Oncophone20 study: Patients’ perception of telemedicine in the COVID‐19 pandemic during follow‐up visits for gynecological and breast cancers

Abstract Objective To analyze oncological patients’ perception of telemedicine during the COVID‐19 pandemic. Methods A total of 345 women, of whom 267 experienced breast cancer and 78 experienced a gynecological cancer, were enrolled. Specific questionnaires about their experiences and feelings about telemedicine in the COVID‐19 era were collected. Results In the breast group, “enhanced care” showed moderate positive perception (mean 4.40) among less‐educated women that was slightly lower among better‐educated women (mean 4.14) with a significant difference (P = 0.034). “satisfaction” had an opposite pattern: a mean of 3.99 for a lower level of education and 4.78 for a higher level of education, with a strong significant difference (P < 0.001). “privacy and discomfort” approached neutrality for less‐educated women, while for higher‐educated women the lower mean of 2.93 indicted a more positive perception (P = 0.007). In the pelvic group, younger women had a better perception towards telemedicine for “telemedicine as a substitution” (mean 3.68) compared to older women (mean 3.05). The privacy and discomfort subscale was in favor of better‐educated women (mean 2.57) compared to less‐educated women (mean 3.28; P = 0.042). Conclusion Telemedicine was generally well accepted, not only among younger and higher‐educated women but also by women needing intensive care, in both cancer groups.

Due to COVID-19 limitations, the study hospital decided to organize follow-up visits differently from the beginning of the pandemic in March 2020. To prevent patients from coming to the hospital, the secretary notified the patients on the subsequent phone call from the oncologist of the replacement for the ambulatory follow-up visits. During the phone call, the physician evaluated the health status and possible hematologic results of the patients by asking them direct questions. Patients with a history of previous gynecological cancer (age above 18 years) were enrolled in the study during routine follow-up phone calls. The Service User Technology Acceptability Questionnaire (SUTAQ), 1 reported in appendix 1, was administered by phone call after about 2 months after the follow-up phone call.
The mean estimated time to answer the questionnaire was 20 min.
To evaluate the perception of the phone call for the follow-up visit in patients with gynecological cancers, a survey was conducted through a self-administered SUTAQ with 27 closed questions. [2][3][4] The questionnaire was translated from English into Italian. 5 All patients

| Statistical analyses
To compare the SUTAQ questionnaire results among the breast cancer group versus the pelvic cancer group, average values and standard deviations were calculated for each subscale, stratified by age group (≤55 years vs ≥56 years), level of education (middle school or below vs high school or above), and intensity of treatment (intensive care vs non-intensive case). Actual comparisons were then performed using t-tests. In the pelvic group, five different sites of cancer (endometrial, ovarian, vulvar, vaginal, and cervical cancer) were included, with deep differences in treatment.
For statistical analyses, the treatments were separated into intensive care and non-intensive care: care intensity was defined "intensive care" if the patient received chemotherapy and/or radiotherapy after surgery, and defined as "non-intensive" if the patient received hormonotherapy or only follow-up after surgery.
To investigate the role of sociodemographic characteristics of patients towards their acceptance of telemedicine, a classical linear regression model was run. A total score summarizing the whole SUTAQ was found as the sum of the subscales reflecting a positive perception of telemedicine (enhanced care, satisfaction, increased accessibility, TMS) minus the subscales reflecting uncertainty about telemedicine (privacy and discomfort, CPC). No departure from normality was detected by visual inspection (histogram and Q-Q plot).
The total score of the SUTAQ was considered to be the outcome and the following dependent variables were included as regressors: age at follow-up (continuous); marital status (single vs married or in a relationship); level of education (middle school or less vs high school or more), and occupational status (unemployed vs employed/students).

The model was adjusted by cancer site (breast/pelvic).
Data analyses were performed using SAS version 9.4 (SAS Institute Inc, Cary, NC, USA).

| RE SULTS
A total of 346 women were enrolled: 267 in the breast cancer group and 79 in the pelvic cancer group. Women in the pelvic cancer group were younger (median age 56 years) and had a higher level of education (61.53% achieved a high school diploma or higher) than those in the breast cancer group (median age 67 years; 23.22% with a high level of education). The majority of patients in the pelvic cancer group were employed or students (87.34%) compared to 75.28% of women in the breast cancer group. In the pelvic cancer group, 70.89% of women were living with their partner compared to 37.08% in the breast cancer group.
Of the women enrolled with breast cancer, 18% received chemotherapy treatment, 71% received hormonotherapy, and 67% received radiotherapy. Of the women in the pelvic cancer group, 41.8% received chemotherapy treatment, 20.25% received radiotherapy, and 37.95% had only a follow-up after surgery. Table 1 compares the SUTAQ subscales between the breast cancer and pelvic cancer groups. The enhanced care, satisfaction, and increased accessibility subscales showed a mild agreement in both groups (mean values of approximately 4). While the differences between the enhanced care and increased accessibility groups were not significant, the satisfaction group approached statistical significance.
For TMS, agreement was a bit lower, especially in the pelvic cancer  favor of higher-educated women (mean 2.57) compared to lessereducated women (mean 3.28; P = 0.042). No significant differences were detected between intensive and non-intensive treatment. In fact, the enhanced care, satisfaction, increased accessibility, and privacy and discomfort subscales reached good responsiveness towards telemedicine, irrespective of care level. Table 4 shows the influence of certain sociodemographic factors on patients' perception of telemedicine. Significant coefficients were estimated for level of education (P = 0.047) and occupational status (P < 0.001). These results highlight that higher-educated women have a more positive approach toward telemedicine. Conversely, employed women/students seemed to be less satisfied with this service compared to unemployed women.

| DISCUSS ION
The WHO definition of telemedicine is "the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease of injuries, research, and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities". 6 Moreover, in most of the previous reviews, telemedicine was defined as the evaluation of patients by a healthcare professional by a written, audio, or video method. 7 Note: Statistically significant differences between groups are in bold.
Abbreviations: CPC, care personnel concerns; EC, enhanced care; IA, increased accessibility; PD, privacy and discomfort; ST, satisfaction; SUTAQ, Service User Technology Acceptability Questionnaire; TMS, telemedicine as a substitution.
a Values are given as mean ± SD. b Intensity of treatment was not determined for 20 women due to incomplete data.
been previously adopted at the study institution, available tools such as Android and IOS applications for chatting and videocalls as well as other artificial-intelligence-based tools and software were not immediately available. Therefore, telephone social networks were used to begin the project. After 3 months, patient feedback about this experimental kind of telemedicine was evaluated to utilize telemedicine in the future regardless of the COVID-19 pandemic.
Telemedicine was a useful and convenient tool because the risk of infection of COVID-19 in crowded outpatient clinic waiting rooms was reduced to a minimum.
The results of the present study show that patients with pelvic cancer were more satisfied with telemedicine compared to patients in the breast cancer group (approaching statistical significance, P = 0.058). Moreover, the breast cancer group reported telemedicine as comparable to a face-to-face appointment more than the pelvic cancer group, even though they were overall less satisfied (statistically significant, P = 0.001). It is possible that patients with pelvic cancer regard a gynecological examination as necessary for a follow-up with pathology instead of other methods such as a telemedicineonly approach. In the study population, patients with breast cancer are older and less educated than those with pelvic cancer, and this could explain the differences observed among the two groups. With regard to privacy and discomfort, there was a general acceptance of telemedicine as a substitute for a face-to-face visit. Among the pelvic  12 The tele-oncology platform is also a potential source of collaboration with specialists from other hospitals who are not immediately available for planning a personalized strategy for the patient. 13 For these reasons, telemedicine shows economic and health advantages. The present study has two major unanswered questions: (1) the analysis of the economic impact; and (2) the detection rate of relapses with this follow-up method.
However, they do not represent the objectives of the investigation.
Communication composed only of electronic tools may be perceived by patients and healthcare professionals as less empathetic in comparison with personal contact. Patients with cognitive disabilities may not be best suited for any assessment by telemedicine but, at the same time, may benefit by avoiding unnecessary travel. 14 It is believed that this is the first and largest study involving telemedicine to follow up patients with female cancers during the COVID-19 pandemic.

| CON CLUS ION
Telemedicine was generally well accepted in both cancer groups, not only among younger and higher-educated women but even by women needing intensive care.
Although there are many points that can be improved, telemedicine is undoubtedly a tool that can also be used in the post-COVID-19 era, thanks to its varying potential.

ACK N OWLED G M ENTS
Open Access Funding provided by Universita degli Studi di Torino within the CRUI-CARE Agreement.
[Correction added on 07-May-2022, after first online publication: CRUI-CARE funding statement has been added.]

CO N FLI C T S O F I NTE R E S T
The authors have no conflicts of interest.

AUTH O R CO NTR I B UTI O N S
EP and MM: substantial contributions to the conception or design of the work; CA, FG, and AM: acquisition, analysis, or interpretation of data for the work; AS, MGB, and SD: drafting the work or revising it critically for important intellectual content. All authors approved the final version to be published.