Abstract
Our objective was to assess gynecologic cancer survivor preferences for telehealth cancer care. Gynecologic cancer survivors participating in a prospective cohort study were invited to complete a cross-sectional survey regarding their experience with and preferences for telehealth. Of 188 participants, 48.9% had undergone a telehealth visit since March 2020, and 53.7% reported a preference for exclusively in-person visits for their cancer care and surveillance. Furthermore, 80.5% of participants were satisfied with the telehealth care they received and 54.8% would recommend telehealth services to patients with similar conditions. Most participants thought a physical examination was critical to detecting recurrence, and concern that their provider may miss something during telehealth visits was greater among those who preferred in-person visits. With many gynecologic cancer survivors preferring in-person care, building a future care model that includes telehealth elements will require adaptations, careful evaluation of patient concerns, as well as patient education on telehealth.
Keywords: gynecologic cancer, telehealth, cancer survivorship, cancer care delivery
Telehealth services most likely will be integrated into cancer care models, but cancer patients’ long-term preferences regarding telehealth are unknown and may differ depending on individual circumstances. This article assesses preferences for telehealth services among gynecologic cancer survivors.
Introduction
Several studies have highlighted benefits of telehealth including convenience, decreased costs, and reduced perceived distress.1,2 However, telehealth was not widely adopted until the SARS-CoV-2 pandemic when organizations such as the Centers for Disease Control and Prevention and Society of Gynecologic Oncology recommended remote visits to minimize risk of infection for patients and providers.3 Some telehealth elements will likely be integrated into cancer care long term; but preferences of patients with cancer with regard to telehealth are unknown and may differ depending on individual clinical circumstances and change as social distancing becomes less urgent.4 We assessed patient perspectives on telehealth among gynecologic cancer survivors and explored factors associated with interest in continuation of telehealth in order to inform post-pandemic gynecologic cancer care. We hypothesized that patients with greater concerns about the pandemic or with a primary cancer with reliable tumor markers for progression/recurrence would have greater preference for telehealth whereas older patients, those without access to technology, and patients who view a physical exam as critical would prefer in-person visits.
Materials and Methods
This study recruited from the ongoing Gynecologic Oncology—Life after Diagnosis (GOLD) prospective cohort study which has been described elsewhere.5 Briefly, the GOLD study recruited individuals between 2017 and 2020 with gynecologic cancer treated at the University of Minnesota, aged 18 years or older, and able to read and write in English. Participant recruitment was closed in spring 2020 and the cohort was transitioned from longitudinal surveys to a cross-sectional design, with approximately biannual 1-time surveys on specific research questions. Of 457 total original GOLD participants, 316 were alive and invited in May 2021 to complete a cross-sectional survey (paper or online per participant preference) regarding telehealth use during the SARS-CoV-2 pandemic and preferences for gynecologic cancer care going forward. The telehealth-specific survey questions were adopted from the validated Service User Technology Acceptability Questionnaire,6 with additional items particular to gynecologic oncology care (Supplementary Table S1). A total of 199 (63.0%) participants completed the survey, with 188 providing sufficient data for this analysis.
The University of Minnesota Gynecologic Oncology clinics converted almost all survivorship visits to telehealth (telephone or video) starting March 2020. In-person visits were prioritized for patients with cervical and lower genital tract malignancies where physical examination was deemed imperative. All other patients were scheduled for telehealth, with exceptions at provider discretion based on patient and disease characteristics.
We described cohort characteristics, use of, preferences for, and satisfaction with telehealth visits, and perceived importance of a physical exam. We categorized participants into 2 groups based on their stated preferences for future gynecologic cancer care: those favoring an in-person-only care model versus those favoring telehealth alone or in combination with in-person care. We compared characteristics between these 2 groups using Chi-squared and Fischer’s exact tests.
Results
The median age of participants in this analysis was 64.1 years. Most participants self-identified as white, were not currently receiving cancer treatment, had access to reliable transportation and technology enabling telehealth, and felt confident in using telehealth technology (Table 1). Most (76.1%) reported contact with their gynecologic oncology provider since March 2020, and 48.9% reported ≥1 telehealth visit. Among those who used telehealth, 80.3% at least somewhat agreed they were satisfied with their experience and most agreed it saved time (75.7%) and was easier (61.4%) compared with in-person visits. Greater difficulty building a relationship with their provider (29.8%) was the most cited disadvantage of telehealth, while not having to travel (45.2%) and greater ease of scheduling around other obligations (30.3%) were frequently endorsed advantages.
Table 1.
Participant characteristics.
| Characteristic | n (%)∗ |
|---|---|
| Age at survey, years, median (range) | 64.1 (32.7-91.4) |
| Time since gynecologic cancer diagnosis, years, median (range) | 4.4 (1.4-23.8) |
| Race | |
| Non-Hispanic white | 184 (98.4%) |
| Asian | 2 (1.1%) |
| Black | 1 (0.5%) |
| Partner status | |
| In a relationship | 110 (62.2%) |
| Not in a relationship | 67 (37.8%) |
| Education | |
| Less than college degree | 100 (55.6%) |
| At least college degree | 80 (44.4%) |
| Household annual income | |
| <$50 000 per year | 57 (32.0%) |
| $50 000-99,999 per year | 63 (35.4%) |
| ≥$100 000 per year | 44 (24.7%) |
| Prefer not to say | 14 (7.9%) |
| Primary cancer disease site | |
| Cervical | 21 (11.2%) |
| Endometrial | 84 (44.7%) |
| Ovarian | 70 (37.2%) |
| Vaginal/vulvar | 13 (6.9%) |
| Current treatment status | |
| Not currently receiving treatment | 151 (80.8%) |
| Receiving initial treatment | 2 (1.1%) |
| Receiving treatment for disease progression/recurrence | 34 (18.2%) |
| Disease stage | |
| I | 97 (52.4%) |
| II | 24 (13.0%) |
| III | 55 (29.7%) |
| IV | 9 (4.9%) |
| Reliable transportation to clinic | |
| Yes | 182 (96.8%) |
| No | 6 (3.2%) |
| Access to telehealth via phone | |
| Somewhat or strongly agree | 172 (93.0%) |
| Neutral | 4 (2.2%) |
| Somewhat or strongly disagree | 9 (4.9%) |
| Access to telehealth via video | |
| Somewhat or strongly agree | 162 (88.0%) |
| Neutral | 5 (2.7%) |
| Somewhat or strongly disagree | 17 (9.2%) |
| Access to internet for telehealth video visits | |
| Somewhat or strongly agree | 164 (88.7%) |
| Neutral | 4 (2.2%) |
| Somewhat or strongly disagree | 17 (9.2%) |
| Confident using technology for telehealth visits | |
| Somewhat or strongly agree | 150 (82.9%) |
| Neutral | 4 (2.2%) |
| Somewhat or strongly disagree | 27 (14.9%) |
| Preferred mode of oncology visits | |
| In person only | 101 (53.7%) |
| Telehealth only | 6 (3.2%) |
| Combined, but primarily in person | 68 (36.2%) |
| Combined, but primarily telehealth | 13 (6.9%) |
| In contact with oncology team since COVID-19 pandemic began | |
| No | 45 (23.9%) |
| Yes | 143 (76.1%) |
| Any telehealth visits since March 2020 | |
| No | 96 (51.1%) |
| Yes | 92 (48.9%) |
Data expressed as n (%) unless otherwise indicated.
A majority (53.7%; 39.1% among those with ≥1 telehealth visit versus 67.7% among those without any telehealth visits, P < .0001) preferred exclusively in-person visits for their cancer care and surveillance; few preferred telehealth exclusively (1.6% telephone, 1.6% video visits). Those who were younger (<65 years old), had used telehealth during the pandemic, or were on active treatment were more likely to consider continuing some telehealth in the future (Table 2). Over half (58.8%) of participants considered a physical examination critical to detecting recurrence. Concern their provider may miss something during telehealth visits was more common (43.9% vs 19.5%) among those who preferred in-person visits only. Patients who had undergone imaging for cancer surveillance or monitoring of tumor markers (ie, CA-125) were more open to continuing telehealth visits as part of their care going forward. Primary cancer site and concerns about contracting SARS-CoV-2 were not associated with preference for future visit modalities.
Table 2.
Factors influencing preference for telehealth or in-person visits for gynecologic oncology care.
| Characteristic | In-person only (N = 101) | Telehealtha (N = 87) | P-value |
|---|---|---|---|
| Age category | .05 | ||
| <65 years | 45 (45.5%) | 52 (59.8%) | |
| ≥65 years | 54 (54.5%) | 35 (40.2%) | |
| Since March 2020, visits with oncology team have primarily been: | <.0001 | ||
| Telehealth—video | 7 (7.0%) | 20 (23.3%) | |
| Telehealth—telephone | 5 (5.0%) | 18 (20.9%) | |
| In-person | 71 (71.0%) | 32 (37.2%) | |
| None planned since March 2020 | 17 (17.0%) | 16 (18.6%) | |
| Any telehealth visits since March 2020 | <.0001 | ||
| No | 65 (64.4%) | 31 (35.6%) | |
| Yes | 36 (35.6%) | 56 (64.4%) | |
| Cancer site | .74 | ||
| Cervical | 12 (11.9%) | 9 (10.3%) | |
| Endometrial | 48 (47.5%) | 36 (41.4%) | |
| Ovarian | 34 (33.7%) | 36 (41.4%) | |
| Vaginal/vulvar | 7 (6.9%) | 6 (6.9%) | |
| Current treatment status | .004 | ||
| Not currently receiving treatment | 88 (88%) | 63 (72.4%) | |
| Receiving initial treatment | 2 (2.0%) | 0 (0.0%) | |
| Receiving treatment for disease progression/recurrence | 10 (10.0%) | 24 (27.6%) | |
| Has had tumor marker blood tests (ie, CA-125) since COVID-19 pandemic began | .05 | ||
| No | 64 (63.4%) | 41 (47.1%) | |
| Yes | 34 (33.7%) | 39 (44.8%) | |
| Uncertain | 3 (3.0%) | 7 (8.1%) | |
| Any imaging tests for surveillance since March 2020 | .02 | ||
| No | 76 (76.0%) | 50 (57.5%) | |
| Yes | 23 (23.0%) | 34 (39.1%) | |
| Uncertain | 1 (1.0%) | 3 (3.4%) | |
| Concern for contracting COVID-19 | .17 | ||
| Not at all | 35 (34.7%) | 16 (18.4%) | |
| Slightly | 31 (30.7%) | 27 (31.0%) | |
| Somewhat | 12 (11.9%) | 18 (20.7%) | |
| Moderately | 12 (11.9%) | 14 (16.1%) | |
| Extremely | 7 (6.9%) | 7 (8.1%) | |
| Already had it | 4 (4.0%) | 5 (5.8%) | |
| Feel physical exam is critical for detecting recurrence | <.0001 | ||
| Strongly agree | 76 (76.0%) | 34 (39.1%) | |
| Somewhat agree | 15 (15.0%) | 28 (32.2%) | |
| Neutral | 6 (6.0%) | 13 (14.9%) | |
| Somewhat disagree | 1 (1.0%) | 8 (9.2%) | |
| Strongly disagree | 2 (2.0%) | 4 (4.6%) | |
| Worry provider will miss something by telehealth | .01 | ||
| Strongly agree | 43 (43.9%) | 17 (19.5%) | |
| Somewhat agree | 24 (24.5%) | 28 (32.2%) | |
| Neutral | 19 (19.4%) | 26 (29.9%) | |
| Somewhat disagree | 3 (3.1%) | 6 (6.9%) | |
| Strongly disagree | 9 (9.2%) | 10 (11.5%) |
Telehealth alone or in combination with in-person care.
Discussion
Despite a high degree of technological access and acumen, many gynecologic cancer survivors in our study did not find telehealth visits an appropriate substitute to in-person visits, and about half preferred to have no telehealth care at all. Our data suggest that inherent limitations of telemedicine (eg, inability to perform a pelvic examination) may limit its wider acceptance post-pandemic. This mirrors other authors’ findings that the lack of a physical examination in gynecologic oncology telehealth increased patient anxiety and concerns about recurrence.7 Factors associated with finding telehealth visits acceptable in addition to in-person visits included having used telehealth, being in active treatment, having had blood tests or imaging during the pandemic, and being under 65 years old. These findings suggest that for those with frequent in-person visits or other time obligations such as work, some telehealth may be acceptable if coupled with in-person monitoring of potential cancer progression. Greater skepticism among those who never used telehealth highlights the importance of patient education regarding telehealth to foster acceptance. While providing key data to support future work, this study has limitations, including a cross-sectional study design and a study population of established cancer survivors with reliable transportation at one academic institution. Our overwhelmingly white patient population limits the generalizability of our findings since racial and ethnic minorities have been disproportionately affected by SARS-CoV-2,8 and Black patients have used telehealth more often during the pandemic than white patients.9
Moving forward, integrating a successful telemedicine practice into gynecologic oncology will require targeted adaptions,10 thoughtful patient selection, and patient education to ensure telehealth offerings align with best practices and patient preferences.
Supplementary Material
Contributor Information
Nicholas Quam, Department of Obstetrics, Gynecology and Women’s Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA.
Ashley E Stenzel, Department of Obstetrics, Gynecology and Women’s Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA; Program in Health Disparities Research, Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN, USA.
Katherine Brown, Department of Obstetrics, Gynecology and Women’s Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA.
Patricia Jewett, Department of Obstetrics, Gynecology and Women’s Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA; Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA.
Helen M Parsons, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA.
Jane Hui, Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
Rahel G Ghebre, Department of Obstetrics, Gynecology and Women’s Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA.
Anne Blaes, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA.
Deanna Teoh, Department of Obstetrics, Gynecology and Women’s Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA.
Rachel I Vogel, Department of Obstetrics, Gynecology and Women’s Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA.
Funding
This research was supported by the Masonic Cancer Center at the University of Minnesota by a National Institutes of Health National Cancer Institute grant (P30 CA77598). Support for the use of REDCap was provided by a National Institutes of Health’s National Center for Advancing Translational Sciences grant (UL1TR002494). AES is supported by National Institutes of Health Cancer Health Disparities T32 Training Program (T32CA163184). R.I.V. is supported by a Department of Defense Ovarian Cancer Research Program Ovarian Cancer Academy Early Career Investigator Award (OC180392 W81XWH-19-1-0013). The funders had no role in the implementation of this study or presentation of results.
Conflict of Interest
The authors indicated no financial relationships.
Author Contributions
Conception/design: N.Q., P.J., H.M.P., J.H., R.G.G., A.B., D.T., R.I.V. Provision of study material/patients: D.T., R.I.V. Collection and/or assembly of data: K.B., R.I.V. Data analysis and interpretation: A.S., P.J. Manuscript writing: N.Q., A.S., K.B., P.J., H.M.P., R.I.V. Final approval of manuscript: All authors.
Data Availability
The data underlying this article will be shared on reasonable request to the corresponding author.
References
- 1. Cox A, Lucas G, Marcu A, et al. . Cancer Survivors’ Experience With Telehealth: A Systematic Review and Thematic Synthesis. J Med Internet Res. 2017;19(1):e11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Johnson BA, Lindgren BR, Blaes AH, et al. . The New Normal? Patient Satisfaction and Usability of Telemedicine in Breast Cancer Care. Ann Surg Oncol. 2021;28(10):5668-5676. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Schrag D, Hershman DL, Basch E.. Oncology Practice During the COVID-19 Pandemic. JAMA: the Journal of the American Medical Association. 2020;323(20):2005-2006. [DOI] [PubMed] [Google Scholar]
- 4. Mojdehbakhsh RP, Rose S, Peterson M, Rice L, Spencer R.. A quality improvement pathway to rapidly increase telemedicine services in a gynecologic oncology clinic during the COVID-19 pandemic with patient satisfaction scores and environmental impact. Gynecol Oncol Rep. 2021;36:100708. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Jewett PI, Teoh D, Petzel S, et al. . Cancer-Related Distress: Revisiting the Utility of the National Comprehensive Cancer Network Distress Thermometer Problem List in Women With Gynecologic Cancers. JCO Oncol Pract. 2020;16(8):e649-e659. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Hirani SP, Rixon L, Beynon M, et al. . Quantifying beliefs regarding telehealth: Development of the Whole Systems Demonstrator Service User Technology Acceptability Questionnaire. J Telemed Telecare. 2017;23(4):460-469. [DOI] [PubMed] [Google Scholar]
- 7. Khan ZM, Kershaw V, Madhuvrata P, Radley SC, Connor ME.. Patient experience of telephone consultations in gynaecology: a service evaluation. BJOG: an International Journal of Obstetrics and Gynaecology. 2021;128(12):1958-1965. [DOI] [PubMed] [Google Scholar]
- 8. Tai DBG, Shah A, Doubeni CA, Sia IG, Wieland ML.. The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States. Clin Infect Dis. 2021;72(4):703-706. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Campos-Castillo C, Anthony D.. Racial and ethnic differences in self-reported telehealth use during the COVID-19 pandemic: a secondary analysis of a US survey of internet users from late March. J Am Med Infrom Assoc. 2021;28(1):119-125. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Mancebo G, Sole-Sedeno JM, Membrive I, et al. . Gynecologic cancer surveillance in the era of SARS-CoV-2 (COVID-19). International Journal of Gynecological Cancer: Official Journal of the International Gynecological Cancer Society. 2021;31(6):914-919. [DOI] [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 underlying this article will be shared on reasonable request to the corresponding author.