Telemedicine-Enabled Clinical Trial of Metformin in Patients With Prostate Cancer

'The best thing since sliced bread': Patient experiences of teleoncology in western NSW

OBJECTIVE

This study explored experiences of rural cancer patients who were receiving treatments by remote video-assisted chemotherapy (RVAC) or participating in clinical trials remotely.

SETTING

Participants lived in Coonabarabran or Dubbo in western NSW.

PARTICIPANTS

Seven cancer patients undergoing treatment for breast, bladder or colon cancer, renal cell carcinoma or lymphoma.

DESIGN

Appreciative inquiry informed this qualitative study. Semi-structured interviews were conducted between July 2018 and January 2019 and thematically analysed.

RESULTS

The patient experience of teleoncology was overwhelmingly positive. Patients explained the value of relationships that developed with the local and virtual care team. Patients felt they received better care if they saw the same oncologist for the duration of their treatment and felt RVAC had accommodated this. Teleoncology allowed patients to remain independent because they were able to maintain their usual support mechanisms including family, friends and health care team. Patients described the reduced physical and emotional travel burden in addition to reduction in travel time and cost.

CONCLUSIONS

These findings highlight the acceptability of teleoncology for rural patients as chemotherapy can be added to the health care and social and emotional supports, which exist in their hometown. Expansion of teleoncology should be codesigned with local communities with a focus on establishing care teams with consistent staffing to build trust between the treating team and the patient. These relationships improve the patient experience and enhance patient independence, which is a desirable attribute of cancer survivorship. Recruitment to clinical trials using teleoncology is acceptable and should be factored into trial development.

Digital health: trends, opportunities and challenges in medical devices, pharma and bio-technology

Digital health interventions refer to the use of digital technology and connected devices to improve health outcomes and healthcare delivery. This includes telemedicine, electronic health records, wearable devices, mobile health applications, and other forms of digital health technology. To this end, several research and developmental activities in various fields are gaining momentum. For instance, in the medical devices sector, several smart biomedical materials and medical devices that are digitally enabled are rapidly being developed and introduced into clinical settings. In the pharma and allied sectors, digital health-focused technologies are widely being used through various stages of drug development, viz. computer-aided drug design, computational modeling for predictive toxicology, and big data analytics for clinical trial management. In the biotechnology and bioengineering fields, investigations are rapidly growing focus on digital health, such as omics biology, synthetic biology, systems biology, big data and personalized medicine. Though digital health-focused innovations are expanding the horizons of health in diverse ways, here the development in the fields of medical devices, pharmaceutical technologies and biotech sectors, with emphasis on trends, opportunities and challenges are reviewed. A perspective on the use of digital health in the Indian context is also included.

Telemedicine and Telehealth in Urology-What Do the 'Patients' Think About It?

Telemedicine is the delivery of healthcare to patients who are not in the same location as the physician. The practice of telemedicine has a large number of advantages, including cost savings, low chances of nosocomial infection, and fewer hospital visits. Teleclinics have been reported to be successful in the post-surgery and post-cancer therapy follow-up, and in offering consulting services for urolithiasis patients. This review focuses on identifying the outcomes of the recent studies related to the usage of video consulting in urology centers for hematuria referrals and follow-up appointments for a variety of illnesses, including benign prostatic hyperplasia (BPH), kidney stone disease (KSD), and urinary tract infections (UTIs) and found that they are highly acceptable and satisfied. Certain medical disorders can cause embarrassment, social exclusion, and also poor self-esteem, all of which can negatively impair health-related quality-of-life. Telemedicine has proven beneficial in such patients and is a reliable, cost-effective patient-care tool, and it has been successfully implemented in various healthcare settings and specialties.

Patients' Perspectives on Transforming Clinical Trial Participation: Large Online Vignette-based Survey

Background

Patients’ participation is crucial to the success of randomized controlled trials (RCTs). However, recruiting and retaining patients in trials remain a challenge.

Objective

This study aims to describe patients’ preferences for the organization of RCTs (visits on- site or remotely) and evaluate the potential impact of fulfilling preferences on their willingness to participate in a clinical trial.

Methods

This was a vignette-based survey. Vignettes were case scenarios of real clinical trials assessing pharmacological treatments. These RCTs evaluated 6 prevalent chronic diseases (ie, osteoporosis, osteoarthritis, asthma, cardiovascular diseases, diabetes, and endometriosis). Each vignette described (1) the RCT and characteristics of the treatment tested (ie, doses, administration routes) and (2) the trial procedures and different options (on-site or remotely) for how the trial was organized for informed consent, follow-up visits, and communication of results when the trial was completed. We recruited 628 participants from ComPaRe (www.compare.aphp.fr), a French e-cohort of patients with chronic diseases. The outcomes were the participants’ preferences for the way the trial was organized (on-site or remotely) and their willingness to participate in the trial.

Results

Of the 628 participants who answered the vignettes, 491 (78.2%) were female (median age 55 years), with different chronic diseases ranging from endometriosis in 59 of 491 (12%) patients to asthma in 133 of 628 (21.2%) patients. In addition, 38 (6.1%) participants wanted to provide informed consent and all trial visits on-site, 176 (28%) wished to participate in the trial entirely remotely, and 414 (65.9%) wanted to combine remote-based and hospital-based visits. Considering the trial as a whole, when the trial was organized in a way that the patients preferred, the median (Q1-Q3) likelihood of participation in the trial was 90% (80-100) versus 60% (30-80) if the trial followed the patients’ nonpreferred model. Furthermore, 256 (40.8%) patients responded to open-ended questions expressing their experience with trial participation and visits to the hospital and providing suggestions for improvement. The patients emphasized the need to personalize the way a trial is organized according to each patient’s needs and conditions.

Conclusions

There was a significant diversity in the participants’ preferences. Most participants preferred hybrid organization involving both on-site and remote visits. Participants were more likely to participate in a trial organized according to their preferences.

Targeting Mitochondrial OXPHOS and Their Regulatory Signals in Prostate Cancers

Increasing evidence suggests that tumor development requires not only oncogene/tumor suppressor mutations to drive the growth, survival, and metastasis but also metabolic adaptations to meet the increasing energy demand for rapid cellular expansion and to cope with the often nutritional and oxygen-deprived microenvironment. One well-recognized strategy is to shift the metabolic flow from oxidative phosphorylation (OXPHOS) or respiration in mitochondria to glycolysis or fermentation in cytosol, known as Warburg effects. However, not all cancer cells follow this paradigm. In the development of prostate cancer, OXPHOS actually increases as compared to normal prostate tissue. This is because normal prostate epithelial cells divert citrate in mitochondria for the TCA cycle to the cytosol for secretion into seminal fluid. The sustained level of OXPHOS in primary tumors persists in progression to an advanced stage. As such, targeting OXPHOS and mitochondrial activities in general present therapeutic opportunities. In this review, we summarize the recent findings of the key regulators of the OXPHOS pathway in prostate cancer, ranging from transcriptional regulation, metabolic regulation to genetic regulation. Moreover, we provided a comprehensive update of the current status of OXPHOS inhibitors for prostate cancer therapy. A challenge of developing OXPHOS inhibitors is to selectively target cancer mitochondria and spare normal counterparts, which is also discussed.

Rapid Implementation of Telemedicine During the COVID-19 Pandemic: Perspectives and Preferences of Patients with Cancer

Introduction

The use of telemedicine in oncology practice is rapidly expanding and is considered safe and cost effective. However, the implications of telemedicine on patient‐physician interaction, patient satisfaction, and absence of the personal touch have not been studied to date. Following the spread of COVID‐19, telemedicine services were rapidly incorporated at the Oncology Division of Tel Aviv Medical Center. We aimed to evaluate patients' perspectives and preferences regarding telemedicine and to assess whether this virtual communication platform affects the patient‐physician relationship.

Methods

Between March 2020 and May 2020, adult cancer patients who conducted at least one successful telemedicine meeting were interviewed by trained medical personnel. The interview was based on validated patient satisfaction questionnaires and focused on patient‐physician interaction in relation to the last in‐patient visit.

Results

Of 236 patients, 172 (74%) patients agreed to participate. The study population comprised mainly patients with gastrointestinal malignancies (n = 79, 46%) with a median age of 63 years (range 21–88). The majority of patients were male (n = 93, 54%). Eighty‐nine (51.7%) patients were receiving active oncologic treatment, and 58 (33.7%) were under routine surveillance following completion of active therapy. Almost all had a sense of secured privacy (n = 171, 96%), the majority of patients affirmed that their concerns were met (n = 166, 93%) and perceived that eye contact with the treating physician was perceived (n = 156, 87%). Only a minority felt that the absence of physical clinic visits harmed their treatment (n = 36, 20%). Most patients (n = 146, 84.9%) wished to continue telemedicine services. A multivariate analysis revealed that higher satisfaction and visits for routine surveillance were both predictors of willingness to continue future telemedicine meetings over physical encounters (odds ratio [OR] = 2.41, p = .01; OR = 3.34, p = .03, respectively).

Conclusion

Telemedicine is perceived as safe and effective, and patients did not feel that it compromised medical care or the patient‐physician relationship. Integration of telemedicine is ideal for patients under surveillance after completion of active oncologic treatment. Physician communication skills workshops are warranted with implementing this platform.

Implications for Practice

During the COVID‐19 pandemic, telemedicine was rapidly implemented worldwide to facilitate continuity of quality care and treatment. Despite many potential setbacks, telemedicine has become a useful and safe tool for oncology practitioners to care for their patients. The use of telemedicine regarding patients' perspectives, emotions, and patient‐physician communication in daily oncology practice has not been studied to date. This study demonstrated telemedicine is perceived as safe and effective and does not compromise medical care or the patient‐physician relationship. Its use is ideal for surveillance after completion of active oncologic treatment. Physician communication skills workshops are warranted with implementing this platform.

The use of telemedicine in oncology practice is rapidly expanding; however, the implications for patient‐physician interaction and patient satisfaction have not been well studied. This article evaluates patients' perspectives and preferences regarding telemedicine and whether a virtual communication platform affects the patient‐physician relationship.

Virtual oncology clinics during the COVID-19 pandemic

Background

The COVID-19 pandemic has resulted in radical changes in the delivery of healthcare worldwide. Our oncology service (at an Irish national cancer centre) rapidly transitioned to the use of telemedicine or virtual clinics (VC) to minimise potential risk of exposure to COVID-19 amongst an immunosuppressed, high-risk population. Our study aimed to evaluate the use of VC in this setting.

Methods

An 18-point questionnaire was designed to investigate the patient experience of VC during the COVID-19 pandemic in Ireland and compliance with guidelines developed in Ireland to conduct VC and the role of VC in the future. Questionnaires were distributed following the receipt of verbal consent from patients during the VC. Descriptive statistics were utilised for data analysis using SPSS®.

Results

One hundred and four patients returned completed surveys (n = 104/164, 63% response rate). Overall satisfaction levels were high with most patients (n = 58/100, 58%; no answer provided (NAP), n = 4) equally satisfied or nearly equally satisfied with VC in comparison to a usual clinic encounter. The majority of patients felt that there should be a role for VC in the future (n = 84/102, 82%; NAP, n = 2). The majority of patients (n = 61/99, 61%; NAP, n = 5) were very relieved to avoid a hospital visit due to perceived risk of potential exposure to COVID-19.

Conclusion

The majority of oncology patients were satisfied with a VC encounter. VC may have a role in the future of medical care in Ireland post the COVID-19 pandemic.

The Impact of the COVID-19 Pandemic on Genitourinary Cancer Care: Re-envisioning the Future

CONTEXT

The coronavirus disease 2019 (COVID-19) pandemic necessitated rapid changes in medical practice. Many of these changes may add value to care, creating opportunities going forward.

OBJECTIVE

To provide an evidence-informed, expert-derived review of genitourinary cancer care moving forward following the initial COVID-19 pandemic.

EVIDENCE ACQUISITION

A collaborative narrative review was conducted using literature published through May 2020 (PubMed), which comprised three main topics: reduced in-person interactions arguing for increasing virtual and image-based care, optimisation of the delivery of care, and the effect of COVID-19 in health care facilities on decision-making by patients and their families.

EVIDENCE SYNTHESIS

Patterns of care will evolve following the COVID-19 pandemic. Telemedicine, virtual care, and telemonitoring will increase and could offer broader access to multidisciplinary expertise without increasing costs. Comprehensive and integrative telehealth solutions will be necessary, and should consider patients' mental health and access differences due to socioeconomic status. Investigations and treatments will need to maximise efficiency and minimise health care interactions. Solutions such as one stop clinics, day case surgery, hypofractionated radiotherapy, and oral or less frequent drug dosing will be preferred. The pandemic necessitated a triage of those patients whose treatment should be expedited, delayed, or avoided, and may persist with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in circulation. Patients whose demographic characteristics are at the highest risk of complications from COVID-19 may re-evaluate the benefit of intervention for less aggressive cancers. Clinical research will need to accommodate virtual care and trial participation. Research dissemination and medical education will increasingly utilise virtual platforms, limiting in-person professional engagement; ensure data dissemination; and aim to enhance patient engagement.

CONCLUSIONS

The COVID-19 pandemic will have lasting effects on the delivery of health care. These changes offer opportunities to improve access, delivery, and the value of care for patients with genitourinary cancers but raise concerns that physicians and health administrators must consider in order to ensure equitable access to care.

PATIENT SUMMARY

The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the care provided to many patients with genitourinary cancers. This has necessitated a transition to telemedicine, changes in threshold or delays in many treatments, and an opportunity to reimagine patient care to maintain safety and improve value moving forward.

Telehealth in Urology: A Systematic Review of the Literature. How Much Can Telemedicine Be Useful During and After the COVID-19 Pandemic?

Context

Coronavirus disease 2019 (COVID-19) pandemic has caused increased interest in the application of telehealth to provide care without exposing patients and physicians to the risk of contagion. The urological literature on the topic is sparse.

Objective

To perform a systematic review of the literature and evaluate all the available studies on urological applications of telehealth.

Evidence acquisition

After registration on PROSPERO, we searched PubMed and Scopus databases to collect any kind of studies evaluating any telehealth interventions in any urological conditions. The National Toxicology Program/Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal Studies was used to estimate the risk of bias. A narrative synthesis was performed.

Evidence synthesis

We identified 45 studies (11 concerning prostate cancer [PCa], three hematuria management, six urinary stones, 14 urinary incontinence [UI], five urinary tract infections [UTIs], and six other conditions), including 12 randomized controlled trials. The available literature indicates that telemedicine has been implemented successfully in several common clinical scenarios, including the decision-making process following a diagnosis of nonmetastatic PCa, follow-up care of patients with localized PCa after curative treatments, initial diagnosis of hematuria, management diagnosis and follow-up care of uncomplicated urinary stones and uncomplicated UTIs, and initial evaluation, behavioral therapies, and pelvic floor muscle training in UI patients, as well as follow-up care after surgical treatments of stress urinary incontinence or pelvic organ prolapse. The methodological quality of most of the reports was good.

Conclusions

Telehealth has been implemented successfully in selected patients with PCa, UI, pelvic organ prolapse, uncomplicated urinary stones, and UTIs. Many urological conditions are suitable for telehealth, but more studies are needed on other highly prevalent urological malignant and benign conditions. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine. More robust data on long-term efficacy, safety, and health economics are necessary.

Patient summary

The diffusion of coronavirus disease 2019 (COVID-19) infections has recently increased the interest in telehealth, which is the adoption of telecommunication to deliver any health care activity. The available literature indicates that telemedicine has been adopted successfully in selected patients with several common clinical urological conditions, including prostate cancer, uncomplicated urinary stones, uncomplicated urinary infections, urinary incontinence, or pelvic organ prolapse. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine, but more robust data on long-term efficacy, safety, and costs are necessary.

The increasing value of eHealth in the delivery of patient-centred cancer care

The increasing use of eHealth has ushered in a new era of patient-centred cancer care that moves beyond the traditional in-person care model to real-time, dynamic, and technology-assisted assessments and interventions. eHealth has the potential to better the delivery of cancer care through improved patient-provider communication, enhanced symptom and toxicity assessment and management, and optimised patient engagement across the cancer care continuum. In this Review, we provide a brief, narrative appraisal of the peer reviewed literature over the past 10 years related to the uses of patient-centred eHealth to improve cancer care delivery. These uses include the addressal of symptom management, health-related quality of life, and other patient-reported outcomes across cancer care. In addition, we discuss the challenges of, and opportunities for, accessibility, scalability, and implementation of these technologies, important areas for further development, and future research directions.