Novel telehealth strategy will treat three cancer risk behaviors at once

After people are diagnosed with cancer, their health risk behaviors — smoking, overeating and lack of physical activity — affect the likelihood that they will not respond to treatment, that they will have side effects from treatment and that they will get a new cancer. They also are more likely to get heart disease or diabetes.

A first-of-its-kind trial, funded by the National Cancer Institute (NCI), a part of the National Institutes of Health, will test whether a telehealth-based intervention that addresses all three behavioral risk factors at once can modify cancer patients’ lifestyles to improve their outcomes. The trial will recruit 3,000 participants at 11 Northwestern Medicine hospitals.

Many cancer patients are more likely to die from cardiovascular diseases than from their cancer.”

Northwestern’s Program for Scalable TELeheaLth Cancer CARe (STELLAR) is part of a new initiative that is funding four NCI Telehealth Cancer Research Centers of Excellence, and is supported by the Cancer Moonshot, a White House initiative first launched in 2016 and reignited by President Biden in 2022 to accelerate the rate of progress against cancer. Northwestern will receive $5.5 million in funding over five years.

“These risk behaviors are the same for most chronic diseases, which is important because many cancer patients are more likely to die from cardiovascular diseases than from their cancer,” said project leader Bonnie Spring, a professor of preventive medicine at Northwestern University Feinberg School of Medicine, program co-lead for cancer prevention at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University and director of the Center for Behavior and Health at Feinberg.

Spring’s center has already developed evidence-based, technology-assisted telehealth interventions to separately treat obesity, smoking and lack of physical activity.

“Nothing like this exists,” Spring said. “Over the years, we have developed separate treatments for these risk behaviors. Now we are putting them together. That’s an efficiency. Ordinarily it would be burdensome and expensive to deliver a treatment for even one of these risk behaviors." 

The project reduces the cost of treatment by training bachelor’s-level ‘health promotionists’ to coach patients under the supervision of clinical health psychologists. Physicians and nurses don’t have time to treat these behaviors, Spring said, and even if they did, the cost would be much higher.

Patients who smoke or are obese add $124.3 million per year to the cost of cancer treatment at Northwestern Medicine, Spring said. These costs accumulate because obesity adds $3,216 per person per year to medical expenses for cancer survivors, and Northwestern’s 11 hospitals treat 27,024 patients with cancer and obesity per year. The cost of overcoming first-line treatment failures caused by smoking is $10,678 per patient, and Northwestern treats 3,500 cancer patients who smoke in a single year. 

Participants are coached remotely by telephone and trained to use an app that tracks their behaviors. They self-report their diet and smoking, stand on a Wi-Fi scale and wear a Fitbit. The data are sent to their coach electronically, so when they have a bi-weekly coaching call, the coach “is up to speed” on how the person is doing, Spring said.

“If they are not losing weight, the coach can see what is causing it,” Spring said. “What high-calorie foods are they eating? Are they eating too late at night? Are they inactive? It’s what makes the coaching very efficient and personalized."

The remote telehealth aspect is critical to success, Spring said. “That’s important because we think this may be a way to reach more underserved people who can't access treatment because they live far away, work multiple jobs, don't have reliable transportation, can't get childcare or can't get time off work.”

The data are integrated into the patient’s electronic health record, so the cancer team is kept updated.

“This enables the team of care providers to encourage the patient to make healthy behavior changes,” Spring said. “It’s giving these doctors a service they all think is valuable, but they’ve not had time or reimbursement to offer it.”

The pandemic forced most fields of health care to try telehealth, Spring said. 

“Not surprisingly (to us), telehealth treatments have generally been effective and seem to have enabled underserved patients to access care more easily,” Spring said. “Because it’s always tempting to regress back to old ways, we now need to establish a strong research evidence base about whether telehealth works for cancer care. That’s how to improve the standard of cancer care and to make it more equitable. And that’s what the four NCI Telehealth Cancer Research Centers of Excellence will do, and why they’re so important."  

STELLAR integrates Spring's obesity treatment with smoking and inactivity treatments developed by project co-leads, Brian Hitsman and Siobhan Phillips, both associate professors of preventive medicine at Northwestern. Co-lead Sofia Garcia, associate professor of medical social sciences at Northwestern, contributed procedures to incorporate a patient’s data into the electronic health record. Hitsman, Phillips and Garcia are all members of the Lurie Cancer Center at Northwestern.