Leveraging Telehealth to Provide Supportive Care to Patients With Metastatic Breast Cancer

J Clin Pathways. 2021;7(10):16-17.

In the United States, 1 in 3 women diagnosed with early-stage breast cancer will go on to eventually be diagnosed with metastatic breast cancer.¹ Also known as stage IV or advanced breast cancer, metastatic breast cancer signifies that breast cancer cells have broken away and metastasized, or spread, via lymphatic channels or the bloodstream beyond the breast and nearby lymph nodes to other organs of the body—often the liver, bones, lungs, and brain—at the time of diagnosis. Some patients with metastatic breast cancer face numerous challenges and disparities in receiving quality cancer care, particularly underserved patient populations that are less likely to receive optimal care due to factors such as low income, ethnicity, uninsured or publicly insured status, and/or geographic disadvantages. 

Patients with metastatic breast cancer facing disparities in care can benefit from telehealth services by saving time and receiving much of their care at home through virtual appointments, patient portal communications, and online education.

In 2019, the Association of Community Cancer Centers (ACCC) held a Multidisciplinary Metastatic Breast Cancer Summit focused on addressing disparities in care for these patients, wherein telehealth solutions were identified as a key action item to improve access to supportive services. In 2021, ACCC held a series of focus groups to learn how cancer programs are effectively implementing telehealth to manage symptoms and treatment side effects, deliver psychosocial screening and support services, and provide genetic counseling and testing.

Telehealth Benefits

In light of the COVID-19 pandemic and the need to socially distance, telehealth has become more common in breast cancer care. Cancer programs offering telehealth and virtual services have reported the following benefits:

• Decreased cancellation rates;
• Increased access to care, notably for patients in hard-to-reach geographic locations;
• Increased flexibility for patients who may feel unwell, have an urgent care request, or cannot immediately obtain an in-person appointment;
• Decreased waiting room time, which can improve patient satisfaction and reduce time away from the job, home, and other responsibilities;
• Frequent patient contact, allowing for more supportive care; and
• Language interpretation options for deaf patients or those who prefer communicating in other languages.

Symptom and Side Effect Management via Telehealth

Disease management in patients with metastatic breast cancer is challenging, with patients commonly in treatment for extended stretches of time, in addition to the added burden of medication side effects, despite intermittent periods of stable disease. Cancer care teams must respond rapidly to disease progression by providing alternative treatment options and working with patients to manage symptoms and side effects—such as pain, nausea, diarrhea, and skin toxicities—while providing supportive care to ensure treatment success. Telehealth services provide the cancer care team the opportunity to effectively evaluate and manage chemotherapy-induced neuropathy or aromatase inhibitors pain, by asking key questions and providing virtual treatment options, if appropriate. Similarly, telehealth appointments allow providers to evaluate the cause of skin irritation and toxicities brought on by radiation or targeted therapies used to treat metastatic breast cancer. Likewise, determining the underlying cause for disease-related nausea and/or diarrhea can, at least initially, be evaluated via telehealth so that the patient can stay close to home rather than travel to the clinic while feeling unwell. If in-person appointments are necessary after the initial virtual appoint, the patient can follow up with an in-person clinic visit or schedule a home health nurse visit, as needed.

Genetic Counseling via Telehealth

Genetic counseling for patients diagnosed with cancer is standard of care at academic medical centers, but patients cared for at community-based programs may not have access to these resources. Telehealth delivery via telephone counseling and video conferencing has become more widely accepted for genetic counseling and is most often offered through two prevailing models: (1) Patients visit a clinic to use clinic equipment to speak with the off-site genetic counselor, or (2) Patients attend a virtual appointment with the genetic counselor by phone or video from home. Both models present with advantages (eg, flexible scheduling, fewer cancellations, easier access to care) and disadvantages (eg, specimen self-collection errors, need for additional staff to manage logistics). However, certain strategies may increase the success of genetic counseling services, including assigning a designated on-site staff member to help with logistics to ensure a smooth process; using home saliva kits or engaging a mobile phlebotomist to visit the patient’s home for a blood draw, since improving sample collection and submission for patients with metastatic breast cancer is key.

Psychosocial Screening via Telehealth

Taking a whole-person approach in patients with metastatic breast cancer includes offering psychosocial services to address patient quality of life. In fact, patients report wanting to know early in the treatment process about the availability and benefits of psychosocial programs. While patients are screened for psychosocial distress during in-person appointments, transitioning this process to telehealth requires new approaches  about which tools to use, and how or when to deliver the tool to the patient. According to the ACCC focus group, individual psychotherapy, group therapy, and mindfulness coaching are successful when conducted over telehealth for most patients, while active crisis management or real-time support for the clinical team are more appropriate for in-person care. Becoming familiar with local or national telehealth support services (eg, Cancer Support Community, CancerCare) is highly recommended, particularly in the absence of offering such services in-house, to help patients receive comprehensive support throughout treatment. 

Looking to the Future

Cancer programs have adjusted well to recent expansion of telehealth delivery of supportive care services for patients with metastatic breast cancer. Adoption of telehealth services has increased patient use, decreased logistic and geographic barriers, and resulted in overall decreases in disparities to access for supportive care. Despite these successes, cancer programs must think creatively to ensure patient access, readiness, and willingness to use telehealth services and technology.  The next logical step requires refining these virtual approaches and adapting to diverse patient needs to ensure that telehealth delivery benefits as many patients as possible. 

1. Breastcancer.org. MBC awareness: one day is not enough. Updated October 13, 2017. Accessed December 1, 2021. https://www.breastcancer.org/symptoms/types/recur_metast/blog/one-day-metastatic