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Aust. J. Rural Health (2015) 23, 1923

Special Issue Rural Cancer

Original Research
Specialist cancer care through Telehealth models
Sabe Sabesan, BMBS(Flinders), FRACP
Tropical Centre for Telehealth Practice and Research, Townsville Cancer Centre, Townsville Hospital,
and School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia

Abstract
Objective: Disparities in outcomes are experienced
between people who live in rural and remote areas and
those who live in larger cities. This paper explores the
ability to deliver specialist cancer care through the use of
telehealth models.
Design: Review of telehealth models for cancer care.
Setting, participants and intervention: Cancer patients
in rural, remote and Indigenous communities who
receive their care through telehealth.
Outcome measures and results: Telehealth models seem
to be applicable to all fields of oncology and all health
professionals. These models not only facilitate the provision of specialist services closer to home in an acceptable, safe and cost-effective manner, but also help
expand the rural scope of practice and enhance service
capabilities at rural centres.
Conclusion: New models of telehealth are another
avenue to help further decrease the disparity of access
and survival outcomes between rural and urban
patients. Implementation of these models requires
health system wide approach for development key performance indicators and allocation of resources.
KEY WORDS: cancer, rural, telehealth, telemedicine.

Introduction

overall work force shortages. These three factors

create and perpetuate a vicious cycle (Fig. 1), with the
end result of lack of availability of specialist services
closer to home and the need for often costly long distance travel.
In this vicious cycle, lack of availability of specialists or
specialist visits may be due to true shortage of specialist
workforce, or low patient numbers, which does not
justify the time and cost of specialist travel to many rural
centres.3 Telehealth is an example of one solution to
break this vicious cycle by increasing the rural access to
specialists from tertiary or larger regional centres.
It appears that there is a role for teleoncology
(telehealth in oncology) models in almost all the
subspecialties in cancer care including medical and
radiation oncology, haematology and bone marrow
transplantation, palliative care, nursing and allied
health. Table 1 summarises the nature of services
provided by various subspecialties. In addition,
teleoncology models are increasingly used for providing
clinicians from smaller centres access to multidisciplinary team meetings at larger cancer centres.13

Outcomes of teleoncology models

Several evaluation studies have reported positive findings with telehealth and teleoncology. These findings
include:

Limited and/or lack of access to specialist cancer services is a well-known health and societal problem
faced by patients from rural and remote areas in Australia and other countries with large travel distances.13
These access problems are partly due to lack of specialist visits or availability of specialists locally, narrow
scope of practice for rural health professionals and

High rates of satisfaction of telehealth models

among patients and rural health professionals,1416
Safety of chemotherapy supervision remotely,17
Cost savings to the health systems.18,19
However, literature on true savings to the patients and
their carers and survival outcomes is limited. These outcomes are summarised in Table 2.

Correspondence: A/Prof Sabe Sabesan, Tropical Centre for

Telehealth Practice and Research, Townsville Cancer Centre,
Townsville Hospital, 100 Angus Smith Drive, Townsville,
Queensland, 4814, Australia. Email: sabe.sabesan@health
.qld.gov.au

Requirements for
teleoncology services

Accepted for publication 4 December 2014.

2015 National Rural Health Alliance Inc.

Various colleges and professional associations have

developed guidelines to assist with the effective
doi: 10.1111/ajr.12170

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S. SABESAN

What is already known on this subject:

There are disparities in outcomes between
people who live in metropolitan and rural/
remote Australia. These disparities are
complex and are not simply related to differentials in access.
New models of care allow a number of therapies to be provided safely closer to home and
some ongoing assessment that otherwise
would require travel.

TABLE 1: Examples of telehealth services provided by

oncology sub-specialities
Subspecialty

Examples of services

Radiation
oncology4,5
Medical oncology6,7

Radiotherapy treatment planning

Patient consultations
Patient consultations
Remote supervision of chemotherapy
Acute care management
Patient consultation and home
management
Patient consultations

Palliative care8,9
Haematology/
Bone marrow
Transplantation
Nursing10

Allied health11,12

FIGURE 1:

Patient education
Supervision of oral and intravenous
chemotherapy administration
Swallow assessment, lymphoedema
management psychosocial
counselling

What this study adds:

This paper is a worked example of telehealth
in the real world, delivering care in the
Australian context.
It provides a framework for models that can
deliver systems change.
It is a successful demonstration project of the
use telehealth, significantly improving specialist access over a large geographic region
within existing funding mechanisms.

implementation of telehealth models. Although these

guidelines are not specific to oncology, the requirements
and principles of establishing such models are same for
all specialities. One such example is the Royal Australasian College of Physicians (RACP) Guidelines and Practical Tips for Telehealth accessible via http://
www.racptelehealth.com.au/guidelines/. Another useful
resource is the practical aspects of Telehealth series of
articles produced by the RACP Telehealth Working
Group.
Essentially, all these guidelines assist the clinicians
and health managers in several requirements of
telehealth including issues such as technology, funding
and resources, training, governance and other aspects of
health care. Specific to oncology, more guidance is
needed in relation to breaking bad news and discussing
prognosis on technology-based consultations.

Enhancing rural capabilities

through telehealth
Telehealth models can improve the access to specialists
closer to home.6 Providing telehealth consultations will

The vicious cycle of issues related to rural specialist services.

2015 National Rural Health Alliance Inc.

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CANCER CARE THROUGH TELEHEALTH MODELS

TABLE 2:

Summary of reported outcomes on telehealth models

Outcome

Results

Comments

Patient satisfaction

High levels of satisfaction among patients

including Indigenous patients
High levels of acceptance of telehealth models

Benefits include reduction in travel, reduced cost of

travel, less disruption to family and work routine
Major benefits for continuity of care, ability to
network with tertiary colleagues and to receive
support
This is based on a single centre study.

Perspectives of health
professionals
Safety of chemotherapy
supervision
Cost

Dose intensity and safety profile was similar

to reports in the literature
Telehealth models can save money to the health
system

FIGURE 2: A Townsville teleoncology network model of rural specialist

service.

Townsville
Cancer Centre
Medical oncology
Staff specialists

When the number of consultations increases, savings

also increase.
Limited studies on cost savings to patients.

Mt Isa Cancer Care Unit

Telemedicine

Staff
Allied health, local senior and
junior medical officers,
nursing
Services
Specialist clinics-new,
routine and on demand,
ward consults, urgent
reviews, most cancer types,
all chemotherapy regimens,
in patient admissions

reduce the need for unnecessary travel to major centres.

If specialist treatment is not provided as part of the
model, it is unlikely that the scope of practice and workforce will improve at rural centres. The following case
study illustrates how rural service capability can be
improved by shifting specialist services closer to home.

Townsville-Mt Isa case study

Prior to the establishment of the Townsville teleoncology
network (TTN)6, all patients had to travel to Townsville
for specialist consultations and most types of chemotherapy regimens. Because the establishment of the TTN,
by shifting specialist medical oncology services to Mt Isa
gradually over 6 years, the scope of practice has
expanded and the number of health professionals
increased to accommodate the new services and scope of
practice. As a result, Mt Isa has become a stand-alone
rural cancer care unit as depicted in Figure 2.
This case study illustrates how telehealth models have
the potential to break the rural viscous cycle depicted in
2015 National Rural Health Alliance Inc.

Figure 1 and to expand the scope of practice and

enhance the rural workforce as illustrated in Figure 3.
As a result of such models rural patients are able to
receive their specialist services closer to home without
travelling long distances and suffering disruption to
work and family routine.

More needs to be done

Current telehealth and outreach models serve patients
from larger rural centres and patients from smaller
centres; however, many are unable to receive cancer
care closer to home due to shortages of chemotherapy
nurses and oncology pharmacists. Therefore, new
models of remote chemotherapy supervision incorporating telenursing and telepharmacy are needed in addition
to the specialist consultations via telehealth.
One such model is the Queensland Remote Chemotherapy Supervision model; endorsed by the Queensland
Health for state-wide implementation.

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FIGURE 3:

S. SABESAN

Impact of telehealth on rural service capabilities.

Another issue for rural centres is the limited access to

clinical trials, which are important aspect of modern
cancer care. Because one of the barriers to participation
in clinical trials is distance and travel,20 pharmaceutical
companies and corporate trial groups need to accept
telehealth models as part of their protocols. Telehealth
models can be used for consenting, monitoring of toxicities, supervising oral medications and follow up as
part of clinical trials.
Because communication skills are paramount in
oncology, health professionals, such as doctors, nurses,
allied health professionals and cancer care coordinators,
involved in cancer care of rural patients need to have
some training in telehealth consultations in order to
provide effective and culturally appropriate cancer care.
Finally, to increase the uptake of telehealth, hospitals
need to incorporate telehealth as part of their core business and implement it through appropriate key performance indicators and allocation of necessary resources.

Conclusion
Telehealth models are applicable to all fields of oncology
and all health professionals. These models not only
facilitate the provision of specialist services closer to
home but also help expand the rural scope of practice
and enhance service capabilities at rural centres. New
models of telehealth are needed to decrease the disparity
of access and survival outcomes between rural and
urban patients.

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