ASCO 2024 Palliative Care

Telehealth Delivers Early Palliative Care as Effectively as In-Person Care

Early palliative care can be delivered via telehealth with quality-of-life effects equivalent to those of palliative care delivered in person to patients with advanced non–small cell lung cancer (NSCLC), according to late-breaking results presented during the June 2, 2024, plenary session at the American Society of Clinical Oncology (ASCO) Annual Meeting.¹

Joseph Greer, PhD | Image: Massachusetts General Hospital

Whether the palliative care was delivered in person or via telehealth, the most common topics discussed during the visit were similar and included building and establishing rapport to create a relationship with the patient and their family, identifying symptoms and grading symptom management, and coping with serious illness, Joseph Greer, PhD, codirector of the Cancer Outcomes Research & Education Program at Massachusetts General Hospital Cancer Center and associate professor of psychology in the Department of Psychiatry at Harvard Medical School, both in Boston, explained during his presentation of the results.

A lung cancer diagnosis disrupts the lives of patients and their families, and Greer and his team began developing this study design well before the COVID-19 pandemic.

National guidelines from ASCO recommend palliative care be integrated with oncology early on for patients with advanced cancer.² However, due to limited access and resources, these guidelines are often not followed, Greer explained. In a discussion of the trial findings following Greer’s presentation, Monika K. Krzyzanowska, MD, MPH, FRCPC, FASCO, of the Odette Cancer Centre at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada, noted that a meta-analysis found a median duration of palliative care before death to be only 19 days.³

Since the onset of the pandemic, telehealth visits have accelerated dramatically, and health care leaders recognize the benefits of this technology. Findings from studies have shown cost savings through the use of telehealth among nonelderly patients with cancer.⁴ The large-scale comparative effectiveness trial of early palliative care delivered via video vs in person was conducted to determine whether telehealth could overcome these barriers to provide palliative care earlier to patients with advanced cancer.

A total of 1250 patients with advanced NSCLC were enrolled between June 14, 2018, and May 4, 2023. The mean age for participants was 65.5 years, and 54% were female patients. The majority of patients were White (82.1%). Quality of life was measured using regression modeling with an equivalence margin of ± 4 points on the Functional Assessment of Cancer Therapy-Lung Scale.

The patients had been diagnosed in the 12 weeks before enrollment and were randomly assigned to meet every 4 weeks with a palliative care clinician either via video or in the clinic. Patients continued their meetings through the course of their disease, and they completed self-report measures at baseline, 12 weeks, and 24 weeks.

By week 24, the telehealth group had a mean of 4.75 palliative care encounters and the in-person group had a mean of 4.92 encounters. The quality-of-life scores were equivalent in both groups (adjusted means: 99.67 for telehealth vs 97.67 for in person; P < .043 for equivalence).

The study also compared caregiver participation rates and found that this was slightly lower in the telehealth group vs the in-person group (36.6% vs 49.7%; P < .0001).

A comparison of patient-reported depression and anxiety symptoms (Patient Health Questionnaire-9, Hospital Anxiety and Depression Scale), coping (Brief-COPE), and perceptions of prognosis (Prognosis and Treatment Perceptions Questionnaire) found the groups did not differ.

“These study findings add critical evidence to support access to telehealth services, especially to vulnerable populations with serious illness, and will ideally inform policy decisions regarding the role and coverage of virtual care in the future,” Greer said.

However, in a press conference, Greer acknowledged the challenge of palliative care referral rates and recruiting participants for the trial. There is a misperception about what palliative care is and how it differs from end-of-life care in a hospice, he said.

“We usually say something to the effect of, ‘A palliative care team is here to support you to live…as well as possible for as long as possible,’” he said.

They train their clinical research coordinators “to describe how palliative care provides an extra layer of support.” When patients start to meet with the palliative care clinician, they are usually grateful the relationship was established with someone who doesn’t “hold the keys to chemotherapy.”

He explained that palliative care clinicians are often treated as a third party with whom the patient can openly share concerns about adverse events or symptoms.

“I am a psychologist, and some of my patients will even share with me how they hide their symptoms and [adverse events] because they fear that they may have to have a hiatus from treatment due to those,” Greer explained. “And so this is another way where that synergy not only helps optimize efficiency and time for both clinicians—the oncologist and palliative care clinician—but really allows for proactive symptom management, ideally, to improve adherence to treatment.”

Although the study findings answered questions around the feasibility of delivering early palliative care by video and the effectiveness of it, there are some unanswered questions, Krzyzanowska noted in her discussion. It is unclear whether these results can be replicated in less ideal settings as well as what the implication is of the lower caregiver attendance in the video group. In addition, it has yet to be determined whether virtual early palliative care is for every patient.

here have been concerns that the increasing adoption of virtual [care] may exacerbate disparities,” she said, pointing to results of a study of almost 30,000 encounters during the early phase of the pandemic,⁵ which found racial minority group status, preference for a language other than English, low household income, and Medicaid coverage “were negatively associated with utilization of virtual care. Hence, it will be very important as we move forward to understand how the adoption of virtual care is impacting different patient populations and communities.”

References
1. Greer JA, Trotter C Jackson V, et al. Comparative effectiveness trial of early palliative care delivered via telehealth versus in person among patients with advanced lung cancer. J Clin Oncol. 2024;42 (suppl 17). Abstr LBA3. doi:10.1200/JCO.2024.42.17_suppl.LBA3
2. Smith CB, Phillips T, Smith TJ. Using the new ASCO clinical practice guideline for palliative care concurrent with oncology care using the TEAM approach. Am Soc Clin Oncol Educ Book. 2017;37:714-723. doi:10.1200/EDBK_175474
3. Jordan RI, Allsop MJ, ElMokhallalati Y, et al. Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Med. 2020;18(1):368. doi:10.1186/s12916-020-01829-x
4. Patel KB, Turner K, Tabriz AA, et al. Estimated indirect cost savings of using telehealth among nonelderly patients with cancer. JAMA Netw Open. 2023;6(1):e2250211. doi:10.1001/jamanetworkopen.2022.50211
5. Qian AS, Schiaffino MK, Nalawade V, et al. Disparities in telemedicine during COVID-19. Cancer Med. 2022;11(4):1192-1201. doi:10.1002/cam4.4518

SPOTLIGHT: Ravi Parikh, MD, MPP, Presents Groundbreaking BE-a-PAL Data on Default Palliative Care Referral

At the 2024 American Society of Clinical Oncology (ASCO) Annual Meeting, Ravi B. Parikh, MD, MPP, presented the final results of the BE-a-PAL study. The investigation evaluated the potential for algorithm-based default palliative care referral among patients who have stage III or IV lung or non-colorectal gastrointestinal cancer,¹ building on prior work using electronic nudges to increase referrals to palliative care.^2,3

Ravi B. Parikh, MD, MPP | Image: Penn Medicine

These newest findings show physicians from Tennessee Oncology allowed referrals in 89% of the cases in the intervention arm, which encompassed weekly default electronic health record notifications to oncologists as prompts for specialty palliative care referrals in high-risk patients.⁴

Parikh is assistant professor of medicine, medical ethics and health policy, and director, Human-Algorithm Collaboration Lab at the Perelman School of Medicine, University of Pennsylvania. Here he speaks with Evidence-Based Oncology (EBO) on data presented June 2, 2024, in the abstract, “BE-a-PAL: a cluster-randomized trial of algorithm-based default palliative care referral among patients with advanced cancer.”

This interview has been lightly edited for clarity.

EBO: What is the main takeaway from your default approach to palliative care referral?

Parikh: Currently, in standard practice, we use more of an opt-in approach to palliative care referral, meaning that if I, a clinician, feel like a palliative care referral is warranted for a patient, then I, usually, or my nurse practitioner, will place that referral. That’s what gets patients into the palliative care field. And we know that when that happens, that has big benefits for our patients. It generally gets them better, more specialized expertise in their symptom management, and it oftentimes eases the transition and their goals of care when we have support from specialty palliative care–trained practitioners.

The challenge is that we don’t do it often enough. Less than half of people with cancer have a palliative care counsel prior to death, despite the fact that it’s an evidence-based practice recommended for anyone with cancer regardless of stage. And so in an effort to increase uptake of an evidence-based practice, default referrals that don’t require a physician to opt in or actually place a referral are a promising strategy. With that in mind, I would say that there are 3 big takeaways from this study.

First, default palliative care works; it increases rates of completed palliative care visits by nearly 4-fold in a busy community oncology setting consisting of 15 practices where palliative care is resource constrained. It’s not like we staffed up palliative care for this trial. So that is a promising sign of real-world effectiveness. The second thing that I think is a big takeaway is that default palliative care doesn’t just increase rates of completed palliative care visits, which is more of a process outcome. It actually had meaningful impacts on, most notably, receipt of chemotherapy near the end of life, which is a bad low-value care practice. That decreased by over 2-fold in our intervention computer. And it also had some promising signals that didn’t reach statistical significance in increasing hospice utilization.

And then the third thing that I would say—and this is more from a practicality standpoint—is that in both quantitative and qualitative data that we’ve gotten from this trial, you might think that a default referral would risk overwhelming community oncology palliative care providers, and that did not happen.

Largely, it was because we only use default referrals for an upper segment of the risk distribution, a sort of high-risk population of patients with cancer that was identified by an automated electronic health record predictive algorithm—that’s near what we’ve tested in the past similarly for other things like advanced care planning. But in this setting, where you might envision a whole flush of new referrals could risk overwhelming the system, it really didn’t because we use more of a risk-targeted approach for that.

So those, I think, are the 3 big takeaways that are most relevant for practicing oncologists and palliative care providers.

EBO: When physicians opted out, can you discuss the reasons they gave for doing so?

Parikh: Across all of our trials with defaults, whether those be default, sort of prompts for advanced care planning, default referrals for certain care management interventions, or default referrals for palliative care in this setting, we’ve always found that there is a relatively large group of accepting physicians and then a relatively small group of physicians or nurse practitioners who just opt out of everything because they want to preserve their own autonomy in deciding whether a patient gets here or not. And that’s OK. We know that these care delivery interventions aren’t accepted by everybody. But the fact that they are accepted by most is a strong signal that 1, I think our algorithm generally got it right most of the time because physicians were largely accepting, and then 2, it suggests that oftentimes physicians just need a little bit of behavioral nudge, a push, toward doing the right thing, rather than relying on them to refer into what should be an evidence-based practice.

You brought up what are the reasons. We actually tracked it because we used a concept called accountable justification to track reasons why clinicians did not accept a certain palliative care referral. What we found was sort of interesting. We found that, at least when it came to opting out of the intervention, the most common reasons why physicians opted out wasn’t because they didn’t feel that patient’s condition was severe enough to warrant a palliative care referral or that they felt that there were certain patient-specific barriers that the algorithm couldn’t see—for example, known reluctance toward discussing advance care planning and end-of-life care. The physicians wanted to avoid putting that in the hands of palliative care specialists by just opting out of the referral entirely.

Now, it should be noted that even if physicians opted in, patients could still refuse to seek palliative care because we offered patients the option and, in fact, only in about 63% of the time did patients actually agree to a palliative care referral, even if a physician did not opt out. And the reasons for that were a little more variable, but they included being overburdened with visits and the health care system and feeling that their own symptoms were relatively well controlled.

EBO: Did having a coordinator set up the referral increase the likelihood that physicians agreed to this process?

Parikh: We’ve run a qualitative study that assesses what worked and what didn’t work well. We interviewed 20 to 25 oncologists and palliative care clinicians that participated in the trial. The No. 1 thing that they felt was most effective was having the coordinator use standardized language to introduce palliative care. If you think about how physicians, oncologists, nurse practitioners introduce palliative care, I bet if you survey 20 of them, you’d get 20 different answers. Some of them see palliative care as anchored to end-of-life care, whereas others use it as an adjunctive supportive care service, or that’s how they describe it.

And so without using standardized language, then you can imagine that you’d have very wildly different rates of acceptance of palliative care, depending on how patients perceive the intervention. If they feel palliative care is only appropriate near the end of life, then maybe they’d be a little more reluctant to accept it than if they saw it as more of a supportive care service that could be used concurrently with systemic therapy—which is very much how we message language and which has been language advocated through both ASCO and the Center to Advance Palliative Care. Having that standardized risk language from a coordinator introducing it is a big motivator, I would think, maybe just as important as the algorithm or the default itself.

The other thing I’ll say that’s come up in some criticism of the work is, well, does every clinic have the staff to be able to do this and to have a dedicated staff member that’s responsible for introducing palliative care? I’d have 2 responses there. One is that this wasn’t the coordinator’s only job; they had a bunch of other things that they were doing during the day than introducing palliative care. And so managing it into the workload is more of a matter of what clinic-level priorities are than whether there’s a dedicated staff member who’s available. But then the second thing is that there’s no reason why this has to be a research coordinator that does the introduction of palliative care. It could be a scheduling nurse, it could be a triage nurse, it could be any number of staff that are part of a routine clinic, as long as they’re using standardized messaging to introduce the palliative care intervention. I think that is a key facilitator toward getting broader uptake rather than relying on submissions. We’re busy, time strapped, and think of palliative care in different ways to be introducing the actual referral.

References
1. Predictive analytics and behavioral nudges to improve palliative care in advanced cancer. ClinicalTrials.gov. Updated February 1, 2024. Accessed June 2, 2024. https://clinicaltrials.gov/study/NCT05590962
2. Parikh RB, Zhang Y, Small D, et al. Long-term effect of machine learning–triggered behavioral nudges on serious illness communication and end-of-life outcomes among patients with cancer: a randomized clinical trial. J Clin Oncol. 2022;40(suppl 16):109. doi:10.1200/JCO.2022.40.16_suppl10
3. Patel MS, Volpp KG, Asch DA. Nudge units to improve the delivery of health care. N Engl J Med. 2018;378(3):214-216. doi:10.1056/NEJMp1712984
4. Parikh RB, Ferrell WJ, Li Y. BE-a-PAL: a cluster-randomized trial of algorithm-based default palliative care referral among patients with advanced cancer. Presented at: ASCO 2024; May 31-June 4, 2024; Chicago, IL. Abstract 12002. https://meetings.asco.org/2024-asco-annual-meeting/15800?presentation=232443#232443

Advancing Geriatric Oncology Care Through Telehealth and the GAIN-S Model

William Dale, MD, PhD, FASCO, is the George Tsai Family Chair in Geriatric Oncology and vice chair for academic affairs, Department of Supportive Care Medicine, and director, Center for Cancer and Aging, City of Hope. He is the senior author of 2 abstracts that were presented at the 2024 American Society of Clinical Oncology (ASCO) Annual Meeting: “Geriatric assessment–directed supportive care intervention (GAIN-S)-implementation via telehealth in a lower-resourced community,” which presented findings from the experience of delivering assessments to patients in remote Antelope Valley, California; and “Quality of life for older patients with metastatic cancer in Brazil: A telehealth-based geriatric assessment and supportive care intervention (GAIN-S).”^1,2

William Dale, MD, PhD, FASCO | Image: City of Hope

Dale is a longtime leader in the field of geriatric assessments in cancer care. This year, he received the B.J. Kennedy Geriatric Oncology Award during the ASCO annual meeting, making him the first non-oncologist so honored. He was the lead author for the 2023 ASCO guideline update, “Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Systemic Cancer Therapy,”³ which drew on 26 studies and was the first update following the COVID-19 pandemic. In an interview, Dale shared details with Evidence-Based Oncology (EBO) on the GAIN-S model and the advantages of telehealth among older patients who have cancer.

“It was a really good option because it got to where they were,” he said. “And once we could get people connected through everything, it was a great way to both see them and see them where they were in their house.”

Satisfaction with the use of telehealth for assessments is reflected in patient feedback. Dale shared some examples of patient comments with EBO:

• “I feel like telehealth accomplishes multiple things with little effort from the patient. I like it. It is very convenient for patients.”
• “It is very convenient for me because Lancaster[, California] is over 120 miles away from me.”
• “I love the new technology and appreciate the service.”
• “I really liked it, and it saved me time and money. It actually felt more private and comfortable talking to her than going to see someone.”
• “Because I don’t drive and need to take the bus for my medical appointments, doing televideo makes it much more convenient and allows me to be home and be more relaxed and engaged during the consult, as opposed to going in person, because I’ll start feeling anxious.”

“I was very impressed by Leana. She was always up to date on my records and knew how to answer every question I had (even if it was outside of her area). She is by far the best nurse I have ever worked with in person [or] via telehealth.”

Dale also shared specifics of the findings presented at ASCO, including elements of the GAIN-S model. This interview has been edited for length and clarity.

EBO: Can you describe the elements of the GAIN-S model?

Dale: This grew out of the desire to take the development of a geriatric assessment and turn it into geriatric assessments plus interventions—that’s the “IN” part of GAIN—geriatric assessment and interventions. How do you partner an intervention approach with the assessment approach? Until now, we developed this model of an intervention, we had predictive ability with geriatric assessment, and we had the idea that we could intervene, but whether we could affect outcomes meaningfully was the big question, as is often the case in this kind of research. That’s hard to prove that you can make a difference on big outcomes. Our approach was to take the standardized and validated geriatric assessments and partner that with interventions matched to the dimensions on the geriatric assessment.

Very concisely, we have what we consider the essential domains for geriatric assessments—functional, cognition, social, nutrition—and for each one, we say, “If this is found to be abnormal, do this.” If you have a mobility problem, you will do physical therapy. If you were having a nutrition problem, you would see a nutrition person. And then sometimes they are more specifically things you can do that are counseling-type things, let’s say, for mental health support, if you can’t immediately get a referral for mental health. So that’s the model, and it’s targeted to be delivered to people right before they have an intervention on their cancer therapy—usually chemotherapy, sometimes immunotherapy—and we believe, and there’s evidence to support in other studies, surgery or radiation would be equally valuable interventions that you would partner this with.

EBO: Why is telehealth a good delivery option for supportive care for older patients with cancer?

Dale: Two things are relevant. In the original GAIN model, we delivered it in person. The big question at the time that we started developing these studies was, could you translate that into some other venue and get it to patients who are “out in the real world”? So 20% of people are in those NCI [National Cancer Institute]–designated cancer centers who have cancer, while 80% are out someplace else. And so how do you do that was the question. We and others had decided, well, let’s try telehealth. Just about that time, the pandemic hit as we were trying to figure out whether this could work. And in a weird way, in the academic world, everybody just started doing telehealth in the middle of us trying to understand if it was going to work. So we benefited, in a way, from having the opportunity to try telehealth in real time while we were studying whether it was working.

You asked why is it a good option or not? The first instinct people had was, older people are going to have trouble with technology. Were we really going to trust that they could use technology? And it’s true, just like all of us, they have trouble with technology, too, but it’s not that much different than the rest of us have trouble with technology, as it turns out. With the forced need to do telehealth, we all sort of learned on the fly. And so, in one way, there’s the technology challenge—and they do need support like others—but in terms of reaching out to people, we realized it was a really good option because it got to where they were. And once we could get people connected through everything, it was a great way to both see them and see them where they were in their house. I couldn’t do a physical exam, but you could actually see things about where they lived, where their medicines were being stored, what their house looked like, tripping hazards. You sometimes would even see on the video who was around. They would call somebody and say, “Hey, could you go get my medicine bottle and bring it so I can show the doctor?” So in many ways it was advantageous.

The other advantage is the convenience for people—so the chance that they’d actually come to a visit went up a lot. And speaking of the Brazil experience, we have really good examples where they would just never get anything like this kind of care, given their circumstances, if you didn’t have a telehealth option to connect with people. The benefits, in my opinion, far outweigh the downside of not being in person and not being able to do a physical exam in that encounter. That has to be done in some other way.

EBO: Because we’ve been through the pandemic, are we at the point where most patients, including older adults, accept the idea of telehealth?

Dale: I’d say mostly, that’s true, that with some caveats. I think we’ve crossed some crucial threshold of saying, we clearly can do it and clearly the majority will accept it. The caveats are some people will have technical challenges that cannot be overcome. I’m impressed how often there’s just some technical barriers and that you have to invest in overcoming those technical barriers. Our team would contact them the day before, and ask, “Can you connect?” and make sure they were able to be there; we do a reminder and kind of tech check. The second caveat is that some people still wanted to come into the office. In our Antelope Valley study, we had multiple modalities. We weren’t solely dependent on the technology; we did have pen and paper on site. And if necessary, we would convert over to a telephone. Some people would say, “I just trust my phone and I don’t want to do it on the telehealth.”

In the Antelope Valley experience, we had about 250 people; 200 of them did a telehealth visit but around 45 or so insisted on having a telephone encounter. And then if they chose to come into the office, we had paper and pencil available. I do recommend having more than 1 modality.

EBO: Has the technology improved? Is it easier for a patient to log on with help from a family member than it was 5 years ago?

Dale: You’ve certainly partly alluded to what the answer is, which is we’ve overcome a lot of technical barriers. One, people are familiar with what they’re familiar with. We found in Brazil, for example, the reach-out to people ended up being through WhatsApp. We figured out we were going to use what’s out there rather than try to teach a new technology to people.

Sometimes we convert over from our preferred mode to something people were comfortable with. Having a second option was often a good idea for people. You mentioned another important thing, which is family members.

Often a daughter, son, or a niece would help with the technology—that person would help make sure the connection was set up. We definitely found that if you had someone who was tech savvy involved, try to keep them involved.

EBO: In either the California or Brazil study did you assess how patients view telehealth vs an in-person visit? Are there some patients who are always going to view the in-person visit as the gold standard, regardless of the quality of the intervention that they’re getting?

Dale: There’s no way to get around people’s personal preferences. And even I, as a provider, often want a first visit to be an in-person one because you get to know people in a certain way with an in-person visit. Having said that, given the circumstances, Antelope Valley is 80 miles from where I am right now—through the mountains. The idea of driving through California traffic for 80 miles—some people were almost to Las Vegas—it’s such an extreme thing to expect them to come those distances. They much prefer to do it at home if they possibly can, I would say.

EBO: How scalable is this model? Can this concept be brought to community practices everywhere?

Dale: My first response is, I think it’s scalable almost everywhere, at least when there’s sufficient technology for people to connect. And given the ubiquity of smartphones these days, the technology is out there now. The pandemic accelerated the availability of this for most places. Having said that, I do have a concept of what I call the minimal effective dose of supportive care, or the minimum effective dose of geriatric oncology. For the minimal effective dose of supportive care, you need—in addition to the technology—some kind of higher-touch care, I’ll call it, to make this work completely. And that doesn’t even mean you physically have to touch people.

But you need 3 things: First, you need leadership in the area that prioritizes this kind of supportive care. You know we’re going to find physical therapy for you; we’re going look into your nutritional status and [ask if] you need somebody who does that. In our case, we had a nurse practitioner who did it; sometimes it’s somebody else in the clinic.

The second thing you need is someone with an understanding of social and mental health. So here, we rely on our social workers. You need someone who can address the mental health concerns that emerged in things like the pandemic and that we identify in these tests.

And then you need what I call resource coordination. You need someone who can identify resources locally in the area to make it work.

References
1. Phillips T, Sun CL, Chien LC, et al. Geriatric assessment–directed supportive care intervention (GAIN-S)-implementation via telehealth in a lower-resourced community. Presented at: ASCO 2024; May 31-June 4, 2024; Chicago, IL. Abstract 1510. https://meetings.asco.org/2024-asco-annual-meeting/15679?presentation=231568#231568
2. Bergerot CD, Bergerot PG, Razavi M, et al. Quality of life for older patients with metastatic cancer in Brazil: A telehealth-based geriatric assessment and supportive care intervention (GAIN-S). Presented at: ASCO 2024; May 31-June 4, 2024; Chicago, IL. Abstract 1514. https://meetings.asco.org/2024-asco-annual-meeting/15861?presentation=232492#232492
3. Dale W, Klepin HD, Williams GR, et al. Practical assessment and management of vulnerabilities in older patients receiving systemic cancer therapy: ASCO Guideline update. J Clin Oncol. 2023;41(26):4293-4312. doi:10.1200/JCO.23.00933