Telemedicine and Cancer Care in Low- and Middle-Income Countries During the SARS-CoV-2 Pandemic.

Introduction

The multifaceted impact of the SARS-CoV-2 pandemic has stretched health services to a great extent, and cancer care is not an exception. With the imposition of lockdowns and movement restrictions in most countries, all aspects of cancer care, including screening, diagnosis, treatment, palliative care, and follow-up, have been compromised because of the pandemic.[1] Curtailment of regular clinical activities because of the lockdowns has not only created a backlog of patients with cancer needing immediate care but has also affected the supply chain of anticancer drugs, delayed essential surgeries, and disrupted the therapy protocols. Cancer is emerging as an important comorbidity associated with a high rate of intensive care admissions following infection with SARS-CoV-2.[2] Hence, cancer care is further complicated because of the vulnerability of patients with cancer to SARS-CoV-2, during and after treatment. The pandemic has also taken a heavy toll on the mental health of patients with cancer and their caregivers, as reported by Ng et al.[3]

The low- and middle-income countries (LMICs) are already burdened by common cancers like breast, oral cavity, cervical, gastric, and lymphomas. Not surprisingly, countries with fragile or fragmented health services have seen dramatic effects on the cancer care continuum (preventive, diagnostic, therapeutic, and survivorship care) during the pandemic. A recent cross-sectional study among 17 LMICs showed that cancer diagnostic services were completely withheld for 30 days or longer in eight (47%) of them, whereas six (35%) countries reported complete suspension of cancer treatment for longer than a month.[4] Vaccination against human papillomavirus has been badly hit because of temporary stoppage or deprioritization of existing programs and delayed introduction of new programs.[5]

However, the SARS-CoV-2 pandemic has also created an opportunity to adopt and adapt technological solutions to mitigate some of the negative impacts. Digital technologies provide concrete opportunities to tackle health system challenges, and thereby offer the potential to enhance the coverage and quality of health practices and services.[6] Telemedicine is one such solution that harnesses the power of the digital revolution and the high penetration of mobile telephones across the world. Teleoncology is a branch of telemedicine to improve cancer patients' access to care by reducing the need to travel to distant tertiary-level oncology centers.[7] This can reduce the workload on oncologists and help hospitals to prioritize services. According to the mode of communication, telemedicine may include video (streamed on mobile phones, tablets, and computers using special software), audio (phone and voice over internet protocol), text, or hybrid methods.

The beneficial role of teleoncology, ranging from the counseling of patients to capacity building of health professionals and researchers, has been demonstrated during the pandemic even in LMICs. The advantages of telemedicine or teleoncology include convenience, safety, a decrease in health care costs by reducing just 1% of emergency department visits through the use of telemedicine,[8] and increased access to care from a distance, especially for patients in rural areas.[9] It can also reduce geographical inequities in access to health care services in many LMICs, where cancer care specialists are often concentrated in cities.[10] The role of telemedicine cuts across cancer sites. Teleconsultation is particularly beneficial for those at higher risk of infection (elderly, having comorbidities, and immunodeficient).[11]

In this commentary, we describe the possible roles of telemedicine to improve services across the cancer care continuum in LMICs, challenges of equitable implementation, and possible strategies to overcome these challenges.

The role of telemedicine along the continuum of cancer care:

Opportunities.

The application of telemedicine, including m-Health, to improve the efficiency, efficacy, and reach of interventions across the cancer care continuum has received a tremendous boost during the pandemic. The role of teleoncology to improve cancer care is described in the following sections:

1. Cancer prevention, early detection, and treatment: Telemedicine could compensate for the deficiencies of the health care workforce and infrastructure in LMICs. The use of mHealth in tobacco control is an example.[12] Mobile phone–based tobacco cessation (mCessation) interventions are effective in high-income countries; however, their effectiveness in LMICs is being evaluated.[13] Rubagumya et al[14] concluded that smartphone-based mobile platforms may be used for teleconsultation approaches to improving the cancer screening community.

Another randomized controlled trial conducted in Bangladesh demonstrated that the smartphone-empowered community health worker model of care for breast health promotion, clinical breast examination, and patient navigation in rural areas was more efficient and effective in breast health promotion compared with the control group.[15]

The European Society for Medical Oncology recommends the use of telephone and web technology for toxicity evaluation, dose adaptation, and supportive care recommendation during the COVID‐19 pandemic.[16] Telemedicine may be useful in reducing personal outpatient appointments for post-treatment follow‐up during the COVID‐19 pandemic.[17] It can facilitate cancer management by providing remote chemotherapy supervision, symptom management, and palliative care as well as psychologic support.[18] Lewis et al[19] concluded that follow-up of patients with cancer in the long term can be complemented by the use of telemedicine services. Beyond the SARS-CoV-2 pandemic, telemedicine-based care may be considered for patients receiving long-term oral therapies or active surveillance.[20]

Several recent studies demonstrated that patients with cancer receiving palliative care favored telemedicine visits and attributed their preference to the increased comfort and safety of their homes.[21,22] Importantly, these visits allowed personalized care, improved quality of life,[23,24] and instilled greater confidence and support to patients' family members.[25]

All these examples demonstrate that telemedicine can effectively help in improving the preventive, promotive, palliative, and, to an extent, curative aspects of health care.

2. Clinical decision support: Telemedicine has applications in decision making as well as counseling the patients and their relatives during treatment planning. Ensuring SARS-CoV-2–free status of patients while undergoing cancer treatment is crucial, and telemedicine may help physicians to evaluate the need for SARS-CoV-2 testing before initiating treatment.[26] Feedback from stakeholders suggests increasing satisfaction with the transition from physical to virtual tumor boards, which can also work toward supporting hub-and-spoke models of care and facilitate multidisciplinary coordination.[27]

3. Capacity building, research, and clinical trials: The use of telemedicine for capacity building during SARS-CoV-2 times has been efficiently demonstrated in a study conducted at the All India Institute of Medical Sciences, New Delhi. All India Institute of Medical Sciences worked with the telementoring platform Extension of Community Health Outcome, India, to conduct a national training session on ventilatory management of SARS-CoV-2 and trained more than 5,000 health care professionals. The virtual training session enabled doctors across the country to better manage patients with SARS-CoV-2 suffering from respiratory issues.[28] In a study from China, the implementation of telemedicine services decreased the death rates and incidences of SARS-CoV-2 by providing prevention, treatment guidance, training, communication, and remote consulting for the community residents and medical staff and, thus, played a considerable role in controlling the SARS-CoV-2 epidemic.[29]

The lockdown because of the SARS-CoV-2 outbreak derailed cancer research activities around the world. Laboratories were shut, and ongoing experiments and clinical trials in oncology were halted because of inadequate recruitment and retention of patients. It resulted in a catastrophic loss to patients and researchers. It also resulted in the diversion of resources to contain the SARS-CoV-2 pandemic, which will lead to a funding crunch in near future.[30,31] A study suggests that telemedicine may have an important role in monitoring patients included in clinical trials during the SARS-CoV-2 pandemic.[32]

4. Other benefits: An unexpected benefit of virtual learning in the pandemic era is a significant increase in academic conference attendance, with more participants joining from Asia and Africa who, previously, might have had difficulty attending in-person meetings because of geographic or financial constraints. With better learning opportunities for clinicians and health care professionals from developing countries, these virtual meetings can greatly improve cancer care in these underserved regions. In addition, Elkaddoum et al[33] reported that teleoncology helps in reducing the demand for COVID-19–related personal protective equipment. It has also been well documented that psychiatric consultation through telemedicine while staying at home can be effective in providing care for patients with mental health conditions, which have been exacerbated during the pandemic.[34]

Challenges.

However, there are several implementation challenges associated with the use of teleoncology that need to be considered before the benefits of telemedicine might be fully realized in any setting. The details of such challenges, their impact, and recommended solutions are described in Table 1.

TABLE 1

Challenges and Recommended Solutions

Additionally, an important obstacle could be the impossibility of carrying out an appropriate clinical examination from a distance, knowing that the routine clinical practice often reveals early signs that could lead to new investigations.[30] The challenges associated with real-time evaluation and loss to follow-up remain one of the key drawbacks.

Newer initiatives

1. Leveraging the social media: Conventional telemedicine requires the physical presence of the patient at a nearby telemedicine center. This is where social media can fill the gap by providing continuity of care without a physical visit.[57] The authors have conducted a longitudinal trial on the use of the SoMe (social media) application for remote monitoring of patients with cancer, and it was as effective as a conventional follow-up. It is imperative that while providing clinical care via SoMe, physicians should have the ability to balance principles of privacy in these settings.[58]

2. The Indian Government recently launched an online consultation service via E-Sanjeevani, a nationwide online medical services platform. This teleconsultation service enables patients to consult with specialist doctors from the safe confines of their homes. The service is particularly helpful in the present scenario as India is experiencing the second wave of the largest pandemic of the century.[59]

In conclusion, technology, if used appropriately, has the potential to mitigate some of the challenges posed by the SARS-CoV-2 pandemic in the equitable provision of quality cancer care and control. New telemedicine-promoting policies and ubiquitous mobile phone access in many LMICs now raise the possibility that telemedicine could help bridge gaps in care for chronic medical conditions including cancer. However, a proper code of conduct has to be followed and guiding principles framed for patients and health care providers in the online world. There is also an urgent need to provide proper training to the patients as well as the health care providers to use telemedicine to yield optimum results. Going forward, a hybrid approach may be the order of the day, and the per-force adoption of technology may prove to be a blessing in disguise, not only saving time, expense as well as a step toward universalizing access to health care.