Post Pandemic Breast Cancer Care: Will TeleHealth still be there?
CAGAYAN DE ORO CITY (BukidnonNews.Net/31 October)- The banner news for 2023 among breast cancer awareness advocates is rosy pink: breast cancer is no longer a death sentence.
But the mantra must begin with the word, ‘early’: early detection, early diagnosis and early treatment would lead to the best outcome of survivorship, oncologists in the country would remind.
These are always on top of Lina Cabigas Hidalgo’s mind. The retired educator is a testament to 23 years of cancer survivorship on her 68th birthday.
At the height of the Covid-19 pandemic, however, she had consulted her oncologist only once, and it was a face-to-face consultation at her clinic in a private hospital in Cagayan de Oro, about three hours away (94 km) from her residence in Malaybalay. It happened after she’d caught the Covid-19 contagion and recovered, and have had two primary doses of the Covid vaccine and two booster doses to boot. It was, however, a route check-up, as she was cancer asymptomatic since 2016.
On the other hand, Eliza M., 42, of the adjacent town of Cabanglasan, had availed of the telehealth services dubbed “Telekonsulta” at the Northern Mindanao Medical Center (NMMC), the hub of Covid-19 medical response in Region-10.
In July 2021, she felt that a painless lump that used to be, as the size of a rice grain had now grown bean-sized. She called one of the six listed phone numbers on the Telekonsulta page of the Northern Mindanao Medical Center (NMMC).
At the back of her mind was her aunt’s early demise for breast cancer in 2016 after a late-stage diagnosis. Two years ago, she had her first mammographic as well as cervical tests at the NMMC. The results were both negative.
The NMMC Telekonsulta used the “forward triage” - - serving as an offsite screening of respiratory symptoms, travel history, exposure history, vaccination history, and developing the need or lack of need for in-person visit.
Unluckily for her, the NMMC at the time of her virtual consultation had just issued the Code Red warning, as serious Covid-19 cases had almost overwhelmed the hospitals 300-bed capacity and outpatient services, including mammography, were paused for weeks. So she was referred to private cancer centers that continued diagnosis and treatment despite Covid.
Eliza once again went through the triage remotely by the private cancer center staff before she was scheduled two weeks later for mammography. Only when the results arrived by email a week later could she find relief. It was a false alarm - the lump was benign.
Northern Mindanao figured notably in a 2020 research by IQVIA, an American health research firm, as one among the regions outside Metro Manila where there is a higher incidence of cancer among families. Aside from Northern Mindanao, the Zamboanga Peninsula also noted a higher incidence. According to the research, breast cancer is the most commonly diagnosed cancer type in Mindanao.
In 2020, 27,163 Filipino women were diagnosed of having breast cancer, the country’s most prevalent cancer type among women. Majority of these cases were diagnosed only in the advanced-stage. The Philippines also leads in breast cancer mortality rate at 27 deaths per 100 women.
At the start of the Covid-19 pandemic in 2020, the Philippine Society of Medical Oncology (PSMO) issued an advice and some guidelines that spotlighted the essential role of telemedicine during the pandemic.
Penned by oncologist Ivan Frederick Ting and three other doctors, the advisory said that technological platforms such as telehealth be considered for those “non-urgent” cases. These cancer patients are those who needed follow-up consultations, are asymptomatic, who have completed their treatments, and are on surveillance may be shifted to remote consultations.
Even screening, according to their advisory, may be done remotely and the results may be communicated via email or social media.
Both Lina and Eliza belonged to the demographics for which pre-pandemic telemedicine was developed in the early 2010s: for those living in the rural areas who needed to travel far to get to centralized cancer diagnosis and treatment hubs, particularly for socially and historically disadvantaged groups like those who are of Lumad (Indigenous Peoples) descent. Lina and Eliza are from the Bukidnon and Umayamnon tribes, respectively. The telemedicine option was particularly developed also for the elderly and the poor.
But Lina asserted that oncologists in Cagayan de Oro did not adapt telehealth for most of their patients. Being a college professor herself at the Bukidnon State University for decades, she puts a premium on face-to-face consultation over virtual consults.
She may be right. As early as October 2020, Dr. Joseph Rhoel de Leon, chief oncologist at the Brain and Cancer Institute at the Capitol University Medical Center (CUMC) and a PSMO member, also expressed the worry that delays in treatment will have dangerous consequences and urged that in- person consultations must not be paused, regardless of the risks.
“Even during the pandemic, my oncologists were so busy attending to patients despite the risks, moving from one hospital to another,‘ he said.
Lina also thought of the telehealth services as handled by Manila-based experts.
Based on anecdotal experiences of her friends, “Lisud man, dugay mag hulat unya dili kasabot og magbinisaya ta (It’s hard, it takes long to wait and they don’t understand Cebuano) and they are not familiar with my case. “
She was referring to the private telehealth services, which sprouted during the pandemic, mostly based in Manila.
Karen Maria Jose Lluch, Founder of the Thrive, a breast cancer advocacy group in Northern Mindanao, echoed this concern.
“Digital technology fills in the gap where there is internet connection, and when face to face consultation, and actual procedures are not needed,” she said.
There are, however, things in breast cancer treatment or problems in the breast that needed face- to-face consultation such as persistent lumps, or obvious changes in its appearance or dimpling and discharge from the nipple.
For cancer survivors, Lluch said oncologist advice a yearly surveillance check-up as required for mammography, breast ultrasound, blood works, and other required tests. Thus, the need to visit the hospital, not just the doctor’s clinic.
For women over 40 who do not have cancer, whose mammogram results in the previous year were good, and who do not have persistent problems of the breast, or anywhere, they may opt for teleconsultation with oncologists.
Ironically, Dr. Gina Itchon, research and development lead at the NMMC, reported during press briefings that they saw a trend among those who availed of telehealth – they veered from the target. They got city-based residents, instead of rural residents; middle class earners instead of indigents; and those of high status who are digitally adept and literate.
The sunny premise that telehealth will be a bonus for patients like Lina - - older adults, a resident of a distant locality, who can save time, travel costs and energy by staying at-home and getting quality healthcare virtually might be theoretically plausible but available data seem to point out the opposite.
Also, telehealth as an alternative mode to in-person early screening and diagnosis, was unable to stave off the pandemics ‘hidden casualties which are the missed and missing appointments for screenings and diagnosis.
A study of cancer diagnosis in the US across 20 major healthcare centers shows steep decline in cancer screenings, with breast cancer sustaining the highest decline at 89 per cent.
At the local level, there is still a need to account for these missing undetected or undiagnosed early stage cases that Dr. De Leon and Lluch had foreseen. These cases represent the dozens of backward steps that the government breast cancer program had taken due to the pandemic.
Still, despite its downturns, Filipino oncologists say telehealth is here to stay. As evident in the government’s memorandum on the implementation of the National Integrated Cancer Control Act of 2019. The law again spotlighted Telehealth’s role in the cancer care delivery infrastructure. The PSMO suggested that “an organized referral system through nationwide telehealth programs and centralised electronic records may improve access in remote parts of the country.”
Hopefully, the rosy pink banner news that breast cancer is no longer a death sentence will reach more women in rural areas, like Lina and Eliza, and lead to early detection, diagnosis, and treatment.