A qualitative study of patients’ attitudes towards telemedicine for gynecologic cancer care

Abstract

Introduction.

Women with gynecologic cancers may face geographic barriers to standard-of-care consultation with a gynecologic oncologist. While telemedicine may help overcome these geographic barriers, there are no qualitative data exploring gynecologic cancer patients’ attitudes towards telemedicine for cancer care. Patients with gynecologic malignancies may have preferences distinct from general oncology populations due to the sensitive nature of the diseases and anatomy involved.

Methods.

Semi-structured interviews were conducted with 15 patients with gynecologic cancers to identify perceived advantages and disadvantages of telemedicine use for gynecologic cancer care. Past experience with telemedicine was elicited as were suggestions for cancer care encounters most compatible with telemedicine. Interviews were transcribed, coded, and analyzed for emergent themes.

Results.

All patients interviewed were open to the use of telemedicine. Emergent themes regarding advantages of telemedicine included convenience, cost savings, reduced travel, avoidance of infectious disease, and availability of care for those too unwell for in-person visits. Themes regarding disadvantages of telemedical care included technical difficulties, perceived need for examination or testing, and potential compromise of therapeutic relationship. Patients were particularly concerned that difficulty in establishing a therapeutic relationship would compromise initial consultations with gynecologic oncologists via telemedicine.

Conclusion.

Patients with gynecologic cancer are open to use of telemedicine for their care. Particular attention should be paid to overcoming patients’ hesitancy to have initial visits with gynecologic oncologists, as these consultations have the greatest potential to improve access to high-quality gynecologic cancer care.

1. Introduction

Approximately 117,000 new gynecologic cancers were diagnosed in 2021, with approximately 34,000 deaths resulting from these diseases [1]. In the United States, the standard of care for patients with gynecologic cancers includes consultation with a gynecologic oncologist. Unfortunately, many women are at risk for geographic barriers to receiving the standard of care for their disease; approximately 15 million women live greater than 50 miles from a gynecologic oncologist [2]. These predominantly rural populations are at increased risk for adverse cancer-related outcomes at least in part due to challenges in accessing high-volume subspecialty care [3–5].

Telemedicine may improve patients’ access to gynecologic oncologists by decreasing the burdens of long-distance travel for care [6]. While stakeholder assessment and effectiveness data exist for telemedical care of non-gynecologic malignancies, data are scarce regarding the specific application of telemedicine to care of patients with gynecologic cancers [6]. Unique among cancer care providers, gynecologic oncologists are trained to provide both surgical and medical (e.g., chemotherapeutic) intervention. Likewise, patients with gynecologic malignancies may have needs and preferences distinct from patients with other types of cancers given the organ systems involved and treatment regimens they undergo. Any potential telemedical intervention must therefore take into account the needs, facilitators, barriers, and patient preferences associated with utilization of telemedicine to expand access to gynecologic cancer care.

To our knowledge, there have been no qualitative investigations of patients’ attitudes towards telemedical gynecologic cancer care. We conducted this study to address this gap in data and to guide future intervention-directed research to expand geographic access to high-quality gynecologic cancer care. Importantly, the overarching goal of this study was to elicit broad themes underlying gynecologic cancer patients’ perception of the use of telemedicine for their care, in order to inform future quantitative investigations of attitudes and preferences in specific populations.

2. Methods

2.1. Participants and setting

Participants were recruited from women receiving gynecologic cancer care at the Wake Forest Comprehensive Cancer Center (WFCCC) in Winston-Salem, NC. WFCCC serves a largely rural 30-county region of western and central North Carolina, southwestern Virginia, and eastern Tennessee. 1200–1400 unique patients are evaluated annually. Approximately 10% of patients are enrolled in Medicaid, and 8–10% are uninsured and/or receive institutional charity care. Eligibility criteria included an active diagnosis or history of a gynecologic cancer. Patients were excluded from participation if they could not be interviewed in English. Goal enrollment was 15 patients, as we anticipated thematic saturation with this number of participants, based on our previous qualitative work with this population [7]. If thematic saturation was not reached, we planned to continue enrollment. We employed purposive sampling to recruit patients of different ages, disease sites, and phases of cancer care, as we judged these to be the most important categories specifically related to the potential use of telemedicine for gynecologic cancer care. Participants were enrolled between January and May 2021. We report results following the consolidated criteria for reporting qualitative research (COREQ) [8].

2.2. Procedure

Semi-structured telephone interviews were conducted by one of two study personnel trained in qualitative techniques (EK, BN) following a pre-planned interview guide. Study personnel were nurse practitioner-(BN) and physician (EK, DS) members of the cancer care team. Interview questions were designed to incorporate domains of the Technology Acceptance Model, a validated predictor of utilization of new technologies in clinical settings [9]. Specifically, questions were designed to elicit views regarding the usefulness and ease-of-use of telemedicine for gynecologic cancer care. Patients were also asked to describe their experiences with telemedicine for care of any kind, types of cancer care they felt were best suited for telemedicine (e.g., perioperative, chemotherapy, or consultative visits), and consider differences between telemedical care for cancer and non-malignant diseases (Appendix). Participants received a $25 gift card after completion of the interview.

2.3. Qualitative analysis

Interviews were audio-recorded, transcribed, and compared to recordings for accuracy. Initial content codes were derived from the transcribed text using the above domains as a guide; additional codes were added as concepts and themes emerged from the data. Two members of the study team (EK, BN) coded each transcript and reviewed coding with the senior author (DS). Thematic analysis was performed via NViVo 12. Coded segments were reviewed and summarized by their prevalence and salience in the data. The Institutional Review Board of Wake Forest Baptist Health approved this study.

3. Results

3.1. Participant characteristics

Enrollment was completed after 15 interviews, as no new themes emerged, and thematic saturation was judged to have been reached. Patients were 100% female, with mean age 58 years (range 38–75). All patients identified as white, non-Hispanic. Eight patients were diagnosed with cancer of the ovary, three patients with cancer of the endometrium, two patients with primary peritoneal carcinoma, and one patient each with cervical and vaginal cancers. Nine patients were undergoing active treatment at the time of their interviews; five patients had no evidence of active disease and were undergoing surveillance, and one patient was interviewed after a perioperative visit. Educational level was generally high; 6 patients had completed college or graduate degrees, 2 patients had completed some college, and 7 had completed high school. 3 patients traveled more than 30 miles for their clinic visit, seven traveled between 15 and 30 miles, and 5 traveled less than 15 miles (Table 1). Interviews lasted a median of 11:31 min, (range 7:26 to 18:15 min). Two major themes arose from analysis, each with multiple subthemes.

Table 1.

Participant characteristics.

#	Age	Race/ethnicity	Disease site	Phase of care	Education level	Distance traveled for care (miles)
1	73	White, Non-Hispanic	Vagina	Surveillance	High School	17.7
2	64	White, Non-Hispanic	Cervix	Chemotherapy	College Graduate	5.7
3	62	White, Non-Hispanic	Endometrium	Surveillance	High School	12.0
4	75	White, Non-Hispanic	Peritoneum	Chemotherapy	High School	18.3
5	66	White, Non-Hispanic	Ovary	Chemotherapy	High School	14.0
6	74	White, Non-Hispanic	Ovary	Chemotherapy	Graduate Degree	18.3
7	43	White, Non-Hispanic	Ovary	Perioperative	High School	17.7
8	73	White, Non-Hispanic	Endometrium	Surveillance	Graduate Degree	24.2
9	38	White, Non-Hispanic	Ovary	Chemotherapy	Some College	38.8
10	43	White, Non-Hispanic	Ovary	Chemotherapy	College Graduate	18.3
11	46	White, Non-Hispanic	Peritoneum	Chemotherapy	College Graduate	12.0
12	54	White, Non-Hispanic	Ovary	Surveillance	High School	24.2
13	55	White, Non-Hispanic	Endometrium	Surveillance	Some College	33.8
14	55	White, Non-Hispanic	Ovary	Chemotherapy	High School	14.0
15	63	White, Non-Hispanic	Ovary	Chemotherapy	Graduate Degree	52.6

3.2. Theme 1: Advantages of telemedicine for gynecologic cancer care

3.2.1. Convenience

In general, participants described telemedicine appointments as more convenient than in-person visits due to decreases in travel and clinic wait times, and increased comfort at home. One participant mentioned being able to step away from work to complete a virtual visit without interrupting the day. Seven participants felt they could schedule an appointment more quickly through telemedicine than in person. Five participants noted the importance of quick communication for cancer care compared to routine healthcare.

“There’s things that come up with the stress of just having cancer that at times you might see a lab report or something and it really upsets you. If you had that option with the telemedicine versus having to wait ‘til you get an appointment and talk about it, you could get a faster response maybe to ease some of the stress off of it. There’s just so much emotional happening when you’re going through cancer versus having a sore throat or something else” - Participant 5.

Four participants felt that cancer care did not necessarily carry more urgency than care for other health conditions.

Four participants preferred telemedicine visits rather than communication via email, an online patient portal, or voicemail. Participant 15 said, “I think having [the] regular ability to talk about symptoms, be able to communicate quickly and easily [is preferable to] actually having to get in your car and go someplace and make an appointment, which is tough to do given schedules.”

3.2.2. Travel and associated costs

Twelve participants identified avoidance of travel as an advantage. The majority of these participants felt telemedicine could help overcome the barrier of travel for patients who travel long distances. Several participants reported that virtual visits could save them more than an hour of driving time.

Participants also identified gas, parking, and compensating a driver as costs associated with travel. For a few participants, a friend or family member was needed to bring them to their visits: Participant 4 said, “It’s really kinda hard on me to make all these trips in there because my sister-in-law brings me, and I have to pay copay, and then I have to pay her gas money, and that gets pretty expensive for me, livin’ off my Social Security check.” Some participants also mentioned discomfort with driving into an unfamiliar city to visit the cancer center.

3.2.3. Health state

Six participants identified telemedicine as beneficial for times when a patientis too sick or in pain for an in-person appointment. Twelve participants mentioned having to sit in the waiting room while feeling unwell from chemotherapy; 14 mentioned feeling ill as a barrier to travel, while only 1 participant suggested that feeling ill would be a barrier to a telemedicine visit.

I would tell my daughter, “Okay, now we go sit and wait.” Now we have to find out whether or not, are we gonna be able to do chemo today or we not gonna be able to do chemo today? It would be nice ‘cause you feel terrible. You feel just terrible. Your whole body is just not right after having chemo or even starting chemo.” - Participant 12.

One participant mentioned post-operative discomfort as a barrier to traveling to an in-person post-operative visit.

3.2.4. Infectious disease risk

As these interviews were conducted during the SARS-CoV-2/COVID-19 pandemic, eleven participants mentioned that cancer care via telemedicine carries the additional benefit of minimizing exposure to infectious disease. Nearly half of participants reported feeling safer with telemedicine visits as a result.

3.3. Theme 2: Disadvantages to telemedicine for gynecologic cancer care

3.3.1. Initial visit

Ten participants expressed a preference for having the initial visit in person. Participants expressed that they perceived it to be easier to establish trust and rapport in person than remotely. Others mentioned the need for an examination by the provider at the first visit, or needing to be in person to process complex information and ask questions. Participants mentioned it felt more comforting to be in person to discuss new information or hear about prognosis.

“I think the initial visit would need to be in person because I think there has to be some kind of rapport built up with your doctor from the beginning to get that trust level and confidence in what’s going to take place.” – Participant 6.

“I think the initial visit, when you’re setting up your care plan, you need to be there in person with your doctor. You need to know that they’re human… That very first one, where you’re frightened and threatened and don’t know what it means, it’s nice to have the doctor take the time and walk you through that in person.” -Participant 15.

3.3.2. Technology

Eight participants had previously participated in telemedicine visits (for any kind of medical care), and five of these reported technological difficulties, most commonly with video functionality. Participant 10 said, “I had to meet with them [daughter’s provider] every two weeks, and it was a disaster. Sometimes, the Zoom volume would work. Sometimes, it wouldn’t. Sometimes, Zoom wouldn’t work at all, so we had to use Facebook whatever it is, so there were a lot of technical difficulties. Same thing with her PT [physical therapy].”

Seven participants (age range 43–74 years) referenced age as a potential barrier. Some of these participants identified as “older” and thought that age influenced their ability to use technology. Four participants mentioned they or others would need assistance when using the technology at first. Participants identified two types of support that could help them successfully participate in telehealth appointments: 1) having someone available to help them set up the visit (most indicated that they had access to someone who could do this), and 2) having someone show them how to use the telehealth platform or explain the process in advance of the appointment (e.g., clinic staff). Two participants emphasized that setup/explanation should be done prior to the telehealth appointment, and that the appointment should not be the first time someone is using or learning the technology.

“I think with seniors, it’s a new process. You definitely have to encourage it to be used. ’Cause I know that when COVID came up, I was trying to get to a urologist, and he did not want to see me. He was willing to talk to me through telemedicine, and I really didn’t know how to do it. I never have done it, so I just think that if it’s a senior, you gotta make sure that we understand how to use it.” – Participant 1.

3.3.3. Patient-physician communication

The majority of participants expressed some concerns about communication through telemedicine. Nine participants felt it was important to develop rapport with a provider before they would feel comfortable doing telemedicine. Ten participants specifically expressed a desire for the first visit to be in person, in order to build rapport with their oncologist. Seven participants described in-person visits as more reassuring and more in-depth, and five patients said they preferred not to use telemedicine because it was less personal or uncomfortable. Participant 7 said, “With this type of care I think it’s just more personal. If you know your doctor, then it’s okay, but talking to a stranger, it could be a little weird.” One patient suggested patients would find telemedical visits to be “comforting” once they had established rapport with their clinicians.

Four participants expressed concerns about understanding their doctor or being able to explain themselves effectively through telemedicine. Participant 11 felt she would not understand the plan unless it was explained to her in person: “If I had to get a surgery, I would like to be, personally, told in person ’cause that’s personal to me. I’d like to be told why and how, and I want them to explain to me. If I’m not in front of you, I’m not going to understand.” However, four participants felt that communication would not be substantially impaired via telemedicine. One participant said reading facial expressions and being able to tell clinicians were paying attention to her was important. Two participants cited distractions at home as a barrier to communication (for example, the presence of pets, other people in the house, and the need for privacy), however five participants noted having a comfortable, private space at home that made telemedical visits possible.

Five participants learned of their cancer diagnosis over the telephone or via a patient portal. Three described this experience as “unprofessional” or “impersonal;” however, one participant acknowledged that receiving her results remotely gave her time to process her diagnosis prior to her appointment.

3.3.4. Need for exams or testing

Multiple participants expressed they were unsure how telemedicine could work for their care given the need for in-person imaging, laboratory evaluation, and examinations. One patient felt that exams were vital to her care. Three participants were unable to see how telemedicine could play a role in their care given frequent chemotherapy or radiation treatments that must occur in person. Two patients mentioned having blood work done prior to treatments and did not think this testing was compatible with telemedicine visits. Seven participants expressed willingness to review test results via telemedicine; one preferred discussing imaging in person, and one had mixed feelings about receiving results via telemedicine.

4. Discussion

To our knowledge, this study is the first qualitative investigation into patients’ perceptions of barriers and benefits related to the use of telemedicine for gynecologic cancer care. Patients were overall open to the use of telemedicine and recognized the potential for improvement in convenience and travel burdens. This finding is consistent with a single-institution survey finding that 76% of gynecologic cancer patients were interested in receiving care via telemedicine, including 89% of rural patients [10]. Simultaneously, however, most patients in our sample expressed logistical concerns (e.g., related to technology, and coordination of in-person testing) and concerns related to the establishment of rapport with their oncologist if initial visits are conducted virtually. Many of the concerns noted by participants were specifically related to cancer care (e.g., communication of cancer diagnosis, routine laboratory testing, and delivery of chemotherapy), and some were related to gynecologic care (e.g., feasibility of pelvic examination via telemedicine). Overall, the themes identified were consistent with the current literature on patients’ views on telemedicine for general cancer care.

Our patient sample may have underestimated their potential satisfaction with telemedical cancer care. Available data suggest a high overall patient satisfaction rate when cancer care is delivered via telemedicine: a systematic review of 19 trials including 709 patients suggested that a variety of clinical outcomes are not compromised by virtual visits and that physicians and patients are satisfied with remote interaction [11]. Additionally, a more recent single-institution survey, composed of a mixed population of gynecologic and breast cancer patients, found a 92% satisfaction rate with delivered telemedical care [12]. However, data specifically from gynecologic cancer patients are scant, and acceptance of telemedicine may be more challenging in this population than in a general oncology population owing, at least in part, to the sensitive nature of the diseases and anatomy involved.

Patients reasonably raised concerns about the ability to perform a physical examination and obtain laboratory and radiographic testing. These concerns are consistent with the preferences of patients in general medical oncology setting [13,14], but can be addressed, especially if virtual consultation with a gynecologic oncologist occurs in a local clinic with a non-physician practitioner present who is trained to perform the relevant examination or procedure [15]. Some of our participants may be responding to well-described challenges in providing clinician-patient telemedical consultation to patients’ homes, which are dependent on the varying quality of patients’ telecommunication devices and internet access [16]. Technological infrastructure is also much less likely to be an issue if patients’ virtual visits are conducted in a clinic, rather than at home (or on a mobile device). Of note, most patients we interviewed seemed to consider only the latter case; more work is needed to investigate the role of remote infrastructure (e.g., outreach clinics) to support telemedical access to cancer care.

Patients’ expressed trepidation about virtual initial consultation with a gynecologic oncologist deserves special consideration for two reasons. First, an initial consultation for diagnosis and treatment planning may arguably be the most important visit in the continuum of patients’ cancer care, especially when subspecialists’ recommendations are provided. Second, one of the most critical decisions in the assessment of advanced ovarian and endometrial cancers is initial triage to medical or surgical therapy. There is strong evidence associating survival with complete tumor cytoreduction performed by a gynecologic oncologist; current professional guidelines recommend that a gynecologic oncologist make the decision regarding surgical triage [17]. As such, remote initial triage may be the most important application of telemedicine to decrease geographic barriers in access to gynecologic cancer care. It is therefore critical that outreach be initiated to overcome “telemedicine hesitancy” for patients who are unable to travel long distances for gynecologic cancer care, and who may have prohibitive concerns about telemedicine. Outreach should include solicitation of concerns, and education about what to expect during a virtual visit. Concerns should be addressed when possible, and used to guide investigation into the use of telemedicine to expand access to gynecologic cancer care.

This qualitative study was limited by data collection from a single institution and lack of self-reported racial and ethnic diversity. Reluctance to utilize telemedicine may be associated with completion of a high school education or less [18]; we were able to sample the relevant educational spectrum adequately. Additionally, there was substantial diversity among participants with regard to disease site, phase of cancer treatment, and distance traveled to their clinic visits. Clinical practices considering the use of telemedicine to improve access to gynecologic cancer care should ensure that stakeholder input is solicited from representative patient populations. Nevertheless, this study does represent the first qualitative investigation into gynecologic cancer patients’ views.

Although many of the concerns expressed by patients in our sample mirror findings from general oncologic populations, we suggest that specific adaptations may be needed to implement telemedicine as an integral part of high-quality gynecologic cancer care delivery. Particular attention should be paid to gynecologic oncologists’ geographic clustering [19], unique scope of practice, and frequent role as a consultant to general medical oncologists. Consideration should also be given to measures that improve patients’ comfort with virtual oncology care for diseases of the female reproductive tract. Institutions’ clinical workflow should be robust enough to support both in-person and telemedical care as components of rational infrastructure supporting access to high-quality gynecologic cancer care. Finally, while substantial focus has been placed on telemedicine’s potential to expand rural patients’ access to gynecologic cancer care, our study highlights the benefits of this technology to other patient populations, including those for whom an in-person visit would be uncomfortable, cost-prohibitive, or expose patients to risks of infectious disease.

HIGHLIGHTS.

• Cost, convenience, safety, and comfort were identified as advantages of telemedical care for gynecologic cancers.

• Testing, examination, and clinician-patient rapport were perceived as barriers to high-quality care via telemedicine.

• Participants were particularly concerned about initial visits and cancer diagnoses delivered remotely.

• These themes should be used as patient-reported outcomes for implementation of telemedicine for gynecologic cancer care.