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Teleoncology: The Youngest Pillar of Oncology
review-article
Author(s):
Puneet Pareek , MD, DNB, MAMS
1 ,
Jeewan Ram Vishnoi , MS, MCh, MAMS
2 ,
Sri Harsha Kombathula , MD
1 ,
Rakesh Kumar Vyas , MD
1 ,
Sanjeev Misra , MS, MCh
2
Publication date (Electronic):
30 September 2020
Journal:
JCO Global Oncology
Publisher:
American Society of Clinical Oncology
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There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.
Abstract
The core pillars of multimodal care of patients with cancer are surgical, radiation, and medical oncology. The global pandemic of coronavirus disease 2019 (COVID-19) has suddenly resurrected a new pillar in oncology care: teleoncology. With oncologists reaching out to patients through telemedicine, it is possible to evaluate and fulfill patients’ needs; triage patients for elective procedures; screen them for influenza-like illness; provide them with guidance for hospital visits, if needed; and bridge oral medications and treatments when a hospital visit is not desirable because of any high risk-benefit ratio. Teleoncology can bring great reassurance to patients at times when reaching an oncology center is challenging, and more so in resource-constrained countries. Evidence-based treatment protocols, dispensable by teleoncology, already exist for many sites of cancer and they can provide a bridge to treatment when patients are unable to reach cancer centers for their standard treatment. The young pillar of teleoncology is going to remain much longer than COVID-19.
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Most cited references27
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Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis.
Patricia Cortazar, Lijun Zhang, Michael Untch … (2014)
Pathological complete response has been proposed as a surrogate endpoint for prediction of long-term clinical benefit, such as disease-free survival, event-free survival (EFS), and overall survival (OS). We had four key objectives: to establish the association between pathological complete response and EFS and OS, to establish the definition of pathological complete response that correlates best with long-term outcome, to identify the breast cancer subtypes in which pathological complete response is best correlated with long-term outcome, and to assess whether an increase in frequency of pathological complete response between treatment groups predicts improved EFS and OS. We searched PubMed, Embase, and Medline for clinical trials of neoadjuvant treatment of breast cancer. To be eligible, studies had to meet three inclusion criteria: include at least 200 patients with primary breast cancer treated with preoperative chemotherapy followed by surgery; have available data for pathological complete response, EFS, and OS; and have a median follow-up of at least 3 years. We compared the three most commonly used definitions of pathological complete response--ypT0 ypN0, ypT0/is ypN0, and ypT0/is--for their association with EFS and OS in a responder analysis. We assessed the association between pathological complete response and EFS and OS in various subgroups. Finally, we did a trial-level analysis to assess whether pathological complete response could be used as a surrogate endpoint for EFS or OS. We obtained data from 12 identified international trials and 11 955 patients were included in our responder analysis. Eradication of tumour from both breast and lymph nodes (ypT0 ypN0 or ypT0/is ypN0) was better associated with improved EFS (ypT0 ypN0: hazard ratio [HR] 0·44, 95% CI 0·39-0·51; ypT0/is ypN0: 0·48, 0·43-0·54) and OS (0·36, 0·30-0·44; 0·36, 0·31-0·42) than was tumour eradication from the breast alone (ypT0/is; EFS: HR 0·60, 95% CI 0·55-0·66; OS 0·51, 0·45-0·58). We used the ypT0/is ypN0 definition for all subsequent analyses. The association between pathological complete response and long-term outcomes was strongest in patients with triple-negative breast cancer (EFS: HR 0·24, 95% CI 0·18-0·33; OS: 0·16, 0·11-0·25) and in those with HER2-positive, hormone-receptor-negative tumours who received trastuzumab (EFS: 0·15, 0·09-0·27; OS: 0·08, 0·03, 0·22). In the trial-level analysis, we recorded little association between increases in frequency of pathological complete response and EFS (R(2)=0·03, 95% CI 0·00-0·25) and OS (R(2)=0·24, 0·00-0·70). Patients who attain pathological complete response defined as ypT0 ypN0 or ypT0/is ypN0 have improved survival. The prognostic value is greatest in aggressive tumour subtypes. Our pooled analysis could not validate pathological complete response as a surrogate endpoint for improved EFS and OS. US Food and Drug Administration. Copyright © 2014 Elsevier Ltd. All rights reserved.
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Virtual health care in the era of COVID-19
Paul Webster (2020)
Patients are under lockdown and health workers are at risk of infection. Paul Webster reports on how telemedicine is being embraced like never before. In the face of a surge in cases of coronavirus disease 2019 (COVID-19), physicians and health systems worldwide are racing to adopt virtualised treatment approaches that obviate the need for physical meetings between patients and health providers. But many doctors are watching warily. “I'd estimate that the majority of patient consultations in the United States are now happening virtually”, says Ray Dorsey, director of the Center for Health and Technology at the University of Rochester Medical Center (Rochester, NY, USA). “There has been something like a ten-fold increase in the last couple of weeks. It's as big a transformation as any ever before in the history of US health care. But the real question is whether these measures will stay in place after the pandemic subsides?” In shifting towards virtualised care in response to COVID-19, health-care planners worldwide are drawing from China's experiences. In China, patients were advised to seek physicians' help online rather than in person after the pandemic first emerged in Wuhan in December, says Yanwu Xu, principal health architect for Baidu Health, one of China's largest internet corporations, and one of three companies contracted by the Chinese Government to implement virtual care technologies. © 2020 TPG/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Speaking to The Lancet from Beijing, Xu, who is a member of WHO's Digital Health Technical Advisory Group, and a researcher at the Chinese Academy of Sciences' Ningbo Institute of Materials Technology & Engineering, explained that China's virtual care transformation was unleashed when the country's national health insurance agency agreed to pay for virtual care consultations because the hospitals and clinics were full. “For the first time, Chinese physicians have really embraced virtual care”, says Xu. “Thanks to these technologies physicians can consult with upwards of a hundred patients a day, which is a very significant increase in the daily caseloads they handled in person in the past.” Following China's example, on March 30, at the direction of US President Donald Trump, the Centers for Medicare & Medicaid Services (CMS), which oversees the nation's major public health programmes, issued what it termed “an unprecedented array of temporary regulatory waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-19) pandemic”. In a press release, the CMS explained that its new measures will allow for more than 80 additional services to be furnished via telehealth. “During the public health emergencies, individuals can use interactive apps with audio and video capabilities to visit with their clinician for an even broader range of services. Providers also can evaluate beneficiaries who have audio phones only. These temporary changes will ensure that patients have access to physicians and other providers while remaining safely at home.” Eric Topol, director of the Scripps Research Translational Institute in La Jolla (CA, USA), praises these efforts, but laments that they have been so long coming. “This is a very big moment for virtual health care. But, of course, there isn't a lot of readiness. There are so many ways to monitor people's health that we aren't doing at any scale, in large part due to interstate regulatory barriers that have meant we are in no way ready for this moment.” Similar steps to sweep aside regulatory and hegemonic professional barriers are being taken in Canada, according to Sandy Buchman, president of the Canadian Medical Association. “As we confront [COVID-19], we're racing to implement virtual health-care technologies as quickly as we can. The scale and pace of change is unprecedented for Canadian health care.” Topol warns that the sudden rush to virtualisation risks diminishing the quality of clinical care. “It's inexpensive and expedient, but it'll never be the same as a physical examination with all of its human qualities of judgment and communication. But with COVID, this is a trade-off we have to accept.” Similar developments are sweeping health care in the UK, says Trisha Greenhalgh, co-director of the Interdisciplinary Research In Health Sciences Unit at Oxford University (Oxford, UK). “We have a research project that has been tracking the use of video conferencing in Scotland over the past 6 months, and in the space of the last 2 weeks we've seen [a] 1000% increase in use”, said Greenhalgh. “It's incredible. [COVID-19] has done what we couldn't do until now, because, suddenly, it's not just the patient who might die—now it's the doctor who might die. So the doctors are highly motivated. The risk–benefit ratio for virtual health care has massively shifted and all the red tape has suddenly been cut.” In Italy, although all 20 regions had implemented national telemedicine guidelines as of 2018, hospital managers have been largely caught off guard by the explosion in digital demand, says Elena Sini, information officer for GVM Care & Research, a network of nine private hospitals in northern Italy. Many Italian hospitals lack the necessary hardware and technical resources, she noted in a March 23 webinar. “Burnout is also a concern for IT staff, so set up some psychological support for IT staff”, she advises. Sini reported a lack of hardware due to broken supply chains and insufficient bandwidth capacities as the demand increased by about 90% on fixed landlines and 40% on mobile networks in Italy. “We have to ramp up telemedicine capabilities, but for most hospitals in Italy this is an issue. We just don't have the capabilities to deliver.” Speaking alongside Sini, Henning Schneider, chief information officer for Asklepios Kliniken, one of Germany's largest private hospital networks, said the COVID-19 pandemic is highlighting a need for intensified IT collaboration between German hospitals. In New Delhi, India, Anurag Agrawal, director of the Council of Scientific and Industrial Research's Institute of Genomics and Integrative Biology, says Indian health-care providers have become similarly preoccupied with virtual health care while the country is in near-total lockdown. “Suddenly, after years of resistance to virtual health care, our physicians keenly want it”, said Agrawal. “[COVID-19] is breaching the barriers to virtual health care faster than anything in history.” Access to virtual health care is far easier within India's publicly financed health-care systems than among private providers, Agrawal notes. However, as India's response to COVID-19 escalates, many private physicians are providing virtual consultations for free. “That could change if the lockdown runs longer”, Agrawal explains. “Meanwhile, the national and state governments will need some time to ramp this up, and the lockdown is buying us time.” To expedite the transformation, he adds, the Indian Government is copying China's tactics by releasing a set of newly developed applications that use instant messaging platforms, such as WhatsApp, to enable a suite of virtual health-care services, including public messaging about behavioural modifications, epidemiological tracing, and access to virtual health-care providers. “The Chinese had a national advantage with their WeChat messaging platform, which is better-suited to hosting virtual health-care apps than WhatsApp is.” Like Topol, Agrawal warns that virtual health care comes with a trade-off in the quality of patient care. “Physicians, too, we should keep in mind, benefit from the in-person consultations as much as patients”, he suggests. “We may mourn that.” African health-care providers have yet to join the global rush en masse, observes Chris Seebregts, chief executive of Jembi Health Systems, a Cape Town-based non-governmental organisation that advises health-system strategists in digital technologies in Cameroon, Ethiopia, Kenya, Malawi, Mozambique, South Africa, South Sudan, and Uganda. “Digital health technologies are being adopted at a huge rate now here in South Africa in response to [COVID-19]”, Seebregts said via video conference from Cape Town, “but we're not seeing much adoption yet elsewhere in Africa. [COVID-19] may accelerate it, but it's too soon to say.” With mobile phone use now globally ubiquitous, technological barriers to the adoption of virtual health care are easily surmountable, even in the most resource-scarce settings, notes Alex Jadad, founder of the Centre for Global eHealth Innovation at the University of Toronto, ON, Canada, where he is the director of the Institute for Global Health Equity and Innovation. “Whether I'm deep in Malawi or deep in the Amazon, all I need is a mobile phone and a connection that allows me to talk to a clinician. That's all it takes for a clinical encounter. These are god-like tools for medicine. There's no need for us to wait for any more sophisticated infrastructure than that”, says Jadad, who is advising on virtual health-care adoption strategies for health groups in Colombia. “The regulatory barriers that have held virtual health care back for all these decades were never justifiable”, Jadad avers. “[COVID-19] is an opportunity to blow all these barriers away. And the question now is ‘how far are we willing to go?’” © 2020 Catherine Lai/AFP/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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Cancer guidelines during the COVID-19 pandemic
Talha Khan Burki (2020)
As of April 1, 2020, more than 800 000 cases of coronavirus disease 2019 (COVID-19) had been confirmed worldwide. The death toll in Italy is approaching 12 000 people, with Spain not far behind. The USA has reported more than 164 000 cases of the disease, including more than 38 000 cases in New York City alone. There are concerns that the COVID-19 could overwhelm health-care systems worldwide. Many nations have reported a shortage of ventilators. The UK is one of several countries to have suspended elective surgery. On March 26, Gethin Williams, a colorectal surgeon at the Royal Gwent Hospital in Newport, Wales, warned that his institution was under severe strain, with operating theatres turned into intensive care units to accommodate the influx of patients with COVID-19. “The rate at which COVID-19 is going through the Royal Gwent, there'll be no colorectal surgery for the foreseeable future”, he said. “Without treatment, some cancers could obstruct, others could metastasise.” Oncology societies and national authorities have been quick to issue guidelines on cancer care during the pandemic. Giuseppe Curigliano (European Institute of Oncology, Milan, Italy) is a council member of the European Society for Medical Oncology (ESMO). “ESMO is taking this very seriously”, he said. “They are offering guidance to medical oncologists and giving training on how to manage patients with cancer while this pandemic goes on.” According to an analysis of Italian patients published in March, 20% of those who died from COVID-19 in the country had active cancer. The ESMO website includes general information on COVID-19, a Q&A section, and links to useful resources. ESMO recommends that oncologists remain ready to adjust their routines. It suggests bolstering telemedicine services, reducing clinic visits, and switching to subcutaneous or oral therapies, rather than intravenous ones, when possible. There is also advice on supporting patients and on infection control. In its guidance for managing patients with cancer requiring acute treatment, NHS England warned that certain groups are particularly vulnerable to serious illness if they become infected with severe acute respiratory syndrome coronavirus 2. These groups include individuals who are undergoing active chemotherapy or radical radiotherapy for lung cancer, and patients with cancers of the blood or bone marrow. “Different cancers produce immune suppression to different extents”, explains Richard Schilsky, chief medical officer of the American Society of Clinical Oncology (ASCO). “The blood cancers often directly compromise the immune system, so those patients are probably most at risk, whereas cancers such as colon cancer, breast cancer, and lung cancer do not typically cause immune suppression that is not treatment-related.” Schilsky notes that standard chemotherapy regimens for most solid tumours mainly cause transient immune suppression that manifests in low white blood cell counts. “You can prop up the white blood cells using colony-stimulating factors, so these patients are probably at lower risk than the blood cancer patients”, he told The Lancet Oncology. The pandemic poses several challenges for oncology services. Caregivers have to think about how to minimise their patients' exposure to health-care facilities. “We are seeing systems adapt to this now, with telephone and telehealth consultations, people receiving laboratory testing at facilities closer to their homes, and some evaluations being delayed”, said Schilsky. NHS England's guidance lists several possible options, including home delivery of oral medications and repeat prescriptions. Then there are issues associated with infection. Oncologists are accustomed to dealing with such complications, but the problem with COVID-19 is that there is no specific treatment. “The risk–benefit calculus is tricky”, said Schilsky. “On the one hand, a patient might be at high risk of contracting the infection and dying from it; on the other hand, the patient might be at high risk of the cancer progressing or causing death if it is not treated appropriately.” Physicians have to assess whether treatment plans should be initiated on schedule or delayed, and if so, for how long? NHS England stresses that individual patient decisions have to be made by multidisciplinary teams. Its guidance establishes priority groups for surgery, systemic anticancer treatments, and radiotherapy. For systemic treatments, NHS England sets out six priority levels. Patients who are in line for curative therapy with a greater than 50% chance of success are in the highest level. Patients who are awaiting non-curative therapy that is unlikely to offer palliation, tumour control, or more than 1 year's extension of life are assigned the lowest priority level. For radiotherapy, there are five levels of priority, patients with rapidly proliferating tumours with little scope for delay are in the highest group. © 2020 NIAID-RML/National Institues of Health/Science Photo Library 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Several other cancer societies have issued some guidance. The Society of Surgical Oncology website includes disease-site specific resources to help guide decisions in the era of COVID-19, as well as a series of podcasts from different specialists. There are information sheets on a range of malignancies, including breast cancer, colorectal cancer, endocrine cancer, and melanoma, with each subdivided into disease types, when appropriate. In a statement issued on COVID-19, the European Society of Surgical Oncology (ESSO) advised against seeing patients older than 70 years in the clinic, unless urgent. ESSO also emphasised the importance of ensuring that the workforce does not burn out. “Rest and recuperation, as well as psychological support should be factored into planning”, the statement concluded. The ASCO website also assembles a great deal of information on patient care and COVID-19, along with links to guidance from organisations such as the US Centers for Disease Control and Prevention and several oncology societies. ASCO has produced guidance on how practices should ready themselves for the virus; advice can be found on staffing, clinical preparedness, infection prevention and control, and patient scheduling. There are also mental health resources. Practitioners can find the tips on enhancing coping useful. The suggestions include avoiding information overload and taking a break from news and social media related to COVID-19. There is also a set of tips for enhancing mental and physical health—one suggested exercise is mindful handwashing, which could be a neat way to combine hygiene and wellbeing. The American Society for Radiation Oncology website contains a large section on COVID-19. The organisation is putting together specific recommendations for its membership, based on the findings of a dedicated workgroup. Its website contains frequently asked questions, several of which are directly relevant to clinical decision making, and links to journal articles and relevant websites. The American Society for Transplantation and Cellular Therapy and the European Society for Blood and Marrow Transplantation (EBMT) have both issued guidelines for COVID-19 management. The EBMT warns that the travel restrictions imposed in Europe are likely to have a serious effect on transplant activities both on the continent and beyond. “Due to the rapidly changing situation, access to a stem cell donor might be restricted either due to the donor becoming infected, logistical reasons at the harvest centres in the middle of a strained health-care system, or travel restrictions across international borders”, note the EBMT guidelines. “It is therefore strongly recommended to have secured stem cell product access by freezing the product before start of conditioning and, in situations when this is not possible, to have an alternative donor as a back-up.” On the regulatory side, the US Food and Drug Administration has issued guidance on managing clinical trials during the time of COVID-19, as have the US National Cancer Institute and the European Medicines Agency (EMA). The EMA document outlines the changes and adaptations that might be required over the course of the pandemic, for example, if trial participants need to be isolated, access to public places is limited, or health-care professionals have to take up different duties. It suggested that trial organisers consider suspensions, extensions, and postponements, depending on circumstances. The UK National Institute for Health and Care Excellence has issued guidance on delivering radiotherapy and systemic cancer therapies, which draws from NHS England's guidance. Finally, the Global Radiation Oncology Targeted Response emerged from an online discussion involving 121 contributors in March, 2020. The paper explores subjects such as infection prevention, rationalisation of working practices, and specific issues related to radiation oncology. Advice on specific diseases is offered, and the authors list radiotherapy treatments that could be omitted. But they also point out that although deferring radical treatment for diseases with favourable biology “might seem immediately preferable, it might have unintended consequence in creating a further unmanageable surge in activity when the crisis has passed.” It is too early to tell what shape this pandemic will take. But it is worth noting that the epidemic in China appears to be slowing down. Yi-Long Wu (Guangdong Lung Cancer Institute, Guangdong, China) points out that the major disruption to cancer care in the country occurred during the first two weeks of February. “From late February, everywhere except for Hubei province, we were able to start giving patients surgery, chemotherapy, and radiotherapy again”, he told The Lancet Oncology. “Now we are coming back to normal.”
Author and article information
Journal
Journal ID (nlm-ta): JCO Glob Oncol
Journal ID (hwp): go
Journal ID (pmc): go
Journal ID (publisher-id): GO
Title:
JCO Global Oncology
Publisher:
American Society of Clinical Oncology
ISSN
(Electronic):
2687-8941
Publication date Collection: 2020
Publication date
(Electronic):
30
September
2020
Volume: 6
Electronic Location Identifier: GO.20.00295
Affiliations
Author notes
Puneet Pareek, MD, DNB, MAMS, Department of Radiation Oncology, All India Institute
of Medical Sciences, Basni Industrial Area, Phase II, Jodhpur 342005, India; e-mail:
drpuneetpareek@
123456gmail.com
.
Author information
Puneet Pareek
https://orcid.org/0000-0002-6055-9872
Jeewan Ram Vishnoi
https://orcid.org/0000-0003-1484-8929
Sri Harsha Kombathula
https://orcid.org/0000-0003-4981-1114
Article
Publisher ID: 2000295DOI: 10.1200/GO.20.00295
PMC ID: 7529505
PubMed ID: 32997540
SO-VID: 08d850d1-95d2-4f04-b75e-2457d3b5fefb
Copyright © © 2020 by American Society of Clinical Oncology
License:
Licensed under the Creative Commons Attribution 4.0 License: https://creativecommons.org/licenses/by/4.0/
History
Date
accepted
: 14
August
2020
Page count
Figures: 0,
Tables: 1,
Equations: 0,
References: 51,
Pages: 6
Categories
Compound subject:
00, Breast Cancer
Compound subject:
00, Head and Neck Cancer
Compound subject:
00, Health Services Research
Compound subject:
00, Radiation Oncology
Compound subject:
00, Surgical Oncology
Compound subject:
00, Thoracic Oncology
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