Telemedicine offers access to state-of-the-art cancer care in rural areas
NEW YORK — Every patient with cancer does not live in a major metropolitan area with direct access to specialized care, but there are ways to provide individuals access to necessary state-of-the-art care and clinical trials regardless of where they live, according to a speaker at Chemotherapy Foundation Symposium.
“We all are in a perfect storm,” Laurence J. Heifetz, MD, FACP, medical director of Gene Upshaw Memorial Tahoe Forest Cancer Center, said during his presentation. “We have a rapidly increasing population in the Medicare age group, as well as an exponential knowledge base growth, with unpronounceable ‘nibs’, ‘mibs’, ‘mabs’ and ‘zumabs’ and new guidelines coming out every 3 months. And we have a legacy medical education culture, where the doctors are supposed to know everything, keep up with journals [and go] to meetings.
“We're fighting this current war with yesterday's thinking,” he said. “Fear is the primary biologic emotion, and everyone with a diagnosis of cancer has these universal fears: death, pain and disability. But, in the rural setting, these additional fears that also exist in the urban setting, are highly amplified. The fear of getting disorganized care, the fear of becoming a burden on your family and caregivers and the fear of getting yesterday's therapy.”
Heifetz, who was tasked with developing the cancer program at Tahoe Forest Cancer Center when it was established in 2006, noted that his original goal was to provide universal access to care and think about what the rural setting does to the fears of getting a diagnosis of cancer.
Additionally, Heifetz said he wanted to harness technology to lessen the sense of isolation in the 50,000-person region the hospital serviced.
“There are 69 NCI-designated cancer centers across the U.S.,” he said. “Forty-five of those have achieved the comprehensive designation, which means they're able to demonstrate effective community outreach with educational programs. In northern California, only UC Davis and UCSF are NCI-designated comprehensive cancer centers.”
Heifetz cited the Pareto principle, also known as the 80/20 rule, to give an example of how 80% of patients with cancer are cared for by community oncologists, and not major NCI-designated comprehensive cancer centers.
As a result, the Tahoe Forest Cancer Center teamed up with UC Davis to establish a virtual tumor board to reduce fears in rural patients with cancer, and offer those patients easier access to state-of-the-art care.
Each day during lunch, different oncology specialists hold a video conference where a patient’s scans can be presented to the audience and every specialist can weigh in on possible best treatment scenarios.
“The virtual tumor board allows us to meet on a regularly scheduled basis with thought leaders at an academic center, and allows community hospitals to present a case at an academic [institution] within a week of making a diagnosis,” Heifetz said. “It allows them to look at CT scans, [as well as] pathology together, and reach a joint decision for the best treatment for that patient. So, the advantage for our community affiliate sites is this puts them in [direct contact] with specialists every day of the week.”
The value academic partner’s have for community practice is incalculable, according to Heifetz. He used the discovery of cisplatin for the treatment of testicular cancer in 1974 by the late Lawrence H. Einhorn, MD, who was Indiana University at the time of his discovery.
Prior to that discovery, 18-month survival for advanced testicular cancer was 38%. After 4 years, and after the first formal paper was published, 18-month survival significantly increased to 80%.
“There was a 4-year knowledge lag,” he said. “If oncologists within 200 miles of Indiana University had been able to participate in a virtual tumor board setting at that time, they would have known about this trial. They would have had access to what was happening, and their patients would have lived instead of died during that 4-year interval. It is extraordinarily important to have an academic partner if you are in a community practice.”
Heifetz said community oncologists should get accustomed to appearing on camera, if they want to consider the telemedicine approach.
After the staff at the Tahoe Forest Cancer Center became accustomed to appearing on camera, remote telemedicine clinics staffed with nurse practitioners at smaller local hospitals were established.
Chemotherapy and radiation are still given at the Tahoe Forest Cancer Center, but follow-up visits, and 10-day blood counts can now be done through the telemedicine system.
While remotely talking with a patient, Heifetz said he can assess the patient’s CT scan and electronic medical record and have a more effective office visit.
The system has also had a benefit for both institutions. UC Davis has had an increase in clinical trial accrual, according to Heifetz, and it has become Tahoe Forest Cancer Center’s preferred referral site.
Additionally, the partnership has elevated a program that did not once exist into an American College of Surgeons, American Society for Radiation Oncology and Quality Oncology Practice Initiative (QOPI)-certified center, and turned it from 100% out-migration from its primary catchment area to 52% in-migration from outside its catchment area.
The program helps financially support labor and delivery, pediatrics and primary care, “which are dying on the vine in community hospitals, especially in rural settings,” he said.
“Get smart, and stay smart at lunch. Develop virtual disease-specific case-based conferences with regional thought leaders. It is the only way to keep up with the exponential knowledge base growth, and insist technology is for doctors and patients, not the bean counters. Use it to improve your doctor-to-doctor relationships, your doctor-patient communication, and use it to enable effective outreach to remote patients, and build systems to address those patients’ fears.” – by Ryan McDonald
Heifetz L. Harnessing telehealth for state-of-the-art rural oncology; Presented at: Chemotherapy Foundation Symposium; Nov. 8-10, 2017; New York.
Disclosure: Heifetz reports no relevant financial disclosures.