Using Telehealth to Address Side Effects of Cancer Immunotherapy

Virtual care modalities have been lauded for their ability to connect patients to healthcare quickly and conveniently. While not all types of care are suited to virtual delivery, certain services, like specialty consultations, can be effectively delivered via telehealth. By digitizing the right parts of the care continuum, healthcare organizations can extend care access and improve the patient experience.

These are some key benefits of the award-winning Duke Endo-Oncology Electronic Consultative Service. Established in May 2020 by Afreen Shariff, MD, the service connects Duke oncologists with the endocrine team at the Duke Endo-Oncology Program, a collaboration program between Duke Cancer Institute and the Department of Medicine Division of Endocrinology, Metabolism, and Nutrition. The service aims to enhance timeliness and quality of care for cancer patients experiencing endocrine immune-related adverse events.

This year, the program won an ACCC Innovator Award, presented by the Association of Community Cancer Centers (ACCC) to cancer programs that bring “visionary and compelling ideas in oncology.”

The Duke endo-oncology e-consults program is unique because it supports cancer care through specialty-to-specialty consultations, said Shariff, who is the director of the Duke Endo-Oncology Program and an associate director for the Cancer Therapy Toxicity Program at the Duke Center for Cancer Immunotherapy.

Typically, electronic peer-to-peer consults occur between primary care physicians and specialists. These are usually not emergencies; the specialist has time to review the patient's information and decide whether they need specialty care.

“But with cancer patients, it's different,” Shariff said in an interview with mHealthIntelligence. “So, when we have a specialty-to-specialty consult, we're talking about an oncologist placing a consult to another subspecialist, which we're all peers in the same kind of area or field of activity, and we are giving more than just, ‘Patient needs to see us, doesn't need to see us.’ We're actually making recommendations within 24 to 48 hours after someone puts in that electronic consult, which is very different than what is done with primary care.”

Cancer care requires specialty-to-specialty consultations because of the unique nature of the disease, immunotherapy treatment, and its side effects.

Shariff explained that in 2011, there was a paradigm shift in cancer treatment with the development of immunotherapy. Compared to treatments like chemotherapy or surgical interventions, immunotherapy drugs boost the immune system, helping it to find and kill cancer cells. But, this acceleration of the immune system can be a double-edged sword.

“[Immunotherapy drugs] enhance the immune system and remove the brakes of the immune system…But along the way, you have accidents,” she said. “Those accidents are nothing but immune toxicities or immune-related adverse events. There's different nomenclature to this, but basically what it means is your immunity is ramped up because of these agents.”

These immune-related adverse events impact gastrointestinal, endocrine, and dermatologic systems and organs. They include inflammation of the lungs, colon, and endocrine glands.

The endocrine, or hormone-producing glands, are delicate, and damage to these glands during immunotherapy can result in thyroid-related diseases, type 1 diabetes, and more. Immunotherapy can also damage the pituitary gland, which is the “mothership or the CEO of all hormones,” causing havoc in the body, Shariff said.

Thus, patients experiencing endocrine immune-related adverse events often need endocrinologists to help manage their symptoms. However, the wait times for these consultations can span months.

“[Oncologists] put in a referral to an endocrinologist and hope and pray that someone's going to see that patient quickly,” Shariff said. “What happens is that patients wait for quite some time. Just at Duke, we started pre-COVID with an average wait time of 50 days.”

The wait time doubled to 100 days following the onset of the COVID-19 pandemic, she added.

In the cancer care arena, putting off care for symptoms and side effects can land patients in the hospital. This led Shariff to establish the Duke Endo-Oncology Electronic Consultative Service.

“There's such a need within our system to have patients seen quickly and triaged quickly,” she said. “So, trying to get the right patient in at the right time at the right place was really the mission behind [launching] electronic consults between specialties.”

Through the service, oncologists can refer cancer patients to the endo-oncology team if they see lab results that concern them or if the patient mentions endocrine immune-related side effects of treatment. Once the patient has consented, they are connected to an endo-oncologist virtually. The consultations last about 10-to-15 minutes, after which the endo-oncologists provide their recommendations in the EHR. If an in-person appointment is needed, the endo-oncologists also send their notes to the schedulers to schedule those visits as soon as possible.

While the ultimate responsibility for the patient still lies with the oncologist, endo-oncologists can quickly step in and close care gaps. For instance, oncologists may recognize that a patient requires insulin, but they may not know the type or the dosage of insulin, and that is where the endo-oncology team can provide guidance, Shariff said.

The implementation of the service was largely smooth on the technology front as Duke already had an infrastructure in place for e-consults between primary care physicians and specialists. According to Shariff, it took about a month to implement the IT infrastructure for a more targeted e-consult service.

The main challenge was educating the oncologists on the change in the referral process after years of following a different approach.

“It's harder to unlearn something than to learn something new,” Shariff said.

Further, there are numerous sub-groups within oncology, such as melanoma, thoracic oncology, breast oncology, and bone marrow cancer. The protocols within these clinics differed, which meant that Shariff and her team had to meet with each group and teach them how to use the new e-consult service.

“It was very important for us to educate them and make them comfortable, give them notes which had the verbiage for [getting the patient] consent so that they don't have to add extra work to their already busy life,” she said.

Another helpful strategy was getting feedback from oncologists and patients early in the deployment process. This helped Shariff and her team understand the helpful aspects of the service and whether anything needed to be tweaked. The feedback process also helped garner support for the e-consults program.

As of July, 320 consultations had been conducted through the program. The time-to-recommendations has dropped significantly from 67 days before the service implementation to one to two days, Shariff said. The endo-oncology team has also seen patients needing in-person care within 30 days of the e-consult. 

Not only that, but the service has also helped cut the hospitalization rate for patients experiencing endocrine immune-related side effects. Shariff conducted a study that found that between 2007 and 2017, the hospitalization rate at Duke for endocrine immune-related side effects or endocrine toxicities was 11 percent. The hospitalization rate of e-consult patients from 2020 to 2021 dropped to 2 percent.

The decrease in the hospitalization rate indicates improved care quality, resulting in reduced healthcare costs. According to Shariff, healthcare organizations could save tens of thousands of dollars per patient by preventing hospitalizations among cancer patients experiencing treatment side effects.

The service has undoubtedly proved beneficial at Duke Health, and scaling it outside the institution could help extend much-needed endo-oncology expertise to community cancer centers where most people receive cancer care, Shariff noted. But this is impossible without support from healthcare payers.

“My hope is that third-party payers, insurance companies, specifically, take note of this and support these kinds of services because we cannot scale,” she said. “We cannot work in community cancer centers and other places because we don't exist in those places. And the only way to connect all of us together is to allow [reimbursement] support.”

As cancer rates rise in the US, particularly among people younger than 50, treatments are improving, but a greater emphasis must be placed on managing the side effects of cancer treatment. According to Shariff, there is a vacuum in which patients are left to deal with treatment side effects on their own while waiting to see a specialist. 

“That's a lot for patients, and I think no one's putting side effects on the center stage,” she said. “We're going to see a lot more of this. In the next decade, younger patients will be treated with these [immunotherapy] agents. They're going to have longer lives, but the quality of life with side effects is going to be the biggest question that has to be answered...This has to be addressed in a multi-pronged approach, and e-consults is just one of them.”