In the randomized comparative effectiveness REACH PC trial involving 1250 patients recently diagnosed with advanced non–small cell lung cancer (NSCLC) and 548 caregivers, the delivery of early palliative care (EPC) via telehealth was shown to be equivalent to in-person visits in terms of quality of life (QOL) benefits, according to lead study investigator Joseph Greer, PhD, during a plenary session at the 2024 American Society of Clinical Oncology (ASCO) Annual Meeting. Greer, co-director of the Cancer Outcomes Research & Education Program at the Massachusetts General Hospital Cancer Center (MGHCC) and a research scientist in the Center for Psychiatric Oncology & Behavioral Sciences at MGHCC, highlighted that the REACH PC study findings underscore the potential to increase access to evidence based EPC through telehealth delivery.
“Despite considerable advances in novel therapeutics, most people with metastatic lung cancer will at some point, along with disease course, experience burdensome physical and psychological symptoms as well as impaired [QOL],” Greer said during the ASCO presentation. “To address these unmet needs, national guidelines for ASCO and other professional organizations recommend integrating palliative care from the time of diagnosis of advanced cancer.”
Greer explained further that these guidelines from national oncology organizations are based on evidence from multiple clinical trials demonstrating the efficacy of EPC for QOL, mood symptoms, coping, and other key outcomes in this vulnerable population.
“Unfortunately, most patients with advanced cancer and their families do not receive this evidence-based care due to multiple barriers, chief among them being the limited availability of specialty-trained palliative care clinicians, and practical issues in accessing supportive care,” Greer said.
One promising solution for helping patients overcome obstacles to obtain medical care is the provision of telehealth using video visits, which has accelerated dramatically since the onset of the COVID-19 pandemic, according to Greer.
“Health care leaders recognize the benefits of telehealth for improving access to supportive oncology services, and recent studies have shown the utility of telehealth for reducing health care–related costs in patients with cancer,” Greer said. “While many health care facilities now have the capacity to offer video visits, whether the virtual modality is as effective as in-person care for improving patient outcomes remains unknown. Our team therefore conducted a comprehensive comparative effectiveness trial to answer this key question.”
Greer noted that the primary aim of the trial was to evaluate the equivalence of the effect of delivering EPC via video vs in-person visits on patient-recorded QOL among patients with advanced NSCLC and their caregivers. Between June 14, 2018, and May 4, 2023, Greer and his colleagues enrolled 1250 patients with advanced NSCLC who were diagnosed in the past 12 weeks into the randomized trial across 22 cancer centers in the United States. Patients were randomly assigned to meet with a palliative care clinician every 4 weeks from enrollment through the course of disease either via video or in-person in the outpatient setting. Participants completed self-report measures at baseline and at weeks 12 and 24.
To evaluate the equivalence of the effect of telehealth vs in-person EPC on QOL at week 24, investigators used regression modeling with an equivalence margin of 4 or greater points on the Functional Assessment of Cancer Therapy-Lung (FACT-L, range = 0-136). Investigators also compared rates of caregiver participation in EPC visits and patient-reported depression and anxiety symptoms (Patient Health Questionnaire-9; Hospital Anxiety and Depression Scale), coping (Brief COPE), and perceptions of prognosis (Perceptions of Treatment and Prognosis Questionnaire) between groups. Notably, recruitment for the trial was placed on hold for 2 months at the onset of the COVID-19 pandemic, according to Greer.
“Both study groups follow the same protocol in terms of having a palliative care visit at least once every 4 weeks, and participants completed outcome measures of [QOL], satisfaction with care, and mood symptoms every 12 weeks up to week 48 post-randomization,” Greer said. “Slightly more than half [of participants] were women, and the majority self-identified as White, non-Hispanic, and married.”
During the trial, participants (mean age = 65.5 years; 54.0% female; 82.1% White) had a mean of 4.75 and 4.92 palliative care encounters by week 24 in the telehealth and in-person groups, respectively. Because of the COVID-19 pandemic, the in-person group had 3.9% of visits occur via video, according to Greer.
“The 2 study groups are generally well-balanced with respect to sociodemographic and clinical characteristics,” Greer said. “To assess [QOL], patients completed the FACT-L, and higher scores indicate better [QOL]. For this primary outcome, equivalence was established at the 90% confidence interval for the estimated difference between groups was within the equivalence margin of plus or minus 4 points on the FACT-L.”
Key Takeaways
- Equivalence of Telehealth and In-Person Palliative Care: The REACH PC trial demonstrated that early palliative care delivered via telehealth is equivalent to in-person visits in terms of quality of life benefits for patients with advanced non-small cell lung cancer. This finding supports the potential for telehealth to expand access to palliative care services without compromising effectiveness.
- Access and Practical Benefits of Telehealth: The study highlights the significant barriers to accessing in-person palliative care, such as the limited availability of specialty-trained clinicians and logistical issues. Telehealth presents a promising solution to these challenges by improving access to supportive oncology services, reducing travel burdens, and mitigating infection risks, especially for vulnerable populations.
- Policy and Future Research Implications: The findings of the REACH PC trial suggest that ongoing access to telehealth services should be supported and integrated into standard oncology practice. This evidence can inform policy decisions regarding the coverage and role of virtual care. Additionally, further research is needed to explore the optimal circumstances for telehealth use and understand the impact of sociodemographic factors on the effectiveness of telehealth interventions.
At week 24, QOL scores for patients assigned to the telehealth group were equivalent to those receiving in-person EPC (adjusted means: 99.67 vs 97.67, P < 0.043 for equivalence), Greer explained. Additionally, although the results showed that the rate of caregiver participation in EPC visits was lower in the telehealth vs in-person group (36.6% vs 49.7%, P < 0.0001), the groups did not differ in depression and anxiety symptoms, use of coping skills, or perceptions of the goal of treatment and curability of their cancer.
“The 2 study groups [also] did not differ with respect to patient and caregiver reported satisfaction with care,” Greer said. “The significantly higher rate of caregiver participation in the palliative care visits among the in-person group [was] likely due to the need for family members or friends to accompany and assist with transportation to clinic appointments.”
According to Greer, these findings add critical evidence to support ongoing access to telehealth services for patients with advanced NSCLC, and especially for vulnerable populations with serious illness. Greer explained this evidence will ideally inform policy decisions regarding the role and coverage of virtual care in the future.
“Nonetheless, questions remain about the circumstances in which video ought to be the preferred modality for delivering palliative care, especially to reduce the burdens of travel, costs, and risk for infection among potentially immunocompromised or frail patients, as compared to when the in-person visits are essential. Follow-up interview studies with patients, caregivers, and clinicians would help answer these important questions,” Greer said. “Finally, further research is needed to increase representation of patients from diverse backgrounds and telehealth studies and to conduct subgroup analyses to determine whether the intervention effects vary based on key sociodemographic variables, such as age or other factors like technology experience.”
ASCO’s chief medical officer Julie Gralow commented on the results of the study, noting that there is a much broader dissemination potential for palliative care based on this evidence.
“This trial follows up on ASCO’s clinical practice guideline that supports integration of palliative care early on after the diagnosis of an advanced cancer into standard oncology practice,” Gralow said. “I worked at an academic medical center for 30 years where we did have a palliative care team, but it wasn't a big team. We actually, even in that setting, had limited availability for this kind of routine, every-month visit out in the community rurally.”
According to Gralow, lots of practices don't have the ability to have a dedicated palliative care team, but may be able to offer EPC through telehealth, when applicable.
“I think this [approach] is more patient-centric,” Gralow said. “Patients can choose whether they would prefer the telehealth vs the inpatient visits—I think it could be mixed and matched too—and we can get palliative care delivered to more patients. I certainly think that with the pandemic waivers, we're using telemedicine a lot more, and we need to lock in, through policy, the ability to be able to deliver telehealth outside of [urban centers to] rural patients.”
During the presentation, Charu Aggarwal, MD, MPH, the Leslye M. Heisler associate professor for lung cancer excellence and director of Precision Oncology Innovation at the Penn Center for Cancer Care Innovation at the University of Pennsylvania, agreed with the sentiments of Gralow and Greer, noting that EPC is an integral component of the delivery of effective lung cancer care.
“Now we have the technology to reduce the burden on patients and use it to our advantage,” Aggarwal said. “Findings from the study underscore the importance of telehealth in improving access and broad dissemination of palliative care to patients who otherwise may not be able to get it. Integration of [EPC] will improve [QOL] and lead to improvements in survival for patients with advanced lung cancer.”
REFERENCE
Greer J, Gralow J, Aggarwal C. On-Site Briefing on Plenary Abstracts. 2024 American Society of Clinical Oncology Annual Meeting; May 31 - June 4, 2024; Chicago, Illinois.
