Access and inclusion: Can we move cancer services closer to home?
Dr Philip Crosbie and Dr Dónal Landers
Traditionally, the vast majority of cancer services take place in hospitals, but new thinking and new technology are rapidly changing this landscape, particularly because of the impact of COVID-19 on the delivery of healthcare services. Delivering cancer services out of the hospital in the community or in the home can offer benefits for both the patient and the healthcare professional, as well as offering potential savings in expenditure. But more should be done to ensure the right protections and incentives are in place, and that barriers are removed to enable this new and promising reconfiguration of cancer care delivery.
A changing landscape
Using new technologies and new methods, it is now possible to move some of the components of cancer care away from the hospital and closer to the home. One way of achieving this is through the monitoring of patients using wearable devices. This enables a structured and continual collection of data from the patient at home, allowing the doctor to assess their progress in a more rigorous way and make decisions accordingly.
In addition, interventions such as community screening help with early detection and therefore improved patient outcomes and can more easily reach socially and economically disadvantaged communities where take up is generally poor. This improved prevention and early detection lessens the strain on the healthcare system by reducing the numbers of patients with advanced disease.
This is not to say that all cancer services ought to be brought closer to the home, and barriers such as the ‘digital divide’ (inequalities of access to internet and other technologies) must not be overlooked. Identifying services that could be moved from the hospital into communities will provide better patient outcomes for our population, as well as setting positive models for healthcare systems around the globe.
Using new technologies and new methods, it is now possible to move some of the components of cancer care away from the hospital and closer to the home.
Research innovation and design
The University of Manchester’s digital Experimental Cancer Medicine Team (digital ECMT) aims to empower patients and healthcare professionals to innovate and design new cancer care pathways. The digital ECMT has developed a proof-of-concept study, IN-HOME, which assesses the feasibility and clinical benefit of in-home sampling, using a device and smart phone application for detecting Acute Kidney Injury (AKI) in patients receiving cancer treatments.
The aim of this study is to understand whether self-monitoring of creatinine levels using a drop of blood and a creatinine measurement device (provided by Nova Biomedical) would lead to early detection of AKI. This study is progressing to its second stage (clinical benefit), and if successful could improve both patient quality of life and patient outcomes. Importantly, it may enable patients with chronic kidney disease, but with stable renal function to enrol in future clinical trials, where most are currently deemed clinically ineligible.
Another trial, NOTION (in-home sampling of cytokines in immunotherapy patients) is a proof-of-concept study run by the digital ECMT which will investigate the collection and measurement of ‘dry blood spot’ samples at home. The primary objective of this trial is to evaluate the feasibility of collecting and measuring cytokines in the blood of patients receiving immunotherapies. The aim is to develop in-home analysis that can predict immune-related toxicities giving clinicians the information they need to avoid damaging inflammatory side effects.
By increasing frequency and accessibility of toxicity monitoring, both of these interventions may impact on care pathways to allow for earlier intervention, reduce treatment complications and potentially increase the time a patient can stay on treatment.
Community screening and engagement
Community screening is a convenient alternative to hospital screening for many communities, particularly those in isolated locations and in areas of deprivation.
In partnership with Macmillan, the lung cancer team at Wythenshawe Hospital (Manchester University NHS Foundation Trust) established the Lung Health Check (LHC), a community-based lung cancer screening service held in convenient community locations. This LHC programme addressed perceived barriers to screening through improving convenience and accessibility while also promoting the message of early detection and a ‘curable’ stage of cancer. Most attendees were from disadvantaged areas, which evidenced the success of this health check in breaking down perceived barriers. 80% of detected cancers were early stage and therefore met the goal of early detection and prevention.
This pilot project has been scaled up locally and nationally through the National Targeted Lung Health Check programme funded by NHS England. It shows the importance of screening to achieve early intervention and reduce lung cancer mortality. It is hoped that a national lung cancer screening programme can be established based on the evidence from the LHC approach.
Our current healthcare system is predominantly designed around detecting cancers at the latter stages of their progression.
Cancer services beyond hospitals – future needs
Our current healthcare system is predominantly designed around detecting cancers at the latter stages of their progression. A shift to prevention and early detection is required to improve patient outcomes. Moving some screening and monitoring to the community or home is necessary in order to achieve this.
With community screening, it is vital to focus on communities where screening take-up is limited. This dynamic switch in attitude requires a measured approach and it is important that steps are taken to mitigate any socio-economic divides being translated into digital divides. It is essential, therefore, that screening is tested in and for the real world, external to clinical trials.
Other barriers to implementing community screening include the logistical challenges of integrating Wi-Fi in mobile units, the current NHS capacity of radiologists and software challenges of combining patient records while complying with current GDPR regulations. Additionally, we need to know that technologies are assessed to ensure we understand any risks and are clear on the benefits. We also need to understand how they change the way health professionals engage with patients and be aware of any negative repercussions.
These critical areas require leadership from the Medical and Healthcare products Regulatory Agency (MHRA) and National Institute for Health and Care Excellence (NICE). Both regulators have a role to play in evaluating and approving the technologies and care pathways necessary to move cancer services out of the hospital and into the community.
At a national policy level, critical attention must be paid by NHS England and the Department for Health and Social Care, with all regulators and policy-makers working in collaboration with experts, using evidence from comprehensive studies.
We cannot afford to ignore the great benefits of transitioning further cancer care from hospitals into our communities and homes. But policy decisions around implementation of new ideas and technology in an ethical way must be grounded in rigorous research with the needs of all patients, particularly the most disadvantaged, at their heart.
We cannot afford to ignore the great benefits of transitioning further cancer care from hospitals into our communities and homes.
About the Authors
Dr Philip Crosbie
Dr Philip Crosbie is a Senior Lecturer in the Division of Infection, Immunity and Respiratory Medicine at The University of Manchester and an Honorary Consultant in Respiratory Medicine based at Wythenshawe Hospital, Manchester University NHS Foundation Trust. His research and clinical focus is the early detection of lung cancer.
Dr Dónal Landers
Dr Dónal Landers is Director of the digital Experimental Cancer Medicine Team, Cancer Research UK Manchester Institute. He is a Clinician and a Fellow of the Faculty of Pharmaceutical Medicine with over 25 years of experience and achievement in early clinical development, clinical practice, healthcare and pharma consulting, and delivering digital health innovation and solutions.