Virtual Visits

On March 17th, CMS released new guidelines on Telehealth. One important pieces of information in that providers can now use apps like FaceTime, Skype or Facebook messenger video for virtual visits. (Please read full details here and FAQs here). Key points include:


  • Providers should only use “non-public facing” communication software. These include software which allow 1:1 interactions. Some of these software listed on CMS guidance include:
    • Apple FaceTime
    • Facebook Messenger video chat
    • Google Hangouts video
    • Whatsapp video chat
    • Skype
    • Texting applications such as Signal, Jabber, Facebook Messenger, Google Hangouts, Whatsapp, or iMessage.
  • Providers should NOT use “public-facing” communications such as TikTok or Facebook Live.

Before using any of the methods used in this post, please check with your hospital leadership and policies regarding virtual visits. This article is intended to help providers and patients. My intentions are not to get anyone in trouble.

Using Apple FaceTime

This is probably the easiest method for virtual visits, provided the patient has access to an Apple device. Advantages include:

  • Most Apple device owners are familiar to the functionality of FaceTime
  • No additional software needs to be installed
  • Both iMessages and FaceTime have end-to-end encryptions therefore ideal for protecting patient privacy.

If you are considering the use of FaceTime calls, there a few things to consider.

AppleID

If you have an iPhone or iPad, chances are that you are logged in using your AppleID. If you make FaceTime calls with your own device, you will be sharing your personal phone number or AppleID with patients. If you want to avoid this, there is a simple fix to the problem.

Create a New AppleID and use an old iPhone/iPad

If you have an old iPhone or iPad, use these steps to prepare these devices for your virtual visits:

Make FaceTime Calls

Potential Pitfalls

There are some issues with FaceTime calls. First, this excludes patients/providers with Android devices. Second, the necessity for a second device or sharing your own AppleID can be significant barrier.

Using WhatsApp

Over a Billion people worldwide use WhatsApp. This app can be installed on iPhone/iPad as well as Android devices.

Installing WhatsApp

Here is a great guide on installing WhatsApp by WikiHow. Consider sending this link to your patients if you would like them to use WhatsApp for video calls (especially android users)

Using WhatsApp without revealing your personal phone number

If you want to use WhatsApp on your personal device, after installation you will have to activate the app using a validation phone number. If you enter your own cellphone number, this number will be revealed to patients.

However, there is a workaround to prevent that from happening. In order to not display your phone number, you can use GOOGLE VOICE phone number to activate WhatsApp. Here is an excellent guide on how to accomplish this https://www.wikihow.com/Use-WhatsApp-Without-a-Phone-Number

Other Apps

Providers can decide on video app of choice for their office.

Billing and other issues

The American Medical Association (AMA) has created a Telehealth guide with a comprehensive guide on billing.
Link to AMA guide on Telehealth

Changing visit type to VIDEO visit in EPIC

To successfully accomplish video visit (and bill for it), you will need to setup the visit type in EPIC as VIDEO visit.
This can be done by either reaching out to your clinic administrator or you can download and follow the steps outlined here:

GOG 157

Randomized phase III trial of three versus six cycles of adjuvant carboplatin and paclitaxel in early stage epithelial ovarian carcinoma: a Gynecologic Oncology Group study.

Pubmed

Hypothesis: 6 cycles of carboplatin (AUC 7.5) and paclitaxel (175mg/m2) improves survival compared to 3 cycles.

Site: Ovary

Eligibility: Stage IA/IB (Grade 3 or clear cell) or stage II completely resected

Experimental arm: 6 cycles of AUC 7.5 carboplatin and 175 mg/m2 of Paclitaxel

Standard Arm: 3 cycles of AUC 7.5 carboplatin and 175 mg/m2 of Paclitaxel

Primary Outcome:

Results:
n=457 enrolled; 427 final cohort
69% were stage 1
31% were stage 2

Parameter 3 cycles 6 cycles p-value
5-year recurrence rate 25.4% 20.1% ns
Adjusted Recurrence rate 1 ref 0.761 (0.51 – 1.13) 0.18
Neurotoxicity G4 2% 11% ss
Neutropenia G4 52% 66% ss
Anemia 32% 48% ss

ss: statistically significant
ns: not statistically significant

Conclusions:

  • 3 cycles of chemotherapy are non-inferior to 6 cycles after complete surgical staging
  • Post-hoc analysis PubmedSerous tumors 6 cycles improve survival

Limitations:

  • High dose of Carboplatin (AUC 7.5)
  • High proportion of incompletely staged patients (about 30%)
  • Study likely underpowered to show difference between 3 and 6 cycles, so although the null hypothesis is no difference, there may be a difference which would have been seen in a fully powered study

  1. Adjusted for FIGO stage and grade ↩︎

Portec 1

Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial

Pubmed

Hypothesis:
Addition of external beam radiation after surgery in early stage endometrial cancer improves survival

Site:
Endometrium

Experimental arm:
Surgery followed by 46 Gy in 2 Gy daily fractions, 3 or 4 field technique (Fields: superior border at L5/S1)

Standard Arm:
Surgery alone

Eligibility Criteria

  • TAH/BSO without routine LND with these criteria
    Invasion Grade
    >50% (deep) 1
    any 2
    <50% superficial 3
  • WHO score of 0-2
  • Histologies allowed:
    • Endometrioid (also including adenocarcinoma with squamous features)
    • Adenocarcinoma not otherwise specified
    • Adenosquamous carcinoma
    • Papillary serous carcinoma
    • Clear-cell carcinoma

Primary Outcome:
Locoregional recurrence and overall survival

Results:

Outcome EBRT Observation p-value
Locoregional Recurrences 4% 14% SS
Overall Survival** 81% 84% NS
Major Toxicity 25% 6% SS
  • 73% recurrences in the vagina. Rate of distal mets same ~7% each arm
  • Prognostic Factors: Age >60, G3, IC predictive for LR; If 2 of 3 criteria, LR 23% vs. 4% (SS)

Conclusions:
Postoperative radiation improves locoregional control, but no survival benefit


See Radiation Oncology WikiBook for more details ↩︎

GOG 99

GOG 99

A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecologic Oncology Group study

Pubmed

Hypothesis:
Addition of external beam radiation to postoperative therapy in intermediate risk endometrial cancer improves recurrence free survival

Site: Endometrium

Study population:
Inclusion: Derived from GOG 33

  • Intermediate Group: Any myometrial invasion with any grade and negative lymph node involvement i.e ([FIGO] stage IB, IC, IIA (occult), and IIB [occult]) – 5-year recurrence rate of 20 – 25%
  • Lymph node – Sampling/debulking if suspicious; Full lymphadenectomy if no enlarged or suspicious nodes
  • Revised during the course of study to enroll only “high intermediate risk” group : Expected 25% recurrence risk:
GOG 99 High Intermediate risk Group. Also used in GOG 249
    -  Age
    -  G2-3 tumor
    -  LVI
    -  Outer 1/3 myometrial invasion

1) >70 yrs old with only 1 other risk factor
2) >50 yrs old with 2 risk factors
3) any age with 3 risk factors

Excluded: High risk pathologies i.e. Clear cell and Papillary Serous, laparoscopic surgery excluded.

Experimental arm:
190 patients: External beam radiation 50.4 Gy given in 28 fractions. No Vag brachytherapy

Standard Arm:
202 patients: No additional therapy after surgery

Outcomes: Experimental arm vs. Standard arm (OR and p-values)

  • Primary Outcome (Recurrence Free @ 24 months) – 3% vs. 12% (OR – 0.42, p=0.007)
  • Secondary Outcome (Overall Survival @ 48 months) – 92% vs. 86% (OR – 0.86, p = 0.557)
  • Local Recurrences – 1.6% vs. 8.9% (p = ss)
  • Significantly Different Toxicity (Grade 2 or greater):
    • Hematologic: 7.4% vs 2.5% (p = ss)
    • GI : 34% vs. 2.5% (p = ss)

Conclusions:

  • Radiation reduced local recurrences but did not improve overall survival
  • Many deaths in the study were not endometrial cancer specific, therefore study underpowered to detect difference in overall survival even if it existed.
  • HIR group (132 total patients) : Defined above
    • Reduction in Hazard of isolated recurrence (RH: 0.37)
    • Reduction in Distant metastatic recurrence related to RT (RH: 0.46)
  • 2/3rd of recurrences and 2/3rd of cancer deaths in this group.
  • HIR – 19% improvement in cumulative recurrence at 24 months compared to no adjuvant therapy group vs LIR group 4% improvement compared to no adjuvant therapy group.

This study was the basis of GOG 249 selection criteria.


SOLO-1: Maintenance Olaparib in Newly Diagnosed Advanced Ovarian Cancer

Title: Maintenance Olaparib in Newly Diagnosed Advanced Ovarian Cancer

Hypothesis: Maintenance PARP-i after initial therapy in high-grade ovarian carcinoma improves progression free survival.

Standard Arm: Placebo

Experimental Arm: Olaparib 300 mg bid daily x 2 years

Design: Double blinded randomized controlled phase 3 study

Inclusion Criteria: High-grade serous or endometrioid ovarian cancer, primary peritoneal cancer, or fallopian-tube cancer with mutation in BRCA1, BRCA2 (germline or somatic)

Primary Endpoint: PFS or death at 3 years

Outcomes: Experimental vs. Standard arm (p-value)

PFS/death at 3 years: 60% vs. 27% (p<0.001)

Median time to subsequent therapy: 51.8 months vs. 15.1 months (HR – 0.30, p<0.001)

Serious Adverse Events:Experimental vs. Standard arm (p-value)

Anemia (G3/G4): 22% vs. 2% (p=s.s.)

Neutropenia (G3/G4): 9% vs. 5% (p=s.s.)

AML: 3/260 (1%) vs. 0/130 (0%) (p=n.s)

New Primary Cancer: 5/260 (2%) vs. 3/130 (2%) (p=n.s.)

Pneumonitis/Interstitial Lung Disease: 5/260 (2%) vs. 0 (p=n.s)

Conclusion: Addition of Olaparib 300mg bid for two years maintenance after completion of primary chemotherapy and debulking surgery in BRCA 1/2 (both germline or somatic) increases progression free survival or risk of death at 3 years.