Telemedicine in Lung Cancer Rehabilitation


Telemedicine refers to the use of telecommunication technologies to deliver healthcare services at a distance. The concept of telehealth refers to the broader scope of healthcare services, including nonclinical services. In contrast, telemedicine, a subset of telehealth, refers to the delivery of clinical services by a practicing healthcare provider (physician, nurse practitioner, or physician assistant). Throughout this chapter, the terms telehealth and telemedicine will be used synonymously. Telemedicine uses various technology-based applications with the overall goal of enhancing communication between patients and providers, increasing continuity of care, decreasing travel burden, and overcoming workforce shortages in areas lacking specific providers. The rapid growth of telemedicine has extended into various medical disciplines, including oncology and, most recently, physical medicine and rehabilitation. “Teleoncology” and “telerehabilitation” are used to describe the use of telemedicine within these specialties, respectfully. This chapter provides a general overview of cancer telerehabilitation and discusses the practical applications of telerehabilitation, focusing on individuals with lung cancer.

Telemedicine in Cancer

The growth of telemedicine in oncology began with the goal of redistributing the workforce to rural areas that lack oncologic-specific programs or specialists. In recent years, further adaptations of telemedicine in oncology have given rise to interventions such as remote symptom monitoring, chemotherapy supervision, remote office visits, and home-based rehabilitation programs. Yet, despite the potential benefits of these established programs, integration of telemedicine remained a challenge because of various clinical and administrative barriers including fear of losing interpersonal relationships, need for trained personnel, provider resistance to change, and lack of adequate reimbursement. The use of telemedicine accelerated during the height of the novel, highly virulent, Sars-Cov2 (COVID-19) outbreak in 2020 after clinics and services was closed due to government-mandated physical distancing orders to minimize viral spread and lessen the burden on the healthcare system. There was a dramatic rise in telemedicine services (almost 4000%) in April 2020, mainly due to adaptations by patients and changes in licensing policies and reimbursements by third-party organizations. In oncology, the use of telemedicine during this public health crisis lessened the incidence of viral transmission while simultaneously minimizing disruption of care for cancer patients through improved access to care and timeliness of treatments. Experts are optimistic about the use of telemedicine beyond the COVID-19 pandemic period, given the numerous benefits and implications in cancer care, including improvements in patient–provider communication, participation in multidisciplinary collaboration, symptom monitoring, and participation in cancer clinical trials.

Overcoming Barriers to Cancer Rehabilitation With Telemedicine

Cancer survivors experience a variety of complex physical and functional impairments as a result of tumor-related or treatment-related adverse effects. Despite robust evidence supporting cancer rehabilitation efforts, cancer patients continue to have unmet rehabilitative needs. The underutilization of cancer rehabilitation services by the patient and referring physicians results from a lack of knowledge that such services exist, lack of access to specialists or programs, or difficulty with adherence due to physical or financial inconveniences. These barriers highlight the importance of integrating cancer rehabilitation into standard cancer care to identify cancer-related impairments early on and prevent functional decline. Over the years, several rehabilitation models have been proposed including prospective surveillance models, triggered rehabilitation referrals, hospitalized-based care delivery pathways, and center-based programs. Implementing these delivery models in clinical settings across the nation has been challenging due to the lack of reimbursement mechanisms and infrastructure. , Advancements in communication technology can offer cost-effective strategies to effectively integrate rehabilitation in cancer care. Historically, telerehabilitation has focused on neurological rehabilitation in which remote therapies are offered to stroke patients and their progress is monitored. Randomized clinical trials have shown telerehabilitation is an equally effective way of improving patient outcomes after stroke compared to in-clinic care. However, the use of telerehabilitation services in cancer care remains limited. The primary reason for this is that exercise-based rehabilitation programs are not yet part of the standard of care for cancer patients, and therefore, cancer rehabilitation is not regularly recommended by oncologists. There may also be hesitancy to refer a patient to virtual rehabilitation programs versus supervised face-to-face programs due to the perceived fragility and medical complexity of this population. Nevertheless, there is emerging evidence to support the use of telemedicine in cancer rehabilitation as an effective, accessible, feasible, and cost-effective alternative to traditional care.

Lung Cancer Telerehabilitation

Multidisciplinary rehabilitative assessments and interventions are important for individuals living with lung cancer to mitigate symptoms, optimize their physical health, prevent falls, and improve quality of life. This section discusses the role of telerehabilitation to address common rehabilitation needs of lung cancer patients and their symptom management.

Pain

Pain is one of the most prevalent and complex symptoms in patients diagnosed with lung cancer and can stem from local invasion of chest structures or metastatic disease affecting bones, nerves, or other anatomical structures or as a consequence of treatments. Patients with unrelieved pain also can experience physical symptoms such as insomnia, anorexia, profound fatigue, reduced cognition, and overall reduced vital capacity. Persistent pain can cause existential and spiritual suffering, limiting the patient's coping skills. This underscores the importance of frequent pain assessments to ensure adequate pain control. The ease of access using telemedicine has allowed for more frequent symptom monitoring through a variety of technological interfaces (video, phone call, web-based messaging, etc.). An NCI-funded clinical trial found that a 6-month physical rehabilitation program delivered by telephone modestly reduced pain and improved function for people with advanced cancer. The telerehabilitation program also reduced the time patients spent in hospitals and long-term care facilities such as nursing homes.

Managing pain through telerehabilitation has many challenges despite advancements in technology such as videoconferencing. Limitations include interpreting nonverbal cues, rapport building, and performing an in-depth physical exam—all of which are necessary parts of pain management visit. With a focused pain history, physical exam, and mental health assessment, a rehab physician's knowledge of pain physiology can assist in identifying the pain generator and assist in designing a therapeutic blueprint. The clinical history not only localizes the pain but distinguishes whether the pain is somatic, visceral, neuropathic, or mixed in etiology. The history provides information about what measures were previously attempted to alleviate pain and can guide future therapies. In addressing pain through telemedicine conferencing, providers may use typical pain scales to aid in assessments such as the numeric rating scale (NRS), verbal rating scale (VRS), and visual analog scale (VAS). It is also possible to use multiple dimension instruments to assess pain such as the McGill Pain Questionnaire and the Brief Pain Inventory (BPI), which incorporates the impact of chronic pain on day-to-day functioning as well as a mental health screening tool as the Patients Health Questionnaire-9 or General Anxiety Disorder-7. Generally, the physical exam follows a standard in-person exam with exceptions made for palpation, range of motion, and special testing, for which the patient or a family member can be guided through to approximate.

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