By Carolyn B. Hendricks, MD, FASCO
The COVID-19 pandemic has affected every aspect of cancer care. The most significant change has occurred with the rapid transition to telemedicine. Telemedicine is loosely defined as caring for patients remotely when the doctor and patient are not physically present with each other. Telemedicine has its history in rural medicine. Telehealth visits were originally envisioned for patients living in rural areas. But initially, the patients were located in health care facilities for these visits, not in their own homes. Prior to the COVID-19 pandemic, many cancer centers and oncology researchers were studying ways to deliver cancer care via telemedicine in pilot projects. The COVID-19 pandemic sped up the process dramatically.
Once firm guidance was established among experts that cancer care needed to be modified to reduce the risk of COVID-19 infection for both patients and their health care teams, oncology practices mobilized rapidly to adopt the new technology and offer it to their patients. Medicare rapidly adopted temporary codes for billing for televisits (both phone and video) and other health insurers rapidly followed.
In March 2020, my group practice adopted telemedicine using a licensed Zoom platform. Similar to other community and academic practices, my proportion of televisits grew rapidly to approximately 30%. The proportion has waned somewhat, but it remains about 20%. This option is made available to all of my patients, including new patients. Fortunately, my practice has had a very low incidence of COVID-19–positive tests among my patients, their families, and my staff. The option of televisits has helped to reduce this risk, particularly in my highest-risk patients whose immune systems are affected by their cancer treatments, as well as for my patients who have vulnerable family members in their households. It has also helped to overcome the severe visitor restrictions that COVID-19 has imposed on our in-person visits.
Within the limitations of digital communication (by phone or video), I offer the same quality of cancer care as I do during my in-person visits. These visits typically require more advance preparation by both doctor and patient. My charts need to be prepared more thoroughly in advance of my televisits. My clinical care coordinator helps to ensure that all of the technology (internet access, phone lines) are in working order in advance of the visits. I also need to be very mindful of my schedule throughout the day because televisits and in-person visits are interspersed throughout the day and the televisits are time sensitive. I actually enjoy seeing my patients in their own homes, without restrictions on the number of family members who can participate in the visits. I also really enjoy the “share screen” function during the visits to review scan reports and lab tests along with lots of patient educational materials, which I typically email to the patient after the visit. Another positive aspect of these visits is the two-way nature of the visits. My patients can tell that I am fully engaged with them during the time that we share. Because the visits are timed and staggered, there are very few interruptions on either end.
A breast medical oncologist like me sees a variety of patients with breast cancer throughout my day: new patients, patients on active treatment for either early or advanced cancer, patients in long-term follow-up, and problem visits of many kinds. With the caveat that I have only 5 months of experience with telemedicine, I feel very comfortable meeting new patients and outlining a treatment plan via televisit. I also think that check-ins between treatments for patients receiving chemotherapy are ideal for this type of visit, as are appointments with long-term patients who need to be monitored for signs or symptoms of recurrence and encouraged to remain on their medications. The most challenging visits are new problems. Although the majority of patients with breast cancer do very well and do not experience serious complications of treatment or recurrence of their cancers, some problems related to treatment and recurrence are very difficult to evaluate and treat using phone or video. In that instance, I typically reschedule those visits to the in-person version, accompanied by lots of handwashing, hand-sanitizing, scrupulous cleaning of our exams and infusion suite, strict use of masks, and social distancing.
Although I was an early adopter of telemedicine and confident that it has benefitted my patients by reducing their potential exposure to COVID-19, there are three things that I miss during televisits:
- Routine breast exams are an important part of breast cancer care. Becoming familiar with a patient’s clinical breast exam starts with the initial new patient visit and continues throughout their breast cancer care journey with me.
- Reassurance that things are going to be okay, ranging from a handshake greeting during the initial visit to a big hug at the end of a challenging course of chemotherapy.
- Comfort with human touch when needed to help relay news about scans that will trigger a change in treatment or when treatment has been exhausted.
Because of their rapid uptake, popularity, and usefulness, televisits are likely here to stay. But I will be thrilled on the day that I can resume doing routine breast exams, and providing reassurance and comfort to all of my patients, when needed, in person. Until then, I’m ready to Zoom now.
Dr. Hendricks is a breast-dedicated medical oncologist in community practice in Bethesda, Maryland. She did all of her medical training at Johns Hopkins. She is a member of the Breast Program at Suburban Hospital Johns Hopkins Medicine. She is also an active ASCO volunteer, primarily in the areas of quality of care, mentoring and leadership development, government relations, and advocacy. Her non-breast cancer related passions are living sustainably off the grid, birdwatching, cycling, and conservation of air, land, and water in Western Pennsylvania. Follow Dr. Hendricks on Twitter @carolyn5353. Disclosure.