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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 103-108

The utility of telemedicine for postoperative follow-up care in head and neck cancer patients during the COVID-19 pandemic


Department of Head and Neck Surgical Oncology, Health Care Global Enterprises Limited, Bengaluru, Karnataka, India

Date of Submission30-Jan-2022
Date of Decision11-Mar-2022
Date of Acceptance12-Mar-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
U S Vishal Rao
Regional Director Head and Neck Surgical Oncology and Robotic Surgery, Department of Head and Neck Oncology, HealthCare Global Enterprises Ltd, P Kalinga Rao Road, Sampangi Ram Nagar, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_7_22

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  Abstract 


Introduction: Follow-up care and monitoring of survivorship are key aspects of head and neck cancer management. The unprecedented COVID-19 pandemic has posed an unforeseen challenge before head and neck surgeons and has created an urgent need for deploying processes for triaging patients. This study evaluates the effectiveness of a 3-tiered protocol incorporating principles of “mhealth” proposed by WHO and telemedicine to monitor recurrence, maintain compliance, and address pressing issues in follow-up head and neck cancer patients. Materials and Methods: One hundred and one head and neck cancer patients who have undergone surgery and/or completed chemoradiation between the years 2015 and 2020 were selected. Details of patients who were on regular follow-up until March 2020 were obtained. A 3-tier screening protocol including a telephonic questionnaire, video consultation, and visit to primary care center was utilized to triage patients. Results: Fifty-seven percent of the patients did not require any intervention and were managed through video consultation with specialists. 38% of the patients needed a visit to a nearby health care worker or primary physician along with rehabilitation services. Only 5% of them needed a visit to a tertiary healthcare center for specialist care. The overall dropout from follow-up in this study was 19.8%. There was no significant difference of scores noted between oral cavity and nonoral cavity cancer groups (z = 1.17, P = 0.24, Mann–Whitney Test). Conclusion: The proposed 3-tier screening protocol using telemedicine is a feasible, cost-effective, and time-efficient tool to overcome the negative impact of COVID-19 on follow-up care.

Keywords: Cancer care in COVID pandemic, follow-up care in cancer patients, head and neck cancer, “mhealth” by WHO, screening protocol, telemedicine


How to cite this article:
Reddy N A, Thakur S, Joshna B M, Kumar K, Kudpaje A, Vishal Rao U S. The utility of telemedicine for postoperative follow-up care in head and neck cancer patients during the COVID-19 pandemic. J Head Neck Physicians Surg 2022;10:103-8

How to cite this URL:
Reddy N A, Thakur S, Joshna B M, Kumar K, Kudpaje A, Vishal Rao U S. The utility of telemedicine for postoperative follow-up care in head and neck cancer patients during the COVID-19 pandemic. J Head Neck Physicians Surg [serial online] 2022 [cited 2022 Jun 27];10:103-8. Available from: https://www.jhnps.org/text.asp?2022/10/1/103/347992




  Introduction Top


Follow-up care of patients and monitoring of survivorship are key aspects of head and neck cancer patient management. The National Comprehensive Cancer Network clinical practice guidelines[1] in oncology are widely accepted. However, various institutes have modified these guidelines in clinical practice to enhanced monitoring of patients in case of relapse, recurrent disease, and toxicities, as also for enabling functional recovery.

The unprecedented COVID-19 pandemic has posed an unforeseen challenge before head and neck surgeons as all nonessential services have been severely curtailed to protect health care professionals and the society at large. Travel restrictions across cities and states have seriously impacted patient mobility. Although there are clear guidelines on treating the patients with head and neck cancers, there are no proper guidelines for follow-up in these unprecedented times. Consequently, hazy communication between doctors and patients has significantly reduced patient visits for posttreatment follow-up. Therefore, there is an urgent need for deploying processes for triaging patients at risk who require immediate attention.

Wang et al.[2] have shown that the hospital environment poses a higher risk of infection than the community with about 40% reported transmission rate. In addition, patients suffering from head and neck cancers are at a higher risk during this pandemic. This can be attributed to various factors such as altered immunity, tracheostomy, postirradiation status, and comorbid conditions.

In recent years, the use of mobile applications and telemedicine has increased the outreach of healthcare, as also fuelled innovation and research. Indeed, the need of the hour is the seamless integration of technology into existing health care services to improve their access to patients. The “mhealth platform” developed by WHO is one such example of how mobile technologies can be easily incorporated to support the achievement of health objectives.[3]

Further, many institutions have been gainfully using video consultations and other online platforms to maintain the continuum of care. While stand-alone consultations may be sufficient for general healthcare, monitoring survivorship amongst cancer patients calls for an integrated, stepwise protocol.

The purpose of the present study is to assess the impact of COVID-19 pandemic on patients compliance to postoperative follow-up care in head and neck cancer. Further, we propose a potential 3-tier screening protocol which will help triage patients, to identify the subset who need a specialist consultation. This protocol will help troubleshoot minor health-related issues that can be safely managed at home or nearby clinic. In this study, we have also evaluated the effectiveness of the proposed 3-tiered protocol to monitor recurrence, maintain compliance, and address pressing issues in follow-up head and neck cancer patients.


  Methods Top


On seeking ethical approval from the institutional review board, 101 patients who have undergone surgery and/or completed chemoradiation in the department of head neck surgical oncology between the years 2015 and 2020 were selected for the study. Details of patients who were on regular follow-up until March 2020 were obtained from the medical records department. The patients included were contacted telephonically, the patient and/or family member was informed regarding the nature of the call and verbal consent for answering the questionnaire was obtained.

A 3-tier screening protocol was instituted for all the included head and neck cancer patients requiring regular follow-up [Figure 1]. The team carrying out the data collection consisted of a trained nurse, head and neck surgical resident, and the rehabilitation team. The first-tier screening protocol included a 10-point questionnaire [Table 1] coupled with frequently asked questions during an outpatient follow-up visit. A trained nurse in the head and neck oncology department carried out data collection. These questions were related to symptoms suggestive of recurrence or issues requiring attention during the posttreatment phase. The inputs given by the patient were graded on a scale of 0–2 with 0 being the lowest score [Table 1].
Table 1: Parameter-score matrix

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Figure 1: 3 tier screening protocol

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In the second tier protocol, a video consultation by a resident head and neck surgeon was conducted for validating the concerns raised in the telephonic questionnaire. A cumulative score was calculated for each patient after the questionnaire and video consultation [Table 2] and patients with low score (<2) were referred to rehabilitation services. The rehabilitation team included a Psycho-oncologist, clinical nutritionist, dental specialist, speech and swallow therapists, physiotherapists, and yoga specialists. The third tier protocol included referral to a local health care worker or specialist help at a tertiary care center based on the score [Table 2]. In addition, the rehabilitation teams were asked to ascertain the ease of conducting video consultations and assess viability of the process for their needs. Patients were advised to take photographs or get basic investigations like orthopantomogram, which were reviewed by the expert team. Patients were asked to maintain a diary to monitor progress of pain, insomnia and register any need for intervention.
Table 2: Cumulative score postquestionnaire and video consultation

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  Results Top


Data were tabulated and subjected to statistical analysis to evaluate the patient's need of visit, and impact on follow-up care. Scores between the oral cavity and nonoral cavity cancer groups were compared using Mann–Whitney Test, and P < 0.05 was considered statistically significant. Data were analyzed using SPSS version v20.0 (IBM).

Among the 101 patients included in the study, the majority had oral cavity malignancy (60.5%) [Figure 2]. Nonoral malignancies (39.5%) consisted of oropharynx, larynx, hypopharynx, paranasal sinus, and thyroid cancers. Majority of the patients were males (72%), with ages ranging from 25 to 84 years [Figure 3]. 18 out of 101 patients did not answer the call, while two patients refused to answer questions over the phone. Hence, the overall dropout from follow-up in this study was 19.8%. The average duration of each phone call was 5.4 min. There was no significant difference of scores noted between oral cavity and nonoral cavity cancer groups (z = 1.17, P = 0.24, Mann–Whitney Test) [Table 3] and [Figure 4]. Results showed that 57% of the patients did not require any intervention and were managed through video consultation with specialists. However, 38% of the patients needed a visit to a nearby health care worker or primary physician along with the requirement of rehabilitation services. Only 5% of them needed a visit to a tertiary healthcare center for specialist care [Figure 5].
Figure 2: Patient composition

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Figure 3: Patient age profiles

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Figure 4: Statistical analysis

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Figure 5: Service-wise patient distribution

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Table 3: Score difference - oral cavity/nonoral cavity

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The rehabilitation teams successfully catered to the needs of patients through online services. It is pertinent to note that the psycho-oncology team effectively offered their services, even though inter-personal communication was the preferred option. The clinical nutritionist offered all services online, as patients were directly assessed initially during treatment. Dental evaluation could screen the patients who needed to visit the hospital. Speech and swallow therapists could remotely assess the patients and prescribe exercises for speech and swallow. Patients with issues like aspiration, which necessitated direct one-on-one assessment, were advised a direct visit to specialist. Similarly, physiotherapists and yoga specialists were able to assess the current status and prescribe necessary exercises over a video consultation.


  Discussion Top


Follow-up care in patients treated for head and neck cancer is critical for the early detection of recurrence and management of physical and psychological symptoms. The principle aim is to allow for successful salvage treatment and thereby improve survival outcomes.[4],[5] The standard of care involves a thorough head and neck examination including endoscopic evaluation. Besides, routine blood investigations, imaging followed by supportive care, and rehabilitation is required. Rehabilitation services are an integral part of the management of patients with head and neck cancer. The goals of rehabilitation are varied: supportive, preventative, restorative, and palliative. Each stage of rehabilitation is very crucial as it ensures timely care and helps in improving the quality of life of cancer patients.[6]

Unfortunately, the pandemic has led to reprioritization of the healthcare services. There is a pressing need for oncology centers to enforce pandemic preparedness to ensure judicious use of resources and continue rendering high-quality services.[7] Given that further waves of COVID-19 pandemic are imminent; the need of the hour is a transformation of telemedicine and its seamless integration into our clinical practice. According to the International Telecommunication Union, over 85% of the world's population is covered by wireless signal.[8] The growing penetration of mobile phones and technology across all strata, including low-income families, augurs well for extending personalized health care services at large.

A new or significant change in symptoms is often the most telling sign that the patient may be having a recurrence.[9] A tertiary cancer center study[10] showed the efficacy of a symptom-based telephone questionnaire for detecting recurrences as a feasible alternative to in-person clinical visitations. The current pandemic urgently calls for available solution that can minimize unnecessary follow-up visits and ensure efficient management of the complex needs of a head and neck cancer patient.[11]

In our study, the questionnaire and scoring system were formulated keeping in mind the common questions asked during a follow-up visit at head and neck oncology clinic. All effort was made to address the current needs of the patient through video calls with the treating team and rehabilitation teams. The screening involved effective communication, scrupulous counseling, and personal re-assurance.

The present study aimed at assessing the compliance of cancer patients for follow-up in our country. Using a new potential 3-tier screening protocol consisting of a telephonic questionnaire, video consultations, and visit to local health care worker/primary physicians, we were able to effectively screen and triage patients on follow-up, to maintain the continuum of treatment during the COVID-19 pandemic. As showed by our study results, only 5% of screened patients needed to visit a tertiary care hospital, thereby reducing unnecessary exposure risk and travel. The study also showed that the rehabilitation and other nonessential health care workers could offer their services effectively using telemedicine. There were patients who had health concerns that were unrelated to cancer care (34%) and were advised for consultation of nearby primary physician. A limitation of this study is that recurrence rates were not calculated. Even though recurrence was not an endpoint of this study, the questions were designed in a manner that would allow triaging patients suspected to have recurrence.

Studies of tertiary cancer care hospitals in developing countries showed high rates of loss to follow-up,[12],[13] with one study reporting a rate as high as 64.1% at the end of 5 years, among patients with head and neck cancer.[14] However, we noted that the dropout rate in our study was 19.8%. The reasons may be wrong/unreachable contact numbers or unyielding preference for face-to-face conversation. Our study also highlighted the need for stringent maintenance of patient records by the hospital.

Overall, we noted that most of the patients were attuned to and cooperative in answering questions over a telephone call. The elderly and comorbid subset of patients expressed their gratitude towards this initiative as it alleviated their fears regarding travel and hospital visits during this pandemic. This method allowed us to stay intimately connected with patients using telecommunication. Our results also re-emphasized the need for a proactive physician-driven approach to follow-up, as solely relying on the patient's judgment is intangible in the long run.


  Conclusion Top


The proposed 3-tier screening protocol using telemedicine is a feasible, cost-effective, and time-efficient tool to overcome the negative impact of COVID-19 on follow-up care. In most of the follow-up patients, a structured telephonic and video consultation is a viable alternative to regular tertiary hospital visits during this pandemic. These measures, however, do not condone or overrule the sensitivity of direct clinical head and neck examination and endoscopy. Further, this utility of telemedicine can also be applied in the postpandemic period for efficient triaging and adherence of patients for follow-up. A longer duration of follow-up with patients and multi-institutional studies may further validate our study findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.



 
  References Top

1.
National Comprehensive Cancer Network. Bone Cancer (Version 2.2019). Available from: http://www.nccn.org/professionals/physician_gls/pdf/bone.pdf. [Last accessed on 2019 Apr 10].  Back to cited text no. 1
    
2.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 2
    
3.
WHO Global Observatory for eHealth. mHealth: New Horizons for Health Through Mobile Technologies: Second Global Survey on ehealth. Global Observatory for eHealth series - Volume 3: World Health Organization; 2011. Available from: https://apps.who.int/iris/handle/10665/44607. [Last accessed on 2018 Mar 26].  Back to cited text no. 3
    
4.
Grau JJ, Cuchi A, Traserra J, Fírvida JL, Arias C, Blanch JL, et al. Follow-up study in head and neck cancer: Cure rate according to tumor location and stage. Oncology 1997;54:38-42.  Back to cited text no. 4
    
5.
Cooney TR, Poulsen MG. Is routine follow-up useful after combined-modality therapy for advanced head and neck cancer? Arch Otolaryngol Head Neck Surg 1999;125:379-82.  Back to cited text no. 5
    
6.
Guru K, Manoor UK, Supe SS. A comprehensive review of head and neck cancer rehabilitation: Physical therapy perspectives. Indian J Palliat Care 2012;18:87-97.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
The Lancet Oncology. Safeguarding cancer care in a post-COVID-19 world. Lancet Oncol 2020;21:603.  Back to cited text no. 7
    
8.
The World in 2010: ICT Facts and Figures. Geneva: International Telecommunications Union; 2010. Available from: http://www.itu.int/ITU-D/ict/material/FactsFigures 2010.pdf. [Last accessed on 2011 May 13].  Back to cited text no. 8
    
9.
Simo R, Homer J, Clarke P, Mackenzie K, Paleri V, Pracy P, et al. Follow-up after treatment for head and neck cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016;130:S208-11.  Back to cited text no. 9
    
10.
Malik A, Nair S, Sonawane K, Lamba K, Ghosh-Laskar S, Prabhash K, et al. Outcomes of a telephone-based questionnaire for follow-up of patients who have completed curative-intent treatment for oral cancers. JAMA Otolaryngol Head Neck Surg 2020;146:1102-8.  Back to cited text no. 10
    
11.
Szturz P, Van Laer C, Simon C, Van Gestel D, Bourhis J, Vermorken JB. Follow-up of head and neck cancer survivors: Tipping the balance of intensity. Front Oncol 2020;10:688.  Back to cited text no. 11
    
12.
Adeyi A, Olugbenga S. The challenges of managing malignant head and neck tumors in a tropical tertiary health center in Nigeria. Pan Afr Med J 2011;10:31.  Back to cited text no. 12
    
13.
Larsen-Reindorf R, Owusu-Afriyie O, Acheampong AO, Boakye I, Awuah B. A six-year review of head and neck cancers at the KomfoAnokye Teaching Hospital, Kumasi, Ghana. Int J Otolaryngol Head Neck Surg 2014;3:271-8.  Back to cited text no. 13
    
14.
Gilyoma JM, Rambau PF, Masalu N, Kayange NM, Chalya PL. Head and neck cancers: A clinico-pathological profile and management challenges in a resource-limited setting. BMC Res Notes 2015;8:772.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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