While people living with a cancer diagnosis required concerted efforts to mitigate survivorship challenges pre-COVID-19 pandemic, such efforts are likewise required during the pandemic. In this analysis of breast cancer survivor referrals to and participation in supportive services, we show that COVID-19 did not adversely impact patient participation. There was only a transient drop in participation during March to May 2020 (when Ohio was in lockdown) compared to the previous year. Overall, patient referrals for 2020 were similar to the pre-pandemic 2019 numbers, while 2021 numbers are projected to surpass the last 2 years. Surprisingly, the cancelation and no-show rates remained unchanged during 2020 compared to the previous year, likely as a consequence of telehealth options. While the volume of AYA referrals from the breast service line increased in 2020, it was likely due to increased programmatic awareness and a longer time period of data capture in 2020 (12 months) than 2019 (6 months). Furthermore, patient selection focus shifted from nutrition content to exercise as the most utilized program. After lockdown, our SPs were converted to virtual content, and currently, there are hybrid options with in-person options if preferred. Telehealth, by reducing the burden of travel and transportation, may have broadened access to support services.

Before the onset of the COVID-19 pandemic, utilization of telehealth and telemedicine in the USA was limited [22, 23]. Telemedicine growth had been encumbered by lack of uniform coverage policies across insurers and states, and hurdles to establishing telemedicine in health systems (e.g., high startup costs, workflow reconfiguration, clinician buy-in, and patient interest) [24, 25]. The COVID-19 pandemic resulted in social distancing mandates which created a massive need for remote patient encounters. Telemedicine platforms enabled care continuity and demand rapidly increased [22]. While transitioning to digital platforms has been one of our healthcare system’s strategies to limit the disruption of many patient services, this poses some emerging challenges. There are reports of digital access inequalities in both the ability to access and to use telemedicine within local, regional, national, and global populations [23, 26,27,28]. Access to telemedicine may be particularly challenging for low-income patients and patients in rural areas, who may not have reliable broadband access [27, 29,30,31,32]. Recent data from the Pew Research Center shows that while internet non-adoption is linked to a number of demographic variables including income, age, and educational attainment, no statistically significant differences exist in non-internet use by gender or race and ethnicity [33]. However, internet use is strongly connected to age, with older Americans continuing to be one of the least likely groups to use the internet with 25% of adults ages 65 and older reporting never going online [14, 23,24,25, 33, 34].

Elderly patients are a concerning population in which telemedicine solutions may be less feasible. Because older patients are at higher risk for severe symptoms of coronavirus and in general require more frequent primary care, they may benefit greatly from telehealth to reduce in-person risk of exposure [12, 16,17,18]. However, many seniors may not feel comfortable with or be able to use these technologies [29,30,31,32,33,34], although there has been improvement in this area. While 86% of adults ages 65 and older did not go online in 2000, today that figure has fallen to just a quarter [34]. Still when it comes to telemedicine, a recent study by Walker et al. found that patients aged 60–69 (45.3% difference, p < 0.001) and those over age 70 (36.7% difference, p = 0.04) used the inpatient portal less than patients aged 18–29 [35]. In such cases, alternative routes of communication such as telephone conversations can be potentially helpful for survivorship care [7, 19, 20]. Data shows the pandemic increased use of telehealth platforms, whether virtual or web-based or telephone, comprising 30.2% of healthcare visits [26]. A systematic review on patient satisfaction with telemedicine found that patient satisfaction can be associated with the modality of telehealth, but factors of effectiveness and efficiency are mixed with patients’ expectations being met when providers delivered healthcare via telehealth method [36]. A randomized trial, Comparing Modes of Telehealth Delivery: Phone vs. Video Visits (ASSIST), will assess patient satisfaction with visit time as primary endpoint which will provide important insights [37].

There are many limitations in this study. Primarily, data utilized herein was abstracted from our institutional quality database which contains limited variables. For example, participant’s race, ethnicity, other sociodemographic details, and satisfaction with services are not captured. As a result, these data limit our ability to characterize women categorized as cancelation or no-show for scheduled visits or programming. This information could guide further programming to better serve different subgroups of women during the pandemic and beyond. To inform further investigation and result in program changes, more detail is needed. Additionally, this study is situated in the context of a comprehensive and well-resourced institution. This aids in demonstrating possible interventions for other institutions; however, not all institutions may be able to implement the same breadth of interventions. A customized approach to each institution is needed to best serve patients. Nonetheless, we show that during these challenging times, there is sustained interest in supportive services, and especially ones focused on exercise given the physical restriction in place to reduce COVID-19 infection rates. Transitioning to telehealth to deliver our SPs has permitted continued access for our patients.