As an oncology social worker I perused the ASCO abstracts with an eye to identifying topics that resonate with real clinical issues commonly encountered in the Australian context. Hot topic themes for social workers include equity of cancer car service delivery, challenges for rural cancer patients, financial toxicity and survivorship care. Of course the biggest topic for all of us in the current climate is changes and adjustments to care necessitated by the COVID-19 pandemic.
First up was a presentation from our own Cancer Australia team, with Dr Vivienne Milch as lead presenter.
The need for innovative thinking in delivery of cancer care in the context of a pandemic has been a universal challenge. Whilst the number of COVID cases has been mercifully modest in Australia, the oncology community needed to be prepared for the possibility of large numbers of cases and to modify practices accordingly. Enhancements to care were considered and implemented and were required to be achieved in a timely fashion that did not negatively impact the quality of care. Upgraded digital health initiatives are now familiar to all of us in the Australian health care system: telehealth, virtual multidisciplinary team meetings and family conferences, along with treatment modifications and shared care.
The conclusion of the authors is that an unintended consequence of the pandemic is the rapid implementation of new ways of delivering care that are more efficient and beneficial to both patients and clinicians. The challenge is to identify barriers to widespread uptake of practice enhancements, such that they are integrated into evidence-based standard care.
This a contribution from Massachusetts General Hospital in which a cross-sectional survey was conducted with 237 patients with metastatic brain disease, 209 caregivers and 239 physicians. The value of this study is that it considers the impact of brain metastasis from all aspects of patient care and includes psychosocial concerns, treatment options/clinical trials and supportive resources.
Discrepancies were identified between patients/caregivers and clinicians in the manner in which prognosis is discussed, understanding of the implications of brain disease and treatment options. This is a particularly vulnerable patient cohort and better understanding of their experience may result in quality improvement initiatives to enhance communication and well-being.
Financial distress and financial toxicity are garnering increasing importance, even in Australia where high quality cancer care is delivered with relatively few out of pocket costs in the public health care system. Nevertheless, there are costs associated with treatment that extend beyond out of pocket medical costs. These are seen as indirect or opportunity costs and include things like travelling for treatment, parking, reduced income and the cost of domiciliary services to maintain patients and families in their homes. Development of the oncology opportunity cost assessment tool or OOCAT is an extension of the existing COST tool which measures direct financial costs of care.
In a rigorous research process this team from Sidney Kimmel Cancer Centre in Philadelphia engaged with all stakeholders, including patient advisory groups and four virtual focus groups were conducted. The result is a 17 item instrument that quantifies the opportunity costs of cancer care. The tool is in the process of being validated. The potential value of the OOCAT for an Australian population is that it takes a broad view of financial expenses rather than solely focusing on direct costs that aren’t comparable across different health systems. This is one to watch as the instrument is validated and perhaps refined. It could be easily incorporated into Australian studies that aim to measure financial stresses in cancer care.
As cancer treatments and outcomes improve, so too do the number of cancer survivors, resulting in a growing interest in survivorship care within the oncology community. A team from Texas is responsible for a presentation on Patient preferences for cancer survivorship care: Results of an online survey. 975 survivors completed the online survey and the profile of participants was reflective of those who usually take part in such initiatives. Women represented 91% of respondents, 92% were Caucasian and 78% had a college or university graduate degree. This was a well-informed and articulate cohort. Pleasingly there were 36 different cancer types represented.
Only 21% of respondents were happy to be followed up with primary care providers and only about half of the respondents were comfortable with follow up in a dedicated survivorship clinic, instead of at their specialist cancer treatment centre. This raises questions around the increasing moves by oncologists to recommend follow up care in primary care, particularly for early stage cancer patients with a relatively low risk of recurrence. Movement towards primary care follow up would help to address workforce pressures on clinicians who are dealing with rising numbers of newly diagnosed patients, those on active treatment and those with recurrent disease. However, it would appear that the survivors themselves are not yet on board with this idea. The preference of patients seems to favour follow up by their treating oncologist at a large cancer centre, with an emphasis on managing side-effects and late effects of treatment, as well as monitoring for cancer progression or recurrence.
This reports on an initiative in Illinois to help overcome barriers in access to cancer care for people living in its rural catchment. As in Australia, there are concerns that regional, rural and remote cancer patients have poorer survival outcomes due to distance from major centres, transport costs, availability of imaging facilities and lack of timely access to specialist clinicians. Again, as we have experienced in Australia, the COVID pandemic has led to the innovative use of telehealth. This regional cancer centre has developed a hybrid model of combining face to face consultations with virtual appointments and has then evaluated the standard of care as well as time and cost savings to the patients.
The advantages for the patients included better access to specialist input including all oncology disciplines, and specifically better access to targeted treatments and clinical trials. The team has documented and quantified a significant reduction in time from treatment planning to initiation of treatment, along with calculations of the actual savings in patient travelling time, distance and accommodation costs. Patient satisfaction with the model and quality of life have not been measured, but could probably be assumed to be improved in line with more timely and less costly treatment.
