Supporting best practice telehealth in cancer care: Findings from a national study of telehealth use by cancer services and consumers during the COVID-19 pandemic

Aims: To understand consumer and clinician experiences in utilizing telehealth in cancer care since the introduction of newMedicare Benefits Schedule (MBS) item numbers for telehealth in response to the COVID-19 pandemic. Method(s): A mixed-methods approach was used to collect qualitative and quantitative data on telehealth use during the pandemic: MBS services for cancer-related professional attendances were examined by delivery type, provider type and population group. Health service staff (n = 59) and consumers (n = 1162) from cancer services acrossAustralia were invited to complete online surveys and semi-structured interviews about the use of video and telephone telehealth, perceived effectiveness of video and telephone compared to in-person consultations, and the key barriers and enablers. A virtual roundtable was held with more than 40 key cancer control stakeholders regarding strategies to support the cancer community to offer and utilize best practice approaches to telehealth. Result(s): Telehealth was used across all stages of the cancer care pathway, and was most frequently used during the 'treatment' and 'care after initial treatment and recovery' stages. Although video consults were perceived to be more effective than telephone consults, telephone use was more frequent. Patients and their carers often felt less engagedwith their clinician during telephone consults and perceived that they were rarely given a choice between the consultation modes. Key enablers included medical leadership and administrative support, remuneration (MBS telehealth items), reduced risk of infection, reduction in travel time and costs and existing relationship between patient and clinician. Key barriers included inadequate infrastructure, lack of training, access issues (e.g., internet connectivity) and not being offered the choice of a video consultation. Conclusion(s): Telehealth is appropriate for the delivery of cancer care. A hybrid model of care (telehealth and in-person options) and the ability to give consumers choice is integral to supporting best practice telehealth in cancer care.

Telehealth use in cancer clinical trials during the COVID-19 pandemic

Aims: Cancer clinical trials have traditionally been conducted inperson. The COVID-19 pandemic accelerated changes across the entire cancer care continuum, including in clinical trials and teletrials. This study aimed to investigate how telehealth was used in cancer clinical trials during the pandemic, including benefits and barriers to use;and to identify how telehealth can be further enhanced and routinely integrated into cancer clinical trials in Australia. Method(s): A mixed methods approach was used, involving a scoping review of literature, surveys of staff from 14 multi-site Collaborative Cancer Clinical Trial Groups across Australia (n = 98), and qualitative interviews with trial administrators and clinicians (n = 21). Result(s): The literature showed exponential increase in the use of telehealth in cancer trials internationally during the pandemic. Most study participants agreed that telehealth enabled continuation of trials which may have otherwise been postponed or terminated due to the pandemic. Participants indicated strong willingness to use telehealth for certain aspects of trials due to benefits including improved efficiencies in recruitment and consent processes;improved equity of access for people in rural and regional areas;expedited ethics reviews;convenience of e-prescriptions and reduced need for travel. Barriers included technology issues, inequitable access, activities requiring inperson attendance, regulatory obstacles, remote site capabilities, data quality and security issues, lack of training, and resistance to change. Conclusion(s): The rapid shift to telehealth models during the pandemic was viewed positively by participants, with increased innovation and efficiencies.Many, but not all, aspects of cancer clinical trials are appropriate to be delivered via telehealth. Telehealth is most appropriate in later phase trials;for oral (not IV) drugs;and for activities not requiring physical examinations or invasive interventions. Participants preferred hybrid models which include both telehealth and in-person methods, tailored by cancer type, interventions and patient preferences;supported by clear guidelines and staff training.

A CONCEPTUAL FRAMEWORK FOR CANCER MANAGEMENT DURING A PANDEMIC: STRATEGIES FOR SUPPORTIVE CARE

Introduction Early in the pandemic, Cancer Australia developed a conceptual framework which provided guidance on approaches to optimal cancer care in the face of significant health system challenges and risk of exposure to and harm from COVID-19. Emerging evidence during the pandemic indicated that cancer patients experienced considerable psychosocial impacts, including increased distress, depression and anxiety, and unmet information needs. Methods Evidence on the impact of the COVID-19 pandemic on cancer patients, cancer care across the care continuum, and health system capacity was reviewed, to June 2021. The conceptual framework was updated based on international and national published evidence, guidance, recommendations, and position statements. Results Supportive care strategies for cancer patients during a pandemic include extra vigilance by practitioners of screening for distress;improved communication with patients and their carers of changes to cancer care plans;provision of timely information and guidance to inform shared decision making;attention to the impact of infection control measures;, and adoption of innovative models of supportive care. Conclusions Cancer Australia's updated conceptual framework, underpinned by principles defining optimal cancer care, informs optimal supportive care across the continuum during a pandemic. It provides a planning resource for cancer care clinicians and policymakers for the current and future pandemics when supportive care needs are more paramount than ever.

COVID-19 vaccines and cancer: Tailored information for Australia's diverse populations

Background: As the COVID-19 vaccine rollout commenced in Australia in early 2021, limited evidence was available internationally about the safety and efficacy of the COVID-19 vaccines for people with cancer, particularly because cancer patients were largely excluded from the initial clinical trials. As such, people with cancer had many questions about the COVID-19 vaccines. Australia’s Indigenous and culturally and linguistically diverse (CALD) populations experience poorer cancer outcomes and have specific information needs. As the national cancer control agency, Cancer Australia has a leadership role in providing information to support optimal outcomes for people with cancer, including Australia’s Indigenous and CALD populations. Methods: To understand and address the information needs about COVID-19 vaccines for people with cancer, Cancer Australia undertook a scoping review of national and international published literature and guidance, and sought input from key cancer control experts and consumers. In collaboration with Indigenous health and multicultural communications experts, Cancer Australia developed tailored information for Indigenous Australians and CALD populations affected by cancer. Results: Cancer Australia developed a range of information resources relating to the COVID-19 vaccines and cancer, including Frequently Asked Questions (FAQs), and multimedia promotional collateral including animation and radio advertisements. The FAQs were adapted to provide culturally appropriate messaging for Indigenous Australians with cancer and translated into the ten most spoken languages in Australia. Multi-channel social media communication promoted uptake of the resources to CALD and Indigenous communities, and between March and May 2021, the social media campaign received over 800,000 impressions and the FAQs approximately 20,000 page views. Conclusions: Throughout the pandemic, Cancer Australia has been responsive to the unique needs of the Australian cancer community. The development and dissemination of tailored information about COVID-19 vaccines for Indigenous and CALD populations is one example of how Cancer Australia aims to improve outcomes for all people with cancer in Australia. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.

Cancer care in the time of COVID19: A conceptual framework to improve cancer outcomes during a pandemic

Background: At the start of the COVID-19 pandemic, a plan for cancer management during a pandemic did not exist. It soon became clear that without proper planning, cancer outcomes would worsen. Cancer patients are at increased risk of COVID-19 infection, morbidity, and mortality. Health sectors internationally reduced or paused non-urgent cancer care to protect cancer patients from COVID-19. However, disproportionate delays in screening, diagnosis, and treatment can unduly impact cancer outcomes, and backlogs can further burden a strained health system. Tailored approaches to cancer management are required which balance health resource availability along with the risks of exposure and benefits of treatment. Australia's relatively low COVID-19 case numbers afforded Cancer Australia an opportunity to proactively plan for optimal cancer management during this, and future, pandemics. Methods: Cancer Australia's Cancer care in the time of COVID-19: A conceptual framework for the management of cancer during a pandemic (the framework) maps evidence-based cancer care considerations in relation to a health system's capacity across acute and recovery pandemic phases, in relation to steps of the cancer care pathway. The framework promotes infection control and resource prioritisation in the context of innovative care models, triaging approaches and individualised treatment plans, underpinned by effective communication and shared decision-making. Results: The framework supports health system planning and risk-stratified approaches to guide decision-making and improve cancer outcomes. Many aspects of cancer care are recommended to continue (to varying degrees) in most pandemic phases, with modifications or pauses in some aspects of care as the pandemic curve approaches or exceeds health system capacity. Principles of the framework were employed during the second wave of COVID-19 in the Australian state of Victoria, with continuation of cancer screening programs, diagnostic investigations, and treatments wherever it was safe to do so. This resulted in reductions in cancer services and treatment being relatively smaller than in the first wave. Conclusions: Cancer management in a pandemic is not a one-size-fits-all. Countries and jurisdictions need to tailor cancer care according to the risk of the health system becoming overwhelmed. The framework guides optimal cancer care to improve outcomes for people with cancer, while minimising COVID-19 infection. As further evidence becomes available from this pandemic or in future pandemics, this framework can be refined to inform ongoing and future pandemic health system planning.

COVID-19 and cancer: Strategic health promotion for indigenous Australians during a pandemic

Background: Given the impact of COVID-19 on Indigenous and ethnic minority populations observed globally, keeping COVID-19 out of vulnerable Aboriginal and Torres Strait Islander (Indigenous Australian) communities remains a priority. Compared to non-Indigenous Australians, Indigenous Australians experience disparities in cancer incidence and outcomes due to social disadvantage, increased cancer-related modifiable risk factors, poorer access to health services and lower participation in screening. During the pandemic, cancer-related investigations and treatment reduced significantly in Australia, leading to potential decreases in cancer diagnoses and consequences for future survival outcomes. Concerned about the risk of morbidity and mortality due to COVID-19 for Indigenous Australians, as well as worsening cancer outcomes, Cancer Australia undertook strategic health promotion initiatives, to inform and support optimal cancer care. Methods: In consultation with respected Indigenous colleagues to ensure cultural appropriateness of language and information, we published a dedicated webpage titled 'Cancer and COVID-19 - what it means for our Mob∗' with tailored information, advice, and links to key resources and support services for Indigenous Australians. We also released a video titled 'Act early for our Mob's Health', providing targeted, culturally appropriate, consumer-friendly information to encourage Indigenous Australians to see their doctor or Aboriginal Health Worker with symptoms that may be due to cancer. Results: The information hub has been well-received among the Indigenous Australian community, receiving over 3,200 visits, and the social media campaigns have received over 1.4 million impressions and 46,000 video views between mid-March 2020 to mid-February 2021. This campaign has supported proactivity among the Indigenous population in keeping their communities safe during the pandemic, maintaining a population rate of COVID-19 of less than one percent of all confirmed cases in Australia. Conclusions:Culturally appropriate information and resources developed through the process of co-design can help to influence positive health behaviour change in Indigenous populations. We predict that our strategic, multichannel health promotion campaign is contributing to keeping the Indigenous Australian community safe and informed during the pandemic, with additional work needed to monitor cancer rates and outcomes and address the ongoing information needs of the community. ∗Mob is a colloquial term to identify a group of Indigenous Australians associated with a family or community from a certain place.

COVID-19 and cancer care: Embedding high-value changes into practice

Background: Health systems pressures during the COVID-19 pandemic have driven adoption of innovative models of cancer care which optimise resources and protect patients and staff. High-value changes should be identified and retained to improve resilience of cancer care. Methods: Cancer Australia reviewed the literature and consulted with oncology health professionals, cancer control experts and consumers to examine elements of cancer care that changed during the pandemic. Strategies that support high-value care and improve cancer outcomes were identified. Results: The pandemic highlighted models of care which minimise risk of infection for cancer patients, whilst optimising outcomes. Of the numerous cancer care elements that we examined, this abstract focuses on key enhancements in digital health and treatment practices. Digital health helped maintain quality and continuity of cancer care during the pandemic. Use of telehealth (for clinical and supportive care), eprescribing, and e-ordering of investigations increased, supported by national health system funding. Shared care between care settings was facilitated by rapid uptake of telehealth, ehealth records, virtual multidisciplinary team meetings and secure messaging. Treatment modifications included hypofractionated radiotherapy, transitioning to oral chemotherapy where possible, and home-based palliative care. Lower thresholds adopted for use of G-CSF with chemotherapy to reduce risk of febrile neutropenia, aimed to decrease hospital admission rates. It is important to address barriers to uptake of these high value changes. For digital health, variations in patient access to telehealth and digital health literacy can be reduced through technical and coordination support (tailored to people with diverse needs and backgrounds), with telehealth consultations offered in safe, accessible clinical or community settings. Administrative and technical burdens in health service settings can be mitigated through sustainable IT infrastructure, standardised processes for appointments, and improving staff digital health capabilities. Patient anxiety regarding changes in care plans can be mitigated through transparent, accessible, and culturally appropriate communication, documentation and shared decision-making. Clinician uncertainty in calculating risks and benefits in treatment modifications can be addressed through evidence-based standardised care procedures and riskstratification protocols. Conclusions: Many modifications to cancer care made during the pandemic can have long-term benefits and should become standard care, including enhancements in digital health and treatment practices. Strategies have been identified which enable these changes and address barriers to uptake at the system-, service-, practitioner-, and patient-level. Efforts to embed high value changes are required across the cancer control sector.