As a radiation oncologist, Justin E. Bekelman, MD, periodically hears complaints from patients who ask why they can’t receive hormone injections and chemotherapy infusions at home. One woman called her monthly leuprolide (Lupron®) injection a “calendar killer” because she had to structure her day around driving to the hospital just to receive her shot.
After all, patients have routinely received home treatments using infusion pumps for other conditions, including autoimmune diseases and diabetes. “We asked why this couldn’t be a real option for cancer patients, too,” said Dr Bekelman, who is head of the genitourinary service at Penn Medicine, which has 6 hospitals in Pennsylvania and New Jersey. “The idea of hospital-at-home has been around for years and already has a successful track record.”
Dr Bekelman is also the director of the Penn Center for Cancer Care Innovation at the Abramson Cancer Center in Philadelphia. In November 2019, his team got to work creating a model so doctors could prescribe 13 drugs for multiple myeloma, breast, prostate, lung, and head and neck cancers, and the combination chemotherapy regimen R-EPOCH (rituximab-etoposide phosphate-prednisone-vincristine sulfate [oncovin]-cyclophosphamide-doxorubicin hydrochloride [hydroxydaunorubicin]) for certain kinds of non-Hodgkin lymphoma at home. They also educated patients that oncologists would adhere to the same safety protocols as those in infusion centers, such as making sure visiting nurses were equipped with critical medications in case patients had adverse reactions to certain drugs.
When the program was launched in February 2020, 40 patients signed up.
Then a novel coronavirus (SARS-CoV-2) hit.
By the beginning of June, the program had more than 400 patients. “It’s skyrocketed,” he said. “We scaled that quickly because it became clear that we needed to decrease density in the hospital and infusion suites to have capacity for COVID-19.”
To accommodate the surge, some oncology nurses were reassigned to home care and received extra training on how to administer infusions in a residential setting. “There were nurses in the clinic who volunteered. It was incredibly inspiring how everyone rallied,” said Dr Bekelman.
Oncologists periodically have entertained the idea of offering home cancer care, but they never fully embraced it because of logistical challenges, said hematologist Timothy Kubal, MD, MBA, medical director of the infusion center at Moffitt Cancer Center in Tampa, Florida.
Only half of cancer drugs could easily be administered in a home setting. “You need a drug that’s easy to prepare and stable for a long time,” said Dr Kubal, who leads the Infusion Efficiency Workgroup for the National Comprehensive Cancer Network’s (NCCN’s) Best Practices Committee. That requirement eliminates some drugs that take a long time to get ready or have complicated processes.
For example, you need a special heat pump to prepare vincristine sulfate liposome injection (Marqibo®) for Philadelphia chromosome–negative acute lymphoblastic leukemia (ALL). And then there’s the antibody-drug conjugate gemtuzumab ozogamicin (Mylotarg™) that is used to treat acute myeloid leukemia (AML) — it must be made in the dark.