Participating in virtual palliative care delivered through smartphones or computers can be as effective as receiving care in person, according to study results presented at the American Society of Clinical Oncology Annual Meeting (ASCO 2024). Broader use of telehealth could reduce the need for physical health care resources and make palliative care accessible to more people.

“Telehealth has the potential to substantially reduce burden on patients, clinicians and health care resources while maintaining quality care,” said lead study author Joseph Greer, PhD, of Massachusetts General Hospital. “Our findings highlight the critical need for health care systems and policymakers to adopt telehealth more broadly into evidence-based palliative care standards.”

Another study found that stepped palliative care, in which declining quality of life triggers more intensive care, was an effective and more scalable way to deliver palliative care to patients with advanced lung cancer.

“This study demonstrates that early palliative care can be effectively tailored to a patient’s cancer, and care needs to maximize their quality of life while utilizing fewer palliative care resources,” Greer said. “Implementing this patient-centered approach to delivering early palliative care will allow more patients to access essential early palliative care services.”

Oncology palliative care refers to services intended to relieve symptoms and improve quality of life. It is not the same as hospice care, and it can help people at any stage, including those whose cancer treatment may cure them, those who are managing cancer as a chronic illness and those facing the end of life. In fact, studies have shown that starting palliative care early leads to better outcomes, including longer survival.

Palliative care is typically delivered by a team that may include physicians, nurses, social workers and chaplains, thus addressing physical, emotional and spiritual needs. But this type of care is underutilized, in part due to a shortage of providers, especially at smaller cancer centers and in more remote geographic areas. 

National guidelines recommend integrating palliative care from the time of diagnosis for people with advanced cancer. However, a third study presented at the conference, led by researchers with the American Cancer Society, showed that despite an increase in early palliative care—from less than 1% in 2010 to 11% in 2019—utilization remained low among patients with advanced breast, colorectal, lung, pancreas or prostate cancer.

“Unfortunately, most patients with advanced cancer and their families do not receive this evidence-based care due to multiple barriers, chief among them being the limited availability of specially trained palliative care clinicians and practical issues in accessing supportive care,” Greer said at an ASCO media briefing.

During the height of the COVID-19 pandemic, many in-person medical services were shut down, care pivoted to telehealth and policies were changed to expand insurance coverage for remote health services. Virtual palliative care can be more convenient for both patients and providers, but it was unclear whether this sacrifices effectiveness.

Virtual Palliative Care

In the first study, Greer and colleagues included 1,250 adults at 22 U.S. cancer centers who were diagnosed with advanced non-small-cell lung cancer within the past three months between June 2018 and May 2023. The average age was about 66 years, just over half were women and two thirds were married or partnered. More than 80% were white, 10% were Black, 5% were Asian and 5% were Latino. In addition, the study included 548 patient caregivers.

Participants had palliative care sessions every four weeks, conducted either via video for those randomly assigned to the telehealth group or in person for those assigned to the standard care group. (Due to COVID, about 4% of visits in the latter group were actually done via telehealth.) Both telehealth and in-person sessions addressed physical and psychological symptoms, understanding and coping with illness, care preferences and treatment decisions.

Over six months, participants had an average of 4.75 visits in the telehealth group and 4.92 visits in the in-person group. At that point, quality-of-life scores were equivalent in the two groups. What’s more, the groups did not differ significantly in terms of depression or anxiety, coping skills, understanding treatment goals or perception of their prognosis. 

The rate of participation by caregivers was significantly higher in the in-person group compared with the telehealth group, likely due to the need for transportation to appointments. However, caregiver satisfaction did not differ in the two groups. About 40% of patients and caregivers in both groups reported that they were satisfied with the type of palliative care they were assigned.

The study started well before COVID, and some patients were initially hesitant about telehealth due to unfamiliarity and discomfort with the technology,” Greer noted. But after the pandemic, many did not want to go back to in-person visits. They cited greater convenience, flexible scheduling and less transportation time and cost, especially for those who lived in more remote areas. Telehealth can also facilitate the involvement of family members and caregivers.

Clinicians, on the other hand, suggested that certain patient subgroups could benefit from one method of care delivery over the other—for example, those with auditory or visual impairment and those who struggle with technology. Future research will assess whether specific groups might benefit more from telehealth or from in-person care, including evaluations based on age and proficiency with technology. The researchers will also evaluate both delivery methods for end-of-life care, in particular patient-clinician communication about care preferences.  

“This large, randomized study demonstrated that telehealth delivery of palliative care is feasible and results in outcomes comparable to in-person care,” Charu Aggarwal, MD, MPH, of the Penn Center for Cancer Care Innovation at the University of Pennsylvania, said in an ASCO news release. “The findings underscore the considerable potential for improving access to and broader dissemination of palliative care to improve patient outcomes.”

Stepped Palliative Care

In the second study, presented at the ASCO meeting and reported in JAMA, Greer’s team evaluated a stepped care model as a way to deliver less resource-intensive and more patient-centered palliative care. This randomized trial included 507 adult patients at three academic medical centers in Boston, Philadelphia and Durham, North Carolina, who had been diagnosed with advanced lung cancer within the past three months. Patient demographics were similar to those in the previous study.

Participants randomly assigned to the intervention group had an initial palliative care visit within four weeks after enrollment and subsequent visits only when they changed cancer treatment or after hospitalization. They completed a quality-of-life assessment every six weeks, and those with a 10-point or greater decrease were stepped up to palliative care visits every four weeks. Those assigned to the standard early palliative care group had visits every four weeks after enrollment.

The mean number of palliative care visits was 2.4 for patients in the stepped care group and 4.7 for those in the standard care group. At six months, quality-of-life scores were similar in the two groups, indicating that stepped care was noninferior to standard early palliative care. Communication about end-of-life care was also similar in both groups, but those assigned to the stepped care intervention spent fewer days in hospice care (mean 19.5 versus 34.6 days).

“A stepped-care model, with palliative care visits occurring only at key points in patients’ cancer trajectories and using a decrement in quality of life to trigger more intensive palliative care exposure, resulted in fewer palliative care visits without diminishing the benefits for patients’ quality of life,” the researchers concluded. “While stepped palliative care was associated with fewer days in hospice, it is a more scalable way to deliver early palliative care to enhance patient-reported outcomes.”

“These findings are especially salient as patients with advanced cancer are now living longer while being treated with lifelong cancer therapies, so a tailored palliative care model enables greater dissemination of palliative care services while ensuring patients receive the care they need when they need it,” Greer said in a JAMA news release. “This research continues to grow the evidence base that early palliative care is a necessary and integral component of cancer care for patients diagnosed with advanced cancer and provides data on how to increase the number of patients who can access this essential service.”  

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