In the UK, around 367 000 new cases of cancer are diagnosed every year with more than half attributable to breast, prostate, lung and bowel cancer (Cancer Research UK, 2023). Cancer places a heavy socioeconomic burden on the NHS. Most patients undergoing surgery for cancer require postoperative follow-up consultations to plan future treatment and interventions, detect recurrence and provide psychological support. These follow-ups are often done by surgeons, physicians and nurse specialists at outpatient clinics (Strand et al, 2011). Studies have found that nurses were better than other practitioners at detecting psychological issues during follow-up and therefore reduced postoperative morbidity (Beaver and Luker, 2005; Shaida et al, 2007). Their physical examinations were also reported to be more thorough and their consultations lasted longer than those of other practitioners (Beaver and Luker, 2005).
The NHS Long Term Plan aims to reduce pressure on hospital services and make them easier for patients to access, so teleconsultations were introduced and successfully established in primary care health services (Donaghy et al, 2019), with subsequent progression into some areas of secondary care. Virtual NHS clinics were implemented for palliative care, symptom management and routine follow-up after cancer surgery (Healy et al, 2019). The onset of the COVID-19 pandemic in March 2020 forced a drastic change in the way NHS services were provided, with a rapid shift to large-scale teleconsultations in more NHS healthcare services than ever before (Greenhalgh et al, 2020).
Teleconsultation (via telephone or video) is often used where an interactive patient examination is not needed. Therefore, it suits patients with uncomplicated symptoms, follow-ups, medication reviews and sometimes communication of test results. Most post-surgery cancer consultations were conducted in face-to-face clinics before COVID-19. However, services were overstretched and patients had poor experiences because traditional consultations caused issues such as disruption to daily activities, commuting time and hospital parking or transport charges (Adler et al, 2019). Therefore, there has been a swift shift to using teleconsultations, which alleviate pressure and also reduce waiting times (Dalby et al, 2021).
There is a paucity of research on patients' subjective thoughts and feelings about teleconsultations in cancer surgical follow-up. It is crucial that nurses have a better understanding of patients' views of teleconsultations to improve the support they provide. Therefore, this systematic review aimed to explore patient experiences of teleconsultations within UK-based NHS cancer surgery follow-up services.
Methods
Search strategy
A systematic literature search of qualitative studies was performed using Medline, Embase (Ovid), PubMed and Google Scholar for studies up to 1 July 2022. The main search terms were ‘cancer’ and ‘tele*/remote’.
The search was restricted to studies in English carried out in the UK, and where the full text was available. The methodology was reviewed by four independent peers.
Inclusion and exclusion criteria
Eligible studies included published peer-reviewed articles with a qualitative study design that reported cancer patients' experiences of remote follow-up after surgical treatment in secondary care. Studies with a quantitative design reporting non-cancer or paediatric patients were excluded. Non-English papers, abstracts, editorials and conference proceedings and presentations were also excluded.
Quality assessment
In this review, the gold standard for acceptability was set as qualitative studies that included open-ended questionnaires to allow all participants to express their experiences and opinions of remote follow-up in great depth.
There is no universal consensus on criteria to assess the methodological quality of qualitative studies. The quality assessment chosen for this review followed the JBI critical appraisal tool, which assists in evaluating the trustworthiness, relevance and worthiness of published papers (JBI, 2023).
The final studies were critically appraised using 10 questions with three possible answers: yes; unclear; or no. These answers were given scores of 2, 1 and 0 respectively. The papers were then ranked according to their numerical scores. Any papers with a score of less than 14/20 were deemed weak and were excluded. Two independent reviewers performed the ranking, and any discrepancies regarding the studies' quality were resolved through discussion with a third reviewer.
Data analysis and synthesis
An adapted systematic review approach for qualitative research, based on the Cochrane Library guidelines, was used to extract data from articles. The data were identified and synthesised using the Braun and Clark thematic analysis approach (Maguire and Delahunt, 2017). The results were extracted from the studies using an extraction form and themes and subthemes identified and summarised. Consensus was sought, and overarching themes were finalised through discussion with a third reviewer.
Results
A total of 12 425 articles were identified following the database search, of which 1226 were retained after the removal of duplicates and eligibility assessment. Following title and abstract screening, 47 papers were deemed eligible and underwent full-text screening; 41 were excluded. Six UK-based studies published between 2010 and 2019 were included in this review (Table 1).
Table 1. Outline of the sample studied
| Authors | Sample studied | Condition treated surgically |
|---|---|---|
| Beaver et al (2010) | 28 participants randomly selected from a cohort of 173 patients | Breast cancer |
| Greenhalgh et al (2018) | 12 participants | Hepatobiliary and pancreatic cancer |
| Hafiji et al (2012) | 49 participants prospectively recruited over a 4-month period | Non-melanoma skin cancers of the head and neck |
| Mole et al (2019) | 30 participants randomly selected from a cohort of 142 patients | Bowel cancer |
| Williamson et al (2015) | 21 participants randomly selected from a cohort of 65 patients | Colorectal cancer |
| Williamson et al (2018) | 25 participants randomly selected from a cohort of 129 patients | Endometrial cancer |
The main findings of the review were three overarching themes: accessibility; patient experience; and consultation. These were divided into subthemes.
Accessibility
Convenient care
Three out of the six studies highlighted the convenience of teleconsultations for patients. The consultations took place in the comfort of their homes and started on time, which allowed them to plan the rest of their day (Beaver et al, 2010; Williamson et al, 2015):
‘I thought it was quite good actually because it saved all that problem of having to go to the hospital and queue, as you know. Wait around and probably there for a half an hour, an hour, a lot longer than you should be. And well a lot easier all the way around actually, I thought.’
‘It wasn't rushed. You didn't feel you were up against the clock and that you were wasting someone's time … they weren't hurrying you and hassling you … So that's so completely different from a hospital consultation where you feel obliged to be in and out.’
Logistics and operational considerations
Two articles outlined the benefits of avoiding the logistics involved with attending hospital appointments. Remote consultations relieved not only patients of this but also family members who otherwise would have needed to free themselves to accompany their relative to the hospital (Williamson et al, 2015; 2018):
‘My daughter had to get time off work and she is on the district team across a busy area and I thought that was good because it would spare … getting time off work.’
‘I haven't got a car, so I'd have to take two buses, you see, to go to the hospital. When I get to the hospital, I have about an hour and a half to wait in the waiting room. And I go see the doctor, 2 min and I'm out again.’
Four out of six articles described the time saving and cost-effectiveness of teleconsultations as patients did not have to travel or incur transport or parking costs (Beaver et al, 2010; Williamson et al, 2015; 2018; Mole et al, 2019):
‘Because I'm still working, I'm self-employed and I travel all over the country … it's difficult sometimes to be at a hospital at a certain time. So that was good.’
‘Parking at the hospital is difficult so it was helpful to have the phone calls.’
Nonetheless, one article highlighted some technical problems that occurred during the teleconsultations:
‘Yeah but … your picture has frozen. But a uh – at a very happy expression so we don't mind.’
In short, patients described teleconsultations as being easily accessible and convenient for them and their families, despite some interruptions during video consultations.
Patient experience
Acceptability and satisfaction with the service
Five out of the six articles noted that patients were pleased with the service provided and that it gave them a sense of control (Beaver et al, 2010; Hafiji et al, 2012; Williamson et al, 2015; 2018; Mole et al, 2019). Some patients described teleconsultations as normalising because receiving it at home enabled them to feel more relaxed (Beaver et al, 2010).
‘I cannot thank you enough for the call. In today's struggling NHS, my family and I were amazed that the surgeon who had been working all day had taken the time to call to ask how I was. Thank you, so much.’
‘It is much more relaxed to know that you don't have the alien thing of the hospital. You can have [telephone follow-up] in your home. You have it at work. You can have it on your mobile if you want, sat in the car.’
‘I can't fault them at all, and I owe them my life.’
However, some patients did mention aspects of the face-to-face consultation that were missing with teleconsultations, such as the lack of reassurance from physical examination (Beaver et al, 2010), the absence of non-verbal cues and the lack of emotional support from fellow patients and staff (Williamson et al, 2015):
‘I was okay with the telephone, don't get me wrong. Quite happy with that but I think I would prefer to have seen [name of breast cancer nurse] really looking back on it. Because I like her to … when she examines me and you know.’
‘I did miss the camaraderie that you get from other patients … You tend to be there at the same time as the other people who had their ops with you.’
Personalised care/continuity of care
Five studies emphasised that having teleconsultations had made care more personalised as health professionals expressed more empathy towards patients (Williamson et al, 2018; Mole et al, 2019) and took time to explain little details that they would not otherwise have known had it been a face-to-face appointment (Williamson et al, 2015). They found teleconsultations a sustainable way of providing personalised and continuous care without disruption to their everyday lives (Beaver et al, 2010; Hafiji et al, 2012):
‘Well it's a continuation and you feel … it makes you feel comforted that there is somebody to talk to. Because you go to your GP and they're very good and very understanding but they're not specialist … it's nicer to talk to somebody who knows what they're talking about.’
‘It's absolutely vital to be able to get through to someone who knows your case. It's such a comfort to know I can call Sarah at any time to get advice.’
‘In hospital, it was so, um, you know, in and out. Quite frankly, I think the phone probably elicited more information out of you than, than the hospital would have done.’
‘They're looking after you only, there's no one else, and it's been that way right from the beginning. Your own personal nurse, put it that way.’
Overall, patients had a positive view of services provided remotely.
Consultation
Reassurance/rapport building
Two studies reported that patients were comfortable with teleconsultations because they provided a safe environment, enabling rapport to be built with the nurses and doctors, which ultimately made them more relaxed (Williamson et al, 2018). It also made them more likely to retain information on their condition and ask relevant questions (Williamson et al, 2015).
‘I think sometimes with your telephone one, you've more time if you're worried about something, to talk to somebody individually, whereas the hospital you feel as though you know it's, it's, you're on a conveyor belt. It's get you in and get you out.’
‘Quite happy. I did feel that I perhaps gleaned more information, I didn't feel rushed or anything. And I'm sure that I sort of gleaned more information from my colorectal nurse than I would have perhaps done in a clinic situation.’
‘A very thoughtful and reassuring touch.’
Staff competence/training
Three out of the six studies highlighted how satisfied patients were with the level of training of the healthcare staff, praising their professionalism (Beaver et al, 2010; Williamson et al, 2015; Mole et al, 2019).
‘I mean, she's so good that she could even ask me things of a sexual nature with my aftercare, without me being embarrassed. She handled it superbly … The training she's had to deal with, shall we say, awkward subjects which is good.’
‘The nurses are a terrific asset … I know I can ring them whenever I need.’
‘I felt that being asked continually, then that there would be no … error, for want of a better word. It would be no error, because they were constantly asking you … and that made me feel secure.’
In essence, patients were confident with the consultations they received and deemed clinicians to be qualified to provide care remotely.
Discussion
Summary of findings
This systematic review suggests patients had a largely positive experience of using teleconsultations for their cancer surgical follow-up in the UK. These services were perceived as easy to access, cheap and propitious for personalised care. Most patients were pleased with the staff 's ability to handle the consultation remotely; however, there were reports of poor rapport building and emotional support because of the lack of visual cues inherent to some teleconsultations (Beaver et al, 2010; Williamson et al, 2015).
Patients' experience of teleconsultations
This review highlighted that patients found teleconsultation an acceptable method of communication with clinicians because of its easy accessibility, convenience and lower cost. These findings are in line with other studies that investigated patients' experiences of teleconsultations and reported overall satisfaction as they could attend appointments from home without having to make travel arrangements or incur parking charges (Akobeng et al, 2015; Adler et al, 2019).
Another emerging theme was that patients were happy with the health service provided during the consultation as they felt clinicians knew their case personally and empowered them. This was because those consultations were follow-ups with patients who had previously been seen face to face in the department (Williamson et al, 2018). This finding is congruent with some randomised controlled trials that compared patients' experience of face-to-face and telephone follow-up in colorectal and breast cancer surgery health services (Beaver et al, 2009; Qaderi et al, 2020). Those patients reported a higher degree of satisfaction with the level of attention and clarity of the information they were given (Beaver et al, 2009; Qaderi et al, 2020). This shows the significant benefits of remote consultation when it comes to follow-up appointments.
However, a few patients in this review outlined the lack of emotional support inherent to telephone consultation, which made them feel less at ease. Similar findings were made in a study where cancer patients described teleconsultations as being rushed, which negatively impacted their overall experience (Dalby et al, 2021).
Within skin cancer healthcare, teleconsultations were initially introduced to lower patients' anxiety before surgery. However, nearly half of patients reported clinically significantly greater anxiety after taking part in these a week before the surgery compared to those who did not (Sobanko et al, 2017). Patient experience of teleconsultations can therefore vary depending on timeline and surgical specialty, so there is a need to identify how and when to use it to improve patient outcomes.
Moreover, there were negative reports from patients as physical examination and comradeship with fellow patients were not possible with teleconsultations. The former could potentially affect the quality of the relationship between clinicians and patients, as patients could feel their consultation was less thorough, increasing their health concerns (Hwei and Octavius, 2021).
Ultimately, empowering patients and making them involved in their care improves clinical outcomes (Rathert et al, 2013). Consequently, it is important for patients to take part in the decision-making process, which includes the type of consultation they would like. However, patients without internet access (Office of National Statistics, 2020) or those with certain disabilities (Krysta et al, 2021) may not be able to benefit from teleconsultations, so this approach is more likely to be an option to consider than to replace traditional consultations completely.
Teleconsultation in nursing care
Nurses have used teleconsultations for more than 20 years now and they report a higher level of job satisfaction using them as part of their practice (Wright and Honey, 2016). When teleconsultations were first introduced in nursing care, nurses raised concerns that the lack of face-to-face interaction could be detrimental to their relationships with patients; however, they have been able to develop new skills that enabled them to support their patients accordingly (Mohan et al, 2022). They got more efficient at screening patients for disease progression remotely and providing continuity of care (Kwon et al, 2020). Indeed, the use of teleconsultations has enabled nurses practising at more advanced levels to be more autonomous and more efficient as it provides them with a platform to use their skills to deal with complex cases (Harvey et al, 2010).
In addition, teleconsultations have affected nurses' relationships with the other practitioners. A survey carried out in the UK reported that British nurses found the introduction of teleconsultations bolstered their professional relationship with medical staff as they used a range of complex skills to make a more effective contribution to the multidisciplinary team (Lawton and Timmons 2005).
In the context of oncology, nurse specialists have had a pivotal role in improving cancer services. They have contributed significantly to meeting targets for fast diagnosis and treatment and their work has helped to reduce avoidable admissions (Kerr et al, 2021).
Teleconsultation in secondary care
Since the introduction of low-cost, internet-based health IT systems, teleconsultations have expanded widely. They have been used to provide pre- and postoperative care for surgical cancer patients, especially those living in rural areas or isolating (Lesher and Shah, 2018). However, there are logistical matters to consider before they can be made a standard part of health services and clinical practice.
First, proper infrastructure should be put in place, with suitable workspaces such as quiet, private consulting rooms and adequate hardware and software. Hospitals should have a large enough bandwidth to synchronise audio and video along with a reliable, fast internet connection.
Major concerns when considering teleconsultations are the security and privacy of personal health information. Even though regulations are in place to maintain patient confidentiality, some platforms used are not totally safe from breaches and are susceptible to cybercriminal activities. A strong security system therefore needs to be implemented to preserve patients' confidentiality at all times (Czekierda et al, 2015).
Second, the system should be user friendly for both patients and clinicians, allowing the latter to access medical records with ease; additionally, patients need to have the infrastructure in place to conduct a remote consultation at their end (Alkmim et al, 2012). This could potentially raise concerns about unequal access to this service as some patients, such as elderly people, may not be able to use it unless they are familiar with the technology required (Latifi et al, 2016).
Third, staff need to be trained on how to use the system effectively, and this would concern all involved, including administrators as well as nurses and doctors. Service evaluations and audits would need to be carried out regularly to ensure the service is running as expected and to flag up areas where improvements are needed (Deldar et al, 2016).
Nonetheless, there are reports that some medical practitioners are unwilling to adopt teleconsultations as part of their routine practice (Raison et al, 2015). The reasons relate to many of the points detailed above, such as a lack of adequate software or hardware and quiet office space, as well as issues with the employing health trust. In addition, the introduction of an unfamiliar system can increase workload and lengthen consultations, thus decreasing efficiency (Ramli and Ali, 2018).
Strengths, limitations and future directions
This is the first qualitative systematic review to explore the role of teleconsultations in cancer surgical appointments. It followed robust recognised guidelines to ensure quality was maintained and bias was minimised. There is a small amount of quantitative literature exploring teleconsultations but no in-depth qualitative literature exploring patients' and clinicians' views, which is needed to understand acceptability and feasibility. This review, therefore, addresses this lack of data.
This systematic review was focused on UK patients using NHS services. Patients' experiences of teleconsultations may differ in the private sector or other countries with different healthcare systems.
The COVID-19 pandemic meant rapid modifications to how healthcare is provided were made almost overnight. As the pandemic continues to impact the delivery of health services, these changes need to be assessed to ensure patient care is not compromised. As part of that assessment, the authors would recommend that feedback from both staff and patients is used to fine tune services to ensure adequacy and effectiveness.
Conclusion
This systematic review has demonstrated that teleconsultations are generally acceptable for the follow-up of cancer surgery patients. However, rather than replacing traditional consultations, they should be offered as an option to ensure fair access to all patients.
Healthcare staff should be trained and encouraged to use teleconsultations to diversify their practice, and be open to both traditional and virtual consultations.
More research is needed to explore clinicians' perceptions of teleconsultations with cancer surgery patients. The NHS and wider health services should ensure the right equipment, infrastructure and security measures are in place to support the use of teleconsultations in cancer surgery follow-up.
Service evaluations should be performed regularly to maintain a high standard of care.
KEY POINTS
- Teleconsultations are used in cancer surgery follow-up to facilitate patients' access to care
- Patients in the papers examined in this study were generally satisfied with the care provided during remote consultations
- Remote consultations are cheaper and easier to attend as well as more time-effective than traditional consultations
- Poor rapport building and a lack of emotional support can have negative effects on patients' overall experience
CPD reflective questions
- What are your experiences of teleconsultations for patient follow-up and how have they changed your practice?
- What feedback have you had from patients using teleconsultations in outpatient cancer clinics?
- How have teleconsultations improved patient care in your area of practice?