptoms among patients with metastatic cancer receiving treatment in the United States and various Brazilian cities.²⁴

In terms of medical nutrition therapy, telehealth can connect patients with dietitians for virtual consultations and assessments. Health care providers can conduct regular malnutrition screenings, offer personalized dietary advice, and monitor patients' nutritional intake and progress through telehealth. Virtual platforms can also provide educational resources and support groups focused on healthy eating and managing treatment-related dietary challenges. This approach moves care traditionally confined to the clinic into a patient’s home, reaching more people and ensuring that patients have ongoing access to nutritional guidance, which is crucial for maintaining strength and overall health during and after cancer treatment. Notably, with telehealth, patients are more likely to attend nutrition sessions, thereby improving their access to essential nutritional support.

Previous research has demonstrated that telehealth is feasible and effective in helping patients achieve better diet compliance and nutrition outcomes across all disease stages.^25-27 Notably, a study focusing on Hispanic cancer survivors in the United States suggested that texting interventions are feasible and acceptable for promoting lifestyle behavior changes among patients and their caregivers.²⁸ Furthermore, a randomized controlled feasibility trial found that telehealth interventions can promote weight loss and a healthy diet, with a promising effect on physical activity, blood glucose levels, and indicators of inflammation.²⁹

For physical activity recommendations, telehealth can play a pivotal role in educating, monitoring, and supporting patients with cancer. Digital tools such as wearables, activity trackers, and apps accessible via smartphones and tablets provide new avenues for empowering patients to self-manage their health behaviors.³⁰ These platforms can also facilitate virtual exercise programs, personalized fitness plans, and real-time feedback from physical therapists or certified exercise trainers. Patients can participate in guided exercise sessions from the comfort of their homes, making it easier to adhere to physical activity regimens. Additionally, telehealth allows for the remote monitoring of patients' progress and the adjustment of exercise plans on the basis of their evolving needs and capabilities. Preliminary studies support the feasibility and effectiveness of telehealth supervised exercise in oncology for patients with cancer irrespective of their age, disease stage, or country.^23,31-35 A previous meta-analysis has shown that exercise provided through telehealth can increase cardiorespiratory fitness and physical activity levels among patients with cancer while decreasing fatigue.³⁶

By integrating telehealth into cancer care specifically for supportive services, health care systems could provide additional options for patients to receive guideline-concordant comprehensive support addressing their psychosocial, nutritional, and physical activity needs.³⁷ Telehealth offers a more economical alternative for patients, eliminating the need for travel to clinics and overcoming logistical challenges such as arranging childcare. It also benefits health systems by reducing the need for physical space and additional personnel for tasks like patient check-ins and vital signs monitoring. This approach ultimately enhances patients' quality of life and improves treatment outcomes by increasing access to essential supportive care services.

IMPLEMENTATION OF TELEHEALTH IN ONCOLOGY

The successful implementation of telehealth in cancer care requires a multifaceted approach that extends beyond merely deploying specific supportive interventions.^38,39 Central to this is the establishment of robust technological infrastructure, including secure, user-friendly platforms that integrate seamlessly with electronic health records and facilitate real-time communication between patients and health care providers. Additionally, effective implementation involves comprehensive training for both providers and patients.⁴⁰ Providers must be adept at delivering care in a virtual setting, such as effectively using video conferencing tools to conduct thorough assessments and using digital platforms to track patient progress. Similarly, patients need the necessary skills to navigate telehealth platforms, including assessing virtual appointments, managing health data through apps, and troubleshooting basic technical issues. Additionally, they require resources like reliable Internet access, compatible devices, and a private space for consultations to fully engage in telehealth sessions.⁴⁰

Regulatory considerations also play a significant role, as compliance with patient privacy laws, data security regulations, and cross-jurisdictional practice guidelines is essential for maintaining trust and legal integrity.³⁹ Moreover, addressing patient engagement challenges—such as technological literacy and Internet access—is crucial.³⁹ Offering technical support, providing devices to those in need, and designing accessible interfaces can help ensure that all patients, regardless of their circumstances, benefit from telehealth services.⁴¹

Finally, telehealth should be integrated with traditional in-person care, using a hybrid model that balances the benefits of both modalities.⁴⁰ This comprehensive approach to implementation is key to making telehealth a scalable, effective tool in oncology, enhancing the quality of care while expanding access to essential supportive services.

In conclusion, integrating patient-centric and guideline-recommended psychosocial, nutritional, and physical activity supportive interventions into cancer care is crucial for improving the quality of life and overall well-being of patients. These comprehensive approaches not only address the physical challenges of cancer treatment but also attend to the emotional and psychological needs of patients, promoting resilience and coping strategies. However, implementing these recommendations poses significant challenges due to resource constraints, variability in access to specialized care, and patient-level barriers. Telehealth represents a promising solution to overcome these challenges by facilitating remote access to essential health care services, promoting continuity of care, and enhancing patient engagement. By embracing telehealth technologies, health care systems and providers could optimize the delivery of comprehensive cancer care, ensuring that patients receive personalized support throughout their cancer journey. The growing body of evidence supporting telehealth's feasibility and effectiveness underscores its potential to improve patient outcomes, enhance quality of life, and reduce the burden on health care systems. As telehealth continues to evolve and be integrated into standard oncology practice, it promises to play a critical role in shaping the future of cancer care, ensuring that all patients receive the holistic support they need throughout their cancer journey.

AUTHOR CONTRIBUTIONS

Conception and design: Cristiane Decat Bergerot, Paulo Gustavo Bergerot, Errol J. Philip, Enrique Soto-Perez-de-Celis

Collection and assembly of data: Cristiane Decat Bergerot, Paulo Gustavo Bergerot, Enrique Soto-Perez-de-Celis

Data analysis and interpretation: Cristiane Decat Bergerot, Paulo Gustavo Bergerot, Renata Ferrari, Rafaela Mota Peixoto, Tracy E. Crane, Kathryn H. Schmitz, Enrique Soto-Perez-de-Celis

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by author of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/go/authors/author-center.

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