Although the interest of at-home care including the administration of cancer infusions has grown since the start of the COVID-19 pandemic, hesitation looms over its convenience, cost and safety.
The COVID-19 pandemic has motivated cancer centers to find new ways for their patients to obtain timely and safe care including in-home cancer infusion programs, although some advocacy groups are hesitant to support its use due to safety concerns.
In particular, Rutgers Cancer Institute of New Jersey in New Brunswick and RWJBarnabas Health launched a pilot program in September 2020 to administer cancer infusions at home for eligible patients. This was not only to prevent chemotherapy disruption during the COVID-19 pandemic, but also to limit potential exposure to the virus at cancer centers.
“We are constantly looking for ways to be innovative, and to export knowledge and new paradigms throughout our (health care) network,” said Dr. Andrew M. Evens, associate director for clinical services at Rutgers Cancer Institute of New Jersey and medical director of the oncology service line at RWJBarnabas Health, in an interview with CURE®. “This was an example of our motto that cancer doesn’t travel well. Yes, it emerged out of the (COVID-19) pandemic, looking for ways to be more convenient. At the same time, we want to be safe and effective for patients.”
Although this health system keeps patients’ safety in mind, the Community Oncology Alliance (COA) released a position statement in April 2020 — a few months before Rutgers Cancer Institute’s pilot program launch — indicating that it opposed home infusion of chemotherapy, cancer immunotherapy and cancer treatment support drugs due to serious patient safety concerns.
Over a year after that statement was issued, COA still stands by that opinion.
“COA’s mission statement is, we are advocates on behalf of patient safety, effectiveness and access to care,” Dr. Kashyap Patel, president of COA, told CURE®. “If access to care at home is there, I would love to do that. But looking at the risks associated with that, … practice has put extra precautions in place to ensure that we have the capacity of handling all of these reactions. We have a CPR bag ready all the time. And I've had actually done it when we had a situation like that. It's not rare; every week, we're pulled where there is a reaction going on.”
Evens said the following about the COA statement, “I wouldn’t be surprised if that statement or posture is based on financial ramifications. We launched this program with the same hypothesis; we wanted to enhance great patient experience and convenience, but with the critical concurrent tenets of this pilot program were safety and effectiveness. In fact, home therapy had to be identical to everything we do in the clinic.”
Several factors are taken into consideration before a patient is considered for an in-home cancer infusion program, which Evens considered “very strict in a way.” Not all cancer drugs can be administered at home, but rather the drugs that are “safer with the least (number) of possible reactions to them, so it is a select list,” Evens said.
He added, “Historically, these intravenous agents, whether targeted or chemotherapy, have only been given at the oncology center, but there are many of them that are actually quite safe.”
In this pilot program, which has treated approximately 30 patients so far, the cancer team also takes the patient’s disease state into consideration before allowing them to participate in the at-home cancer infusion program. In other words, the program doesn’t allow patients who are sicker or higher risk to have cancer treatments administered at home.
“You could have two patients receiving the same treatment, but for various reasons, whether preexisting conditions, etc., a patient might be weaker, more fragile, etc.,” Evens said. “Especially in a pilot program — is probably not the type of patient (for this program), but the good news is most patients are in pretty good shape and physically fit.”
Once it has been deemed appropriate for a patient to have their cancer infusions administered at home, the first infusion is always given at the oncology center out of an abundance of caution, Evens said.
“Usually, if there’s a reaction, more often than not, it’s with the first infusion,” he said. “If everything goes smoothly there, then (the patient will) enter into that treatment program. Then there’s an oncology-certified nurse that’s onsite at the patient’s home that’s not just delivering (the infusion), but observing and monitoring. It should also be highlighted that we have given a number of chemotherapy agents safely and effectively at home for many years, including multiagent continuous infusion regimens (eg, EPOCH chemotherapy for aggressive non-Hodgkin lymphomas).”
Patel disagreed with some aspects of this safety precaution, especially since some cancer drugs can lead to an increased risk for side effects after the first infusion.
“There's a drug called carboplatin. The likelihood of having a severe reaction increases with multiple infusions,” Patel said. “I would politely disagree. … If a patient did not react to the first infusion, maybe they can react very badly to the tenth infusion.”
Patel explained that treatment with the drug Rituxan (rituximab), which is used for multiple forms of cancer including lymphoma and leukemia, can result in an increased risk for an infusion reaction of at least 50% during the first infusion or subsequent infusions. Although not all reactions from the drug are life threatening, it may be difficult for a health care professional to differentiate when an appropriate intervention is required and when a team should be mobilized to where the patient is.
In addition, Patel noted his concern about how far doctors and other support staff are in proximity to the patient while they undergo an infusion at home.
“What's the geographical distance the doctor has to be within the accessible distance? And then if somebody gets infusion 80 miles away, how are you going to save that patient? … These all make me uncomfortable promoting, supporting or advocating for in-home infusion,” he said.
Evens added that since the launch of this pilot program, it has “really gone fantastic and incredibly smoothly,” as all patients have been treated safely and effectively. He also mentioned that patient experience has been outstanding due to the program’s convenience. Although some people have been hesitant about in-home infusions — similar to what was observed with telehealth appointments during the COVID-19 pandemic — that is a small fraction of patients.
Patient experience and convenience are the main areas of focus for Evens and his team with the in-home cancer infusion program.
The Potential Cost to Patients
Programs like these may also provide a cost benefit to patients, as they do not have to visit the cancer center, which requires paying for gas, tolls, parking and other expenses. Evens, whose specialty is lymphoma, notes a patient he recently referred to for the in-home cancer infusion program who was treated with the monoclonal antibody Rituxan. The patient recently lost his job and was experiencing transportation issues which could have prevented him from visiting the center for his infusions.
Regarding cost, Evens said the program at his institution essentially does not pose an added cost to the patients due to a close collaboration with the insurance company Horizon Blue Cross.
Patel was opposed to this opinion on cost, as there are often many codes involved in every aspect of at-home care that’s required compared what is used (or already offered) in the clinic.
“If the patient is Medicare-only, which is what we are most worried about, in order to request this from their medical insurance, we’re going to include out-of-pocket costs as well,” Patel said. “It’s about a 300% in the home infusion cost versus infusion at the office. If you give a combination of Taxol and carboplatin drugs in my office, the cost of the drugs is very minimal because both are generic. … When given in the home, … because they’ll be using durable medical equipment, it’s driven by economic factors and will be about $1,000 for just the service cost, not the drug cost. If the patient is Medicare-only, their out-of-pocket costs will be $200 versus probably around $60 in the office.”
Patel doesn’t necessarily want to dismiss the concept of in-home cancer infusions completely, but would rather see certain personnel on-hand before he feels more comfortable with the idea. He explained he would like to see a full resuscitation team onsite, a respiratory therapist, integration of someone with medical experience (like a physician) and a CPR nurse.
Despite these hesitations from other parties, Evens feels confident that the pilot program at his cancer center will open the doors to more programs across the country.
“My hope is that this program will help set a precedence not only to quell fears or concerns regarding safety or effectiveness, but also address the financial aspects as well,” Evens said. “I think it is weaving in all of these important aspects. And it will take multiple parties working together: community oncologists, academic oncologists, pharmacists, along with the insurers.”
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