Breast Medical Oncologists' Perspectives of Telemedicine for Breast Cancer Care: A Survey Study

PURPOSE:

The COVID-19 pandemic forced rapid adoption of telemedicine (TM) for breast oncology visits in the United States, but the appropriate role of postpandemic TM is uncertain. We sought to understand physician and advance practice practitioner perspectives on the use of TM for outpatient breast cancer care through an electronically administered survey.

METHODS:

Breast medical oncology clinicians at two academic cancer centers and five satellite locations affiliated with the Dana Farber Cancer Institute and the Massachusetts General Cancer Center were invited to respond to a 21-question survey administered in September 2021 about clinicians' perceptions and attitudes toward TM during the previous 12 months.

RESULTS:

Of the 71 survey invitations, 51 clinicians (36 physicians and 15 advance practice practitioners) provided survey responses (response rate = 72%). Ninety-two percent of respondents (n = 47) agreed that TM visits enhance patient care. Ninety-two percent of respondents (n = 46) also agreed that TM is valuable for early-stage breast cancer follow-up visits. Most respondents felt that there was no difference between TM and face-to-face (F2F) visits when it came to patient adherence, ease of ordering tests, ease of accessing patient records, and workflow outside of the visit (82%, 82%, 78%, and 53%, respectively). Fifty-one percent of respondents (n = 26) said that TM was better for timely access to follow-up appointments. Most respondents said that F2F visits were better for seeing physical problems, personal connection with patients, overall quality of visits, and patient-physician communication (100%, 75%, 65%, and 63%, respectively).

CONCLUSION:

Breast clinicians believe that TM is a valuable tool to enhance outpatient breast cancer care. TM was felt to be appropriate for routine follow-up visits and second opinion consultations and is as good as or better than F2F visits for several routine aspects of breast cancer care.

INTRODUCTION

Telemedicine (TM) has emerged over the past decade as a health care delivery tool to provide medical services remotely. In oncology, before the COVID-19 pandemic, TM was largely restricted to rural populations, where its use was correlated with timelier patient assessment and diagnosis (shorter wait times to see oncologist), access to subspecialty care for patients who live in remote or rural areas, increased convenience and cost savings for patients, family and caregivers related to travel, and shortened time away from work, among other benefits.^1-7 Despite these benefits, TM utilization has been historically limited because of barriers including inconsistent, inadequate, and stringent coverage and reimbursement of TM services, clinician and patient hesitation (eg, preference for traditional in-person visits), disparities in access to TM technology including broadband internet, and lack of appropriate TM infrastructure in health care systems.⁸

Oncology practices rapidly instituted TM to deliver cancer care during the COVID-19 pandemic. This was due to public health emergency–related changes in regulation and reimbursement and ultimately out of concern that patients with cancer are at higher risk of severe COVID-19 infection.^9-12 Importantly, the Centers for Medicare and Medicaid Services loosened geographic restrictions around TM and introduced payment parity for TM and in-person visits.

As the pandemic subsides, TM coverage policies have become less flexible and states have renewed practice limitations on cross-border TM, and as a result, most oncology care has returned to in-person delivery. Yet, the advantages of TM are now more obvious to patients and clinicians alike, and the demand for TM remains. Thus, there is a need to understand clinician preferences regarding the utility of TM for the care of patients with breast cancer in the future.

Breast cancer is a highly prevalent disease with many long-term survivors who have frequent surveillance visits but may have a lower risk of recurrence relative to other cancers. Therefore, these patients may benefit from TM to a greater extent than patients with malignancies that have less protracted courses or are associated with higher symptom burden. Because treatment and surveillance modalities and patterns differ by cancer type, the utility of TM may similarly vary by cancer type, and US-based data on clinician perspectives on TM utilization for breast cancer are limited.

In this article, we describe results from a survey that assessed the attitudes and perceptions of TM for breast medical oncology care by breast medical oncologists at two academic cancer centers and community affiliate sites.

METHODS

Study Design

This was a cross-sectional one-time email survey administered to all breast medical oncology clinicians (physicians and advance practice practitioners [APPs]) at seven clinics (five community practices and two urban main campus practices) at two academic medical cancer centers, the Dana Farber Cancer Institute (DFCI) and the Massachusetts General Cancer Center. At the time that the survey was administered, breast oncology clinicians had been using TM services since the start of the COVID-19 pandemic in March 2020. TM visits were performed either (1) when the clinicians felt that pandemic-related risks outweighed the need for an in-person visit or (2) on the basis of patient preference. Support and training for clinicians in the use of TM services was guided by institutional practices and guidelines at each respective breast oncology clinic.

This study was approved by the Dana Farber Institutional Review Board.

Survey Development

We developed the Clinician TM Satisfaction survey, which was adapted from the Massachusetts General Hospital TeleHealth Provider Survey¹³ and revised after feedback from breast oncology clinicians at DFCI. The survey included 21 items that assessed clinicians' attitudes and preferences regarding TM for breast medical oncology care, on the basis of their experience using combined video-audio TM in the previous 12 months (Data Supplement, online only). In the survey, TM was defined as combined video-audio communications. Four questions assessed clinician perspectives on the use of TM for breast medical oncology care using 5-point Likert items. Eleven questions asked clinicians to rate several aspects of breast cancer care on whether TM is better, in-person visits are better, or if there is no difference between the two. The remaining items asked about professional demographic information about the clinician respondents.

The survey was pilot tested before distribution by a small number of faculty members in the Dana Farber breast medical oncology and Population Sciences divisions (the latter were not included in the final study population).

Survey Distribution and Data Collection

All physicians, nurse practitioners, and physician assistants who see patients at seven breast medical oncology outpatient clinics affiliated with the DFCI and the Massachusetts General Hospital Cancer Center were invited to respond to the survey via email. The surveys were distributed by personalized email generated by the survey distribution tool in Research Electronic Data Capture. The surveys were distributed from July through September, 2021. Surveys were re-sent to nonresponders weekly for 2 weeks after the initial survey invitation.

Analysis Plan

All responses were collected electronically through Research Electronic Data Capture. The collective questionnaire results were analyzed in the SAS statistical software. The results of the survey questions are descriptive. Fisher's exact test was used to compare responses between prespecified subgroups, and a P value of .05 was considered statistically significant.

The reporting of this survey study was prepared using the consensus-based checklist for reporting of survey studies.¹⁴

RESULTS

Respondent Characteristics

Seventy-one unique breast medical oncology clinicians were invited to participate, and 51 provided survey responses (response rate of 72%). Thirty-seven (74%) of the respondents were female, 36 (72%) were physicians, and 14 were APPs (28%, Table 1). Twenty (40%) of the respondents had been in practice for 10-20 years, and 26 respondents (52%) reported having 3-5 half-day clinic sessions per week. Forty (78%) of respondents reported having between 0%-25% of their visits in the last 30 days conducted by TM.

TABLE 1.

Clinician Characteristics

Value of TM Visits

Ninety-two percent of respondents (n = 47) agreed that TM visits are a valuable tool to enhance patient care, with 77% (n = 39) agreeing that they would miss TM visits if the option were no longer available (Fig 1). Ninety-two percent of respondents (n = 46) agreed that TM visits are valuable for early-stage cancer treatment follow-up visits and 78% of respondents (n = 40) agreed that TM visits are valuable for second opinion consultations who will not stay at that site for treatment.

FIG 1.

Breast medical oncologists' perspectives (N = 51) on the value of TM for specific clinical scenarios. DFCI, Dana Farber Cancer Institute; MGHCC, Massachusetts General Hospital Cancer Center; TM, telemedicine.

Comparing Virtual Visits to Face-to-Face Visits

Clinicians reported that TM was better or no different than face-to-face (F2F) visits for timely access to follow-up (51% TM better and 41% no difference), efficiency of visit (37% TM better and 47% no difference), and length of visit (35% TM better and 49% no difference; Fig 2). Most clinicians (82%) felt there was no difference between TM and F2F visits when it came to patient adherence to treatment, ease of accessing records, and ease of ordering tests. Clinicians reported that F2F visits were better for the ability to see a physical problem (100% F2F is better), personal connection with a patient (74% F2F better and 26% no difference), overall quality of visits (65% F2F better and 35% no difference), and quality of communication (63% F2F better and 37% no difference).

FIG 2.

Breast medical oncologists' perspectives (N = 51) regarding TM visits. F2F, face-to-face; TM, telemedicine.

Statistical comparison of responses by the following subgroups showed no meaningful differences in survey responses: number of years practicing oncology (< 10 years v ≥ 10 years), professional role (physician v APP), and number of clinical sessions per week (< 2 sessions v ≥ 2 sessions; Data Supplement).

DISCUSSION

The appropriate role of TM for the care of patients with breast cancer beyond the COVID-19 pandemic is unclear. This survey found that breast medical oncologists would like TM to remain an option for breast medical oncology outpatient care and that TM is valuable for early-stage cancer treatment follow-up visits and second opinion consultations. However, clinicians still preferred in-person visits when emotional connection (eg, delivering bad news) and ability to see a physical problem (eg, new physical examination finding) are highly valued.

The key finding from this survey is that clinicians feel that TM is as good as or better than F2F visits for several routine aspects of breast cancer care. Specifically, respondents felt that TM is similar or better for access to follow-up, visit efficiency, length of visit, ease of accessing records, and ordering tests. If patient perspectives align and TM does not compromise care quality, these findings imply that many aspects of breast cancer care may be provided virtually, particularly when treatment does not need to be administered in the office setting. Although clinicians in this study still prefer F2F office visits in situations where emotional connection and ability to see a physical problem are deemed important, patients may feel differently. To better understand this, future studies could investigate patients' preferences for TM or in-person care for such visits.

A recent National Comprehensive Cancer Network survey study of 801 oncologists (defined as hematologists, medical oncologists, radiation oncologists, gynecologic oncologists, and surgical oncologists) nationwide showed that most oncology providers believe TM is safe for appropriately selected patients, performs well for uncomplicated clinical scenarios, and would be an appropriate mechanism for nearly half of patient visits after the pandemic.¹⁵ The findings of this study were also consistent with previously reported surveys of general oncologists^13,15,16 in which TM was felt to be comparable with in-person care for low acuity encounters (such as routine surveillance and reviewing reassuring laboratory or imaging tests). Unlike these studies in which surveyed clinicians saw a variety of cancer subtypes across a multitude of disciplines, our survey included only breast medical oncology clinicians. Despite this difference, the disease-specific respondents in our survey were also satisfied with TM, and these findings contribute to a growing body of evidence that supports the use of TM for oncology care.

Compared with previous studies examining clinicians' general experience with TM in oncology care, our survey asked more detailed questions to ascertain clinicians' opinions on specific visit types including follow-up, new patient, and second opinion consultations. As a result, our study differentiates the specific components of outpatient visits that TM may be valuable for, as well as for those whom in-person visits are preferable or comparable.

These findings highlight clinician preferences regarding TM for the care of patients with breast cancer moving forward. However, uncertainty remains concerning the optimal use of TM, its impact on safety, patient perceptions of care quality, and the policies necessary to enable ideal TM utilization. Preliminary research suggests that TM visits may be safe and efficacious. A retrospective single center analysis by Hsiehchen et al found no significant differences in telephone encounters, time to staging imaging, time to therapy initiation, three month all-cause or cancer-specific emergency department presentations, or hospitalization as a result of TM use.¹⁷ The few studies that have examined breast cancer–specific patient satisfaction with TM during the COVID-19 pandemic have shown favorable results.^18-20 For example, a survey study of 78 breast cancer patients at the University of Minnesota who had a TM visit in 2020 found high median patient satisfaction scores (5.5 on a scale of 1 to 7) as well as high patient usability scores (median 5.6 on a scale of 1 to 7).²⁰ In a larger study that took place at 18 centers in France and Italy, 1,299 patients with breast cancer who had undergone TM visits for routine breast cancer follow-up or who were on active therapy during the first wave of the COVID-19 pandemic, reported high rates of patient satisfaction on two separate questionnaires (mean satisfaction scores 77.4 and 73.3 for the EORTC OUT-PATSAT 35 and TM satisfaction questionnaires respectively) but expressed concern over lack of breast examination.¹⁸ A prospective randomized control trial of TM versus F2F visits for the routine surveillance of patients with early-stage breast and prostate cancer conducted by the authors of this study is ongoing (ClinicalTrials.gov identifier: NCT04936243) and will measure patients' and clinicians' perspectives on experience and care quality as primary end points.

This study has several limitations. First, respondents are limited to oncology clinicians from two academic cancer centers in Boston, MA, although it incorporates clinicians practicing in both tertiary care and community settings. The TM software, infrastructure, and support were similar at both institutions but may not reflect the TM experience of clinicians from other health systems. Similarly, clinician responses may be influenced by the perceived experiences of their patients, and patients with different geographic and sociodemographic characteristics may have alternative perspectives.

In conclusion, the results of our survey suggest that breast medical oncology clinicians believe that there is an ongoing role for TM in the care of patients with breast cancer beyond the pandemic. Additional work is necessary to determine the optimal, patient-centered use of TM, and regulatory and payment policy will continue to be critical in enabling effective use of this approach to care delivery.

AUTHOR CONTRIBUTIONS

Conception and design: Eleni Stavrou, Eric Winer, Deborah Schrag, Christopher Manz

Financial support: Deborah Schrag

Administrative support: Deborah Schrag

Provision of study materials or patients: Steven Isakoff

Collection and assembly of data: Eleni Stavrou, Jeanna Qiu

Data analysis and interpretation: Eleni Stavrou, Affan Zafar, Angela C. Tramontano, Steven Isakoff, Deborah Schrag, Christopher Manz

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Breast Medical Oncologists' Perspectives of Telemedicine for Breast Cancer Care: A Survey Study

The following represents disclosure information provided by authors 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/op/authors/author-center.

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