Telemedicine has been used in multiple clinical settings and has shown at least equivalency to in-person care and high levels of patient and health professional satisfaction, while, at the same time, improve access to care and decrease health care costs.[1]

A new study by Professor Raymond J. Chan, RN, BNurs, MAppSci, Ph.D., FACN of the Caring Futures Institute, Flinders University in Adelaide, Australia, and his colleagues from the Multinational Association of Supportive Care in Cancer (MASCC) Survivorship Study Group demonstrates the benefit of telemedicine in the management of psychosocial and physical effects of cancer, in particular for improving fatigue and cognitive function. However, the authors show that there is a lack of evidence of using telemedicine in the prevention and surveillance for recurrences and new cancers, as well as in the management of chronic medical conditions, and health promotion.

The findings from an analysis of systematic reviews that examined the use of telemedicine in the post-treatment phase of cancer survivorship are published on 9 September 2021 in the Annals of Oncology.

The authors of the study wrote that telemedicine services have been increasingly used to facilitate post-treatment cancer survivorship care, especially since the COVID-19 pandemic. To inform guidance for the use of telemedicine in the post-COVID era, they evaluated the efficacy of, and survivor engagement in, telemedicine interventions in the post-treatment survivorship phase, and considerations for implementation barriers and facilitators.

A systematic review
They electronically searched PubMed, Cochrane CENTRAL, CINAHL, Embase, and Web of Science databases; of 224 publications considered, 29 systematic reviews met eligibility criteria, all published from 2015 to 2021. Thirteen systematic reviews were of randomized controlled studies, 9 were a combination of randomized and non-randomized studies, and pre/post-test studies, and 7 were of mixed-methods studies including cross-sectional, feasibility studies, and qualitative designs.

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Most (54%) of primary studies in systematic reviews were conducted in the United States, 11% in the Netherlands, 7% each in the United Kingdom, Australia, and Canada, 4% each in South Korea and Spain, 3% in Sweden, 1.5% each in Germany, China, and Denmark, and 1% each in Belgium and Finland.

Primary studies of 7 systematic reviews involved only survivors in the post-treatment phase. Of the remaining systematic reviews, an average of 50% (range, 9-90%) of primary studies within the systematic review examined survivors in the post-treatment phase only.

Four systematic reviews included breast cancer survivors only and the primary studies of 10 systematic reviews included mostly breast cancer survivors. Thus, most participants were female. One systematic review included only survivors with a history of melanoma, and the remaining 14 systematic reviews investigated a mix of cancer types. Three systematic reviews focused specifically on pediatric cancer survivors, while the rest focused on adult cancer survivor populations. Of the 16 systematic reviews in adult populations which reported the age range or mean age of participants in primary studies, ranging from 16 to 82 years of age, no systematic review specifically focused on elderly populations.

Different modes of interventions
Almost all systematic reviews examined multiple different modes of telemedicine interventions, predominantly web-based, telephone-based, and mobile app-based interventions, with others utilizing wearable devices, videoconferencing, or videogames. Four systematic reviews included only web-based intervention studies, and four systematic reviews focused only on telephone-delivered interventions. For the primary studies which included a control group, the comparator was most often usual care or waitlist control, with other comparator groups including paper-based information provision or face-to-face care.

Efficacy data were synthesized narratively. In terms of telemedicine efficacy on patient outcomes, the authors looked at surveillance and management of physical effects (physical symptom burden, physical functioning, fatigue, sleep quality, sexual function, cognitive functioning, pain), surveillance and management of psychosocial effects (motivation, stress, fear of recurrence, social and emotional functioning, self-efficacy, quality of life, body image, mood, distress, depression, anxiety), and health promotion and disease prevention (physical activity, body weight, diet quality, smoking, alcohol). They also explored prevention and surveillance for cancer recurrences and new cancers, as well surveillance and management of chronic medical conditions.

The authors reported that a substantive body of evidence they found indicate benefit from telemedicine in the management of psychosocial and physical effects, particularly for improving fatigue and cognitive function, but there was a lack of evidence on the use of telemedicine in the prevention and surveillance for recurrences and new cancers, as well in the management of chronic medical conditions.

The most prevalent barrier to implement telemedicine stems from the lack of evidence to guide telemedicine design, prohibiting easy adaptation and translation to all cancer types, ages, languages, and settings, sustainability of telemedicine including the lack of cancer-specific apps currently available, cost of staff required to deliver telemedicine, and the complexity of incorporating patient-centered care into the design.

Seven systematic reviews considered the perspective of patients, reporting that low technology literacy, a lack of trust in technology, perceived ethical or security concerns, as well as lack of time, low motivation, or competing priorities in daily life, were barriers to telemedicine use. Six systematic reviews reported issues that impair the usability of telemedicine including lack of technological resources, technical support, and cancer-related fatigue or cognitive issues. Two systematic reviews reported that the absence of face-to-face contact with healthcare providers may be a barrier as telemedicine can be impersonal and lacking companionship, engagement, and emotional support. The included reviews did not report on acceptance or barriers to telemedicine from the healthcare provider’s perspective.

In terms of recommendations for telemedicine in post-treatment cancer survivorship care practice and implementation, the MASCC Survivorship Study Group elaborated domains of design considerations for telemedicine services/interventions, identification of cancer survivors where telemedicine is a suitable care option, promotion of telemedicine uptake by cancer survivors and caregivers, and addressing implementation barriers and incorporation of effective facilitators.

Study Conclusion
The authors conclude that future research on telemedicine efficacy should address the prevention and surveillance for recurrences and new cancers, management of chronic diseases, and health promotion.

Economic studies and studies exploring strategies to improve telemedicine accessibility to diverse population groups based on sociodemographic characteristics and cancer type are warranted. Telemedicine in cancer survivorship care is a rapidly emerging and shifting area of healthcare. As a result, the authors believe that there is a need for standards to guide the optimal implementation of telemedicine based on rigorous, pragmatic clinical studies designed to explore the best model of care in the COVID-19 pandemic recovery phase.

[1] Sirintrapun SJ, Lopez AM. Telemedicine in Cancer Care. American Society of Clinical Oncology Educational Book 2018 : 38, 540-545
[2] Chan RJ, Crichton M, Crawford-Williams F, et al. The efficacy, challenges, and facilitators of telemedicine in post-treatment cancer survivorship care: an overview of systematic reviews. Annals of Oncology; Published online 9 September 2021. DOI: [Article]

Featured image: Telemedicine. Photo courtesy: © 2019 – 2021 Pixabay. Used with permission.

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