Telehealth bridges the gap in rural cancer care
January 15, 2020 | Kelsey Herbers
Lara Ramsey wanted a second opinion about breast cancer treatment options, so she steeled herself for a two-hour drive from the forested hills of Dawson Springs, Kentucky, to the traffic mazes around Nashville.
At Vanderbilt-Ingram Cancer Center (VICC), she got answers to her questions, decided on a treatment plan and learned she could cut her travel time in half for radiation therapy by going to the Gateway-Vanderbilt Cancer Treatment Center in Clarksville, Tennessee. Ramsey also enrolled in the VICC Radiation Oncology Survivorship Program, signing up for telemedicine visits at the Clarksville location.
The telemedicine survivorship program is one example of an expanding array of telehealth services that VICC has launched to make care more readily available and to improve cancer outcomes throughout Tennessee and neighboring states. One new telehealth initiative will benefit people even if they aren’t Vanderbilt patients. It aims to bring advancements in care to rural areas by allowing community clinicians to consult with Vanderbilt molecular tumor board experts on patient cases. It also offers their patients resources for better self-care management.
“I’m not real familiar with Nashville, and I have trouble getting away from work, so telemedicine is a convenient option for me,” said Ramsey.
“I usually only have to take half a vacation day to drive to Clarksville, but if I was driving to Nashville, I’d have to use a full day each time. I value the opinion of my Vanderbilt doctors enough that I would make the drive to Nashville if that was my only option, but I appreciate the opportunity to stay closer to home.”
She underwent radiation therapy every day between March and May 2017 before returning to her job as an aircraft engine welder at the GE Aviation factory in Madisonville, Kentucky. An avid nature and landscape photographer, Ramsey took back roads home each day following treatment so she could stop and take photos of the barns and birds she saw along the way, including eagles at Fort Donelson National Battlefield.
“Photography was my release; it helped occupy my time,” she said.
Tennessee is a vast state with varied landscapes, stretching 430 miles at its widest point. With fewer oncologists per capita in rural areas and a lack of local access to cancer resources, patients and community physicians alike report the need for increased access to care options.
RE-EVALUATING LOCAL NEEDS
In 2018, an analysis of the VICC patient population revealed the center’s reach stretched far beyond its 57-county catchment area. Patients presented from a staggering 123 counties, accounting for all of Tennessee and parts of Kentucky and Alabama. Of those 123 counties, 70 are considered rural by government designation, and many have persistent poverty.
The findings illustrated the need to redefine VICC’s catchment area and to better understand the needs of local rural populations, including transportation challenges.
“It’s well known that there are disparities in cancer outcomes between patients who are treated in rural communities versus urban communities, even when you account for factors such as education and socioeconomic status,” said Debra Friedman, MD, E. Bronson Ingram Chair of Pediatric Oncology and co-leader of the Cancer Health Outcomes and Control Research Program at VICC. “The distance between where a patient lives and a center that can treat their cancer is important for the results of their care.”
According to the Centers for Disease Control and Prevention, death rates from cancer are higher in rural areas than urban areas, with a rate of 180 deaths per 100,000 persons compared to 158 deaths in urban areas. With disparities so consistent across the country, VICC researchers expected to see similar disparities within their newly-defined catchment area.
Through a one-year supplement to VICC’s National Cancer Institute (NCI) Cancer Center Support Grant, researchers spent the last year evaluating the barriers and facilitators for early cancer detection and prevention in rural communities. By gathering existing data, conducting focus groups with community members and stakeholder organizations, and interviewing patients about the challenges they face in receiving care, VICC worked to uncover gaps in rural cancer care to better understand how to help fill them.
“Local communities know what they need and want, so we partnered with the organizations in those communities to understand what the needs are, what’s already being done and where Vanderbilt might be able to help by bringing something unique,” said Pamela Hull, PhD, assistant professor of Medicine in the Division of Epidemiology.
“One of the gaps we found is that because of distance and lower population, rural communities don’t have access to a lot of the cancer care tools they need, all the way from prevention through treatment and survivorship. It’s more difficult to get access to mammograms or lung cancer screenings, cancer specialists, new treatments related to genomics and precision oncology and survivorship services for patients.”
While many of the patients in these communities never walk through VICC’s doors, the center’s responsibilities to improve cancer care delivery expand well beyond its patients to ensure access to care is equal across the region.
“We know it’s not realistic to tell everyone to come to Nashville when they may live hundreds of miles away or lack the means to get here, but we want to bring something to the communities in our catchment area to ensure patients receive the same level of care as if they did,” said Friedman.
AN EVOLVING LANDSCAPE
With advances in technology, standards of care for cancer are constantly shifting, and today’s treatments look vastly different than they did a few decades ago.
“There’s been a whole paradigm shift of how cancer is treated. Before, we were treating based on disease site and what we saw under the microscope. Now, we’re trying to treat based on the cancer’s molecular drivers,” said Tuya Pal, MD, Ingram Professor of Medicine and associate director for Cancer Health Disparities.
While molecular testing can be helpful in identifying the molecular changes driving a patient’s tumor and in developing precision treatments to target those drivers, molecular reports can be difficult to understand without specialized training in genetic testing.
“The reports provide a list of different changes in the tumor’s DNA and offer a laundry list of all the trials that will target those changes, but the doctor needs to understand what’s being reported and how to use that information to best treat patients,” said Pal.
“Some of the trials that are listed are not appropriate for the patient, and without knowledge of how to interpret these tests, you may not even know what you’re going after. It could lead to unnecessary care or a missed opportunity for enhancing care.”
Because there are fewer oncologists per capita in rural areas compared to urban areas, providers are more likely to be generalists, meaning they often care for all types of cancers without the “luxury” of subspecializing. Rapid advances in precision oncology make it challenging to keep up with the latest treatments in a single subspecialty, let alone all subspecialties at once.
“Even the DNA you’re born with could impact how you’re treated for your cancer diagnosis,” said Pal. “With these molecular test results, the report may not identify that something is only an important finding if confirmed with germline testing. The data may require further analyses.”
With targeted therapies and immunotherapies based on the molecular profiles of tumors becoming increasingly complicated, community oncologists face the challenge of keeping up with new methods while also seeing large populations of patients with a variety of cancers each day.
“Those treatments that come out are the new standard of care, but they’re not being disseminated out to rural areas,” said Hull. “To get patients access, we need to work on dissemination and implementation, and a great way to do that is through telehealth.”
A CALL FOR SOLUTIONS
Armed with new knowledge of regional disparities and barriers to care, VICC was quick to respond to a request from the NCI for projects that would improve cancer care in rural areas.
Knowing that community providers and patients alike face challenges accessing specialty cancer expertise, VICC proposed a multilevel telehealth intervention initiative that will allow community clinicians to consult with the VICC HOPE molecular tumor board, which reviews challenging cancer cases with molecular genetic testing results to assess next steps in treatment. The project was awarded $3.3 million in funding for a five-year span.
Led by Ben Ho Park, MD, PhD, Donna S. Hall Professor of Breast Cancer and director of Precision Oncology, the tumor board is comprised of oncologists across multiple subspecialties, scientists, geneticists, pathologists, surgeons and other health care providers. The board will offer expert consultant opinions remotely via a secure videoconference format so community oncologists can access the information from their own offices.
The board will assess the patient’s clinical history and tumor analyses and provide recommendations on next steps.
“At VICC, we have the luxury of having a breast oncologist, a lung oncologist, a pediatric oncologist, etc. It’s hard for any of us to keep up with the rapid advances in oncology, even within a very defined field,” said Friedman, lead primary investigator for the telehealth initiative. “Part of the reason we want these community oncologists to utilize our tumor board is to be able to have the input from subspecialty oncologists as well as those who have expertise in precision oncology.”
“I think having access to content expertise will allow for a consultative service that will bring the latest treatment information for these patients that could impact their responses to therapy and the ability to treat their disease,” said Park.
VICC oncologists will also be available for follow-up consultations after a case has been presented.
Through the stakeholder interviews VICC held over the last year with community organizations in its catchment area, researchers found a broad interest in telehealth among both providers and patients, recognizing it may help eliminate the biggest health disparity stakeholders identified: access to care.
“There’s broad recognition that in rural counties, there’s not always the ability to provide onsite care. We sought to find out how we could make care available to these patients without making it inconvenient for them,” said Pal, another primary investigator on the NCI grant. “Vanderbilt had already implemented the infrastructure to provide telehealth services. This has been part of our strategic direction, so we are utilizing that infrastructure to help grow it further.”
The project will also utilize VICC’s existing connections to rural hospitals through the Vanderbilt Health Affiliated Network, a collaborative alliance of physicians and health systems across Tennessee and surrounding states. Hospitals in the network that serve rural areas will have the opportunity to participate.
Researchers have also partnered with Memphis-based Baptist Memorial Health Care Corporation, which operates rural hospitals in three states, to help with enrollment. Phillip Edward Lammers, MD, medical director of Clinical Oncology Research for the organization, will serve as a site principal investigator.
Another level of the project will involve telemedicine services for patients at various stages in their cancer journey. During VICC’s community needs assessment, patients identified a need for more education opportunities about cancer, how it’s treated, how to choose therapies and what they need to know about managing their personal care needs, such as exercise and managing symptoms. They also identified transportation challenges as a barrier to their care.
Community-based providers participating in the molecular tumor board sessions will be able to offer their patients an interactive self-management program via telemedicine that they can participate in from home. The program will cover topics such as pain management, nutrition and how to communicate better with physicians. It’s tailored after an evidence-based program that, until this point, has only been delivered face to face.
“Everything we are doing, we are doing through telehealth, so patients and oncologists never have to leave their communities,” said Friedman. “All they need is a computer, tablet or a smartphone.”
Sessions will accommodate up to 10 patients at once and will allow patients to interact with one another to share supportive care methods. The program can be accessed through personal devices and will utilize the same secure technology used for the molecular tumor board consultations.
“When people are in the middle of treatment for cancer, they don’t feel like going places. If you’re exhausted and not feeling well, you’re not going to drive an hour to a support group,” said Hull. “This program hopes to meet patients’ needs when they need that support but also need to stay home.”
Patients undergoing therapy will also have access to an online education database and a patient navigator who can answer general questions about cancer care and where the patient can find specific resources in their community.
Patients who have completed therapy will be able to participate in remote survivorship visits with a clinic nurse practitioner to go over their treatment and discuss ways to stay healthy. The patient’s local provider will also be encouraged to join the visit, and the navigator will help communicate a treatment plan with the patient’s oncologist and primary care provider.
“Sometimes when recommendations are made, the primary care provider thinks the oncologist is taking care of it while the oncologist thinks the primary care provider is doing it. This way, when we make this plan, everyone knows their responsibilities upfront,” said Friedman.
A LASTING, TRANSLATABLE APPROACH
At the end of the project’s term, the patients and community providers who participated will be asked to share their feedback on what did and didn’t work.
“We want to design this program in a way that makes rural providers see it as something that’s worth their time and effort,” said Pal.
To determine the program’s effectiveness, the researchers will keep track of how many potentially eligible cases are brought to the tumor board, whether the recommended treatment course was offered by the community provider to the patient and whether the patient accepted the recommended treatment.
For patients, researchers will look at whether their participation in survivorship and self-management sessions impacted their overall quality of life or outcomes.
The team plans to identify and eliminate barriers to making a telehealth approach successful so the model can be used by other cancer centers.
“We want this to work in our catchment area, but we also want to develop something that will be translatable to communities in other parts of the country. Different rural counties are going to have different challenges, but I think there are more similarities than differences in rural health,” said Friedman.
“It’s important to study the barriers to implementation so we might be able to scale this model out,” said Hull. “To reach a wider scale, we need to know what the potential problems could be and then have contingency plans in place to adjust the strategy as needed.”
Beyond developing a successful model, the team hopes to see a sizeable impact in outcomes for rural cancer patients, both locally and beyond.
“What I’m most excited about is beginning to make a dent in this incredibly high degree of disparities we have in cancer care delivery between patients who can walk into an NCI Comprehensive Cancer Center and patients who can’t. We want to start leveling the playing field between urban and rural patients. To me, it’s terrible that patients can’t get the same level of care and may have a poorer outcome from their cancer just because of where they live geographically,” said Friedman.
Participating sites will still have access to the tumor board and VICC subspecialists beyond the lifespan of the project, making a lasting impact on local rural communities. Chosen sites will vary in their economic status and geographic location and will likely adapt the program to meet the needs of their community.
“I think there’s a tremendous opportunity to positively impact cancer care across our catchment area and develop models to reduce disparities. To have the opportunity to build the infrastructure for other people to also leverage and use to grow rural health efforts is exciting,” said Pal. “I think we’re poised to grow these efforts in many different directions.”
THE “BEST-CASE SCENARIO”
While driving to Clarksville every day wasn’t an easy endeavor, Ramsey believes it was the best-case scenario to help her obtain the level of care she was seeking.
“I didn’t want to venture out for a second opinion, but I knew I needed to,” said Ramsey. “I’m thankful I found a great team of radiation technicians, nurses and doctors at Vanderbilt.”
Ramsey encourages other cancer patients to go wherever they feel comfortable and will receive the answers they need.
Her second piece of advice? “Don’t ever pray for extra time to pursue photography,” Ramsey laughed. “Because then I went through this trial, and guess what? I had all kinds of time for my photography.”
Following her final radiation treatment, Ramsey made a collage of the photographs she had taken on her daily drives and printed them on coffee mugs for her nurses.
“I can’t say enough about the team at Vanderbilt. They have always been caring and concerned, and they worked with me to make sure I received the best quality care possible,” said Ramsey. “Yes, it was a long way to drive, but when you’re given that kind of care, it’s worth it. And the telemedicine is worth it.”