As coronavirus disease 2019 (COVID-19) has transformed the world we live in, so too has it changed the paradigms of treatment for many cancers. Across the United States, vulnerable cancer patients have been subjected to a complicated medical system. Dedicated healthcare professionals do their very best to rapidly adapt in a continually evolving setting in which optimal medical care must be balanced with the need to minimize exposure risk.

A diagnosis of breast cancer is challenging but never so much as it is today. Telemedicine has now become normalized to the point that it will likely be part of cancer care on a permanent basis. Before 2020, telemedicine was used at far lower rates and with good reason.[1] Prior to March 6, 2020, traditional Medicare beneficiaries could not use telemedicine unless they lived in a narrow geographic area designated as a health professional shortage area (HPSA) by the federal government. In response to the COVID-19 pandemic, a CARES act waiver authority loosened the restriction on traditional Medicare beneficiaries’ telehealth services. This waiver authority, coupled with an ever-growing need to protect vulnerable cancer patients in the time of COVID-19, led to a swift implementation of telemedicine in the oncology setting. Similarly, both Medicaid and commercial payers that service large employers followed suit by increasing reimbursement and coverage of telemedicine services.

Social determinants of health are potential barriers to telemedicine that must be carefully considered. For example, patients who lack access to broadband internet or public internet access will find themselves disadvantaged. Those who lack digital technology literacy or face economic or housing instability face inequity in healthcare provided via telemedicine. Disparities are especially realized in patients who are older than 65 years of age, have a low income, live in rural areas, or have less than a high school degree. Therefore, special consideration must be given to these vulnerable populations in the application of telemedicine.

For patients who can access it, the expansion of telemedicine not only assists in mitigating the risks of COVID-19 exposure, but it also helps to manage the time commitment newly diagnosed patients are subjected to as they begin their treatment journeys. A recent study by Rocque noted that patients newly diagnosed with metastatic breast cancer spent up to 10% of their time during the first three months of diagnosis either receiving treatment or traveling to receive treatment.[2] These percentages translate to a range of 1.4-3.1 days spent receiving cancer care, waiting for care, and traveling to receive care. This was especially true in southern states where patients might be required to travel longer to specialized tertiary care centers, where an average of 220 minutes was spent at a typical clinical encounter. The authors noted that traveling time, coupled with the need for hospitalization, were significant contributors to the time burden faced by these breast cancer patients and underscored the need for alternative modalities for follow up. Telemedicine in this setting may help close the loop in ways that allow for patient monitoring while prioritizing the patient’s time investment.

Breast cancer physicians have attempted to provide some directives for treatment during this time that considers the level of acuity of the breast cancer patient while balancing the need for ongoing monitoring of disease response, tolerance to treatment, and necessary routine lab work. Dietz and colleagues propose a categorization of patient illness along with a consensus-based approach to treating breast cancer while minimizing patient contacts.[3] They further suggest chemotherapy delays where possible and utilizing neoadjuvant treatment to delay surgical intervention until this may be done safely. They sounded a note of caution about the downstream effects of treatment delays in the surgical, radiation, and medical oncology modalities that all may be incorporated in the treatment of breast cancer. One breast cancer physician noted that telemedicine has allowed her to continue to run her clinic safely with few interruptions to ongoing cancer care, at times comprising 30% of her visits.[4] She noted that more advanced preparation was now required, and this not only accounted for clinical preparation but connectivity and accessibility checks as well. Lastly, she stated that some things remain crucial to in-person visits, such as the importance of breast examinations and the reassurance that can be provided during a face to face appointment.

A silver lining to these uncertain times can be seen for many patients diagnosed with breast cancer as healthcare professionals work to develop new guidelines and provide care in the safest manner allowable. Through the efforts of these clinicians and healthcare policy changes at both the state and national levels, we are seeing more significant optimization in the accessibility and time spent accessing care.

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[1] Kircher, Sheetal M., et al. “Telemedicine in Oncology and Reimbursement Policy During COVID-19 and Beyond.” Journal of the National Comprehensive Cancer Network 1.aop (2020): 1-7.

[2] Rocque, Gabrielle B., et al. “Health care‐related time costs in patients with metastatic breast cancer.” Cancer Medicine (2020).

[3] Dietz, Jill R., et al. “Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. the COVID-19 pandemic breast cancer consortium.” Breast cancer research and treatment 181.3 (2020): 487.

[4] Hendricks, Carolyn B. “The Doctor Will Zoom With You Now: Telemedicine and Breast Cancer Care.” ASCO Connection, 29 Sept. 2020, connection.asco.org/blogs/doctor-will-zoom-you-now-telemedicine-and-breast-cancer-care?cid=DM6158.

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