Home-deliverable antitumoral treatments in the age of COVID-19: the Portsmouth experience and a narrative review
Introduction
The coronavirus disease 2019 (COVID-19) pandemic has required a significant reshaping of oncological care. Patients with cancer, particularly those with lung cancer, have a greater chance of developing a severe form of COVID-19. This risk is due to the immunosuppression associated with the chemotherapy itself, the underlying pulmonary compromise that often accompanies lung malignancy, or their general borderline condition (1-4). Indeed, a report from the Italian Superior Institute of Health based on 3,200 patients who died of COVID-19 showed an over-representation of cancer patients, at 19.4% of the deceased (5).
The question then arose of which treatments to pursue and balancing the benefit of therapy with the potential increased risk in case of infection (6) and increased exposure to COVID-19 during visits and treatment. Several factors, including age and comorbidities and the number of hospital visits for treatment, influence this risk for each patient.
We also know that patients with cancer risk frequent hospitalisations. In the year after an advanced cancer diagnosis, about three-quarters of patients get admitted to the hospital, one-sixth more than three times (7).
While oncology societies have given specific recommendations on the treatment modalities to be favored, such as giving up certain palliative or adjuvant treatments, favoring shorter and less cytopenic treatments (3,8,9), we will discuss how to continue some of these curative treatments by administering them at home. We present the following article in accordance with the Narrative Review reporting checklist (available at: https://med.amegroups.com/article/view/10.21037/med-21-26/rc).
Methods
We searched in Pubmed and Google Scholar for articles in English describing home delivery of chemotherapy and immunotherapy programs since the COVID pandemic [2019] with the keywords: “home delivery”, “oncology”, “treatments”, and “COVID”. We included all studies or reports of programs that were either pre-existing or emerged during the pandemic and provided information on safety and patient satisfaction. We excluded articles about home delivery of oral treatments or those about home care in general. We also searched the reference lists of included papers.
Thus, we selected two studies from 125 articles screened. Two other programs were found by looking through references. We added a real-life experience from a home immunotherapy program in Portsmouth, allowing us to have more details on the characteristics of patients and practical modalities of such programs (Table 1).
Table 1
| Item | Specification |
|---|---|
| Date of search | January 2021 |
| New searches from July to October 2021 | |
| Databases and other sources searched | PubMed |
| Google Scholar | |
| Manual searches of the reference lists of included articles | |
| Search terms used | “home delivery” |
| “oncology” | |
| “treatments” | |
| “COVID” | |
| Timeframe | January 2021 |
| New searches from July to October 2021 | |
| Inclusion and exclusion criteria | Included: |
| Studies or reports of programs | |
| Written in English | |
| Either existed for several years or emerged during the COVID pandemic [2019] | |
| Provided information on safety and patient satisfaction | |
| Excluded: | |
| Articles about home delivery of oral treatments | |
| Articles about home care in general | |
| Selection process | Articles selected by first author |
| Portsmouth experience brought by the team of Portsmouth (Harliana Yusof) | |
| Discussed with last author | |
| Approved by all the authors |
COVID, coronavirus disease.
Background and narrative review
Several models for administering oncological treatments at home exist, with different levels of organisation and challenges related to the delivery of oral therapies, immunotherapy or chemotherapy (10).
Some oral treatments are easily accessible in local pharmacies, such as breast or prostate cancer hormone therapy. Most novel targeted treatments are oral and deliverable in hospital pharmacies (11). Regarding intravenous anticancer treatments, like chemotherapies or immunotherapies, their home administration on a large scale is rare, apart from 5-fluoro-uracil pumps or the availability of oral formulations like for the vinorelbine or etoposide used in selected patients (12,13).
These home treatment programs have existed for a long time and have proven their safety and utility (14). Their primary goal is to improve the quality of life of cancer patients, primarily in the areas of palliative care and paediatrics.
Since the COVID-19 pandemic, these programs, when already in place, have experienced a real boom, or their implementation has been considered to reduce the number of hospitalisations, visits, and the inherent risk of infection those entail.
Recently, recommendations were issued by various oncology societies (3,8,9) and the entire scientific community (7,15,16) to address the issue of continuity of care in a population that has to come and go to the hospital, with a non-negligible risk of exposure.
Previous studies have already tested the feasibility, safety and economic impact of home-based chemotherapy administration. A systematic review was published in 2016 by Evans et al. (17), assessing 54 studies in 4 different countries. Results supported the provision of home-based chemotherapy as a safe alternative to hospital-based therapy. It also gave detailed information on the other chemotherapies administered, patient eligibility criteria, delivery structures and processes, organisational and financial challenges.
In this manuscript, we will describe different preexisting programs that emerged or evolved during the COVID pandemic. We will not develop the feasibility of home-delivered oral treatments, as these are already well established.
In Italy, two programs have been described in a pediatric population. One in Friuli Venezia Giulia (18), that existed before the pandemic. Thirty-five patients received 419 doses of intravenous chemotherapy at home (cytarabine, vincristine, vinblastine). No acute adverse events were reported. Most patients families were satisfied, citing the possibility of maintaining a domestic routine and reducing hospital access time and financial burden. The sample covered years between 2011 and 2019, and the pandemic COVID-19 hit Italy during data collection and analysis. The authors did not give detailed information on how COVID-19 impacted the program but affirmed that it was beneficial.
The second study, based in Padua, offers more information on the impact of such a program during the pandemic. It had a cohort of 44 patients where 18 chemotherapy infusions of vincristine and cytarabine were administered without significant problems. This allowed a decrease of hospital visits by 15% and up to 25% during the critical weeks of the pandemic. No patient or nurse was infected either (19).
In early 2020, 600 chemotherapy visits shifted into patients homes in southern Australia via the expansion of an existing arrangement between a public hospital network and an established private home chemotherapy service. The authors explain that it proved to be a safe and efficient transition despite calls for caution from some oncology organisations. The program details are unfortunately not yet available, as the authors have only published the abstract (20).
The most detailed study on the subject is the Penn Home Infusion Therapy Program report (21) which included an initial cohort of 39 patients treated at home for their cancer. They initially reported several obstacles to include patients, such as prejudices linked to the hospital exclusivity of oncological treatments, the difficulty in identifying the subtypes of patients eligible for such a program, or the administrative barrier with complexity and time burden of organising these home treatments. As of March 2020, during the COVID pandemic, patient inclusion rose by 700%, and the majority of the biases mentioned above were assuaged. Drugs such as pembrolizumab for lung cancer and head and neck cancers, rituximab and EPOCH (etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone) for lymphomas and bortezomib for myeloma have been successfully administered.
Real-life data regarding initiation of home immunotherapy during COVID period in Portsmouth
In Portsmouth, during the COVID-19 pandemic, 43 patients with lung cancer were treated with either atezolizumab, pembrolizumab or nivolumab at home. A nurse team offered patients home-based administrations of immunotherapy after receiving at least two cycles at the hospital. After that, they were asked to confirm their preference about continuing treatment at home or in the hospital setting. Before each administration, the physician performed a telephone consultation, and a blood test was organised at home with a district nurse. A 24 h emergency contact number was provided to the patients within the Acute Oncology departmental service.
Among patients, 80% had a stage IV disease (21% and 7% with bone and brain metastases, respectively): 72% had a performance status of 1 or higher; 21% had two or more comorbidities [an autoimmune disease in 9%, cyclophosphamide, vincristine, dacarbazine (CVD) and chronic obstructive pulmonary disease (COPD) in 56% and 19%, respectively]. Only 24% of patients had progressive disease as the best response. This excellent result could stem from a selection bias, excluding patients with early symptomatic progressive disease (PD) from home-based options.
Long interval schedules were mostly used in immunotherapy regimens, with 4- and 6-weekly dosages in 53% and 33%, respectively. Most (81%) of the treatments were first-line palliative treatments, and only 9% followed chemotherapy (Table 2).
Table 2
| Characteristics | No. | % or (range) |
|---|---|---|
| Age, median | 71 | [46–86] |
| Gender, male/female | 25/18 | 58/42 |
| Tumour: lung/melanoma/renal | 14/25/4 | 33/58/9 |
| Stage III/IV | 9/34 | 21/79 |
| At-risk metastases: bone/brain | 9/3 | 21/7 |
| ECOG PS 0/1/2 | 12/24/7 | 28/56/16 |
| Comorbidity | ||
| Autoimmune | 4 | 9 |
| CVDa/COPD/T2DM/others | 24/8/3/25 | 56/19/7/58 |
| ≥2/≥3 | 21/8 | 49/19 |
| Pretreatment steroids | 6 | 14 |
| NLR, median | 2.6 | (1.2–12.1) |
| ≥4.0 | 13 | 30 |
| PD-L1 | ||
| ≥50%/≥1–50%/<1% | 14/1/4 | 33/5/21 |
| NA | 24 | 56 |
| ICI: Atezo/Nivo/Pembro | 2/24/17 | 5/56/40 |
| ICI schedule: 2-/3-/4-/6-weekly | 2/4/23/14 | 5/9/53/33 |
| Treatment line | ||
| Adjuvant/first line/≥2 line | 4/35/4 | 9/81/9 |
| Following chemotherapy | 6 | 14 |
a, CVD includes: 12 hypertension, 2 atrial fibrillation. No. number; ECOG PS, Eastern Cooperative Oncology Group Performance Status; CVD, cardiovascular disease; COPD, chronic obstructive pulmonary disease; T2DM; type-2 diabetes mellitus; NLR, neutrophils-to-lymphocytes ratio; PD-L1, programmed cell death-ligand-1; NA, not assessable; ICI, immune-checkpoint inhibitor.
In terms of toxicity, there were 47% grade 1/2 and 7% of grade 3/4 immune-related adverse events.
The average time to switch to home treatment was 5.1 months (range, 0.9–22.7 months), 5% of the patients discontinued due to toxicity, no conversion to hospital-based administration was observed, and 100% of the patients preferred home-based treatments (Table 3).
Table 3
| Parameters | No. | % or (range) |
|---|---|---|
| Treatment duration, months | ||
| Since treatment start | 14.2 | (3.9–38.8) |
| Since the switch to home | 8.9 | (1.0–19.0) |
| Time to switch to home | 5.1 | (0.9–22.7) |
| Best disease responsea | ||
| CR/PR | 18 | 42 |
| SD | 13 | 30 |
| PD | 10 | 23 |
| NA | 2 | 5 |
| Treatment discontinuation | 8 | 19 |
| PD/toxicity | 6/2 | 14/5 |
| G1/2 irAEs | 20 | 47 |
| Skin | 11 | 26 |
| Thyroid | 6 | 14 |
| Colitis | 5 | 12 |
| Joint pain | 3 | 7 |
| Fatigue | 2 | 5 |
| Lung | 1 | 2 |
| Renal | 1 | 2 |
| G3/4 irAEs | 3 | 7 |
| Skin | 2 | 5 |
| Joint pain | 2 | 5 |
| COVID-19 PCR swab: negative/positive | 43/0 | 100/0 |
| ICI converted to hospital | 0 | 0 |
| Home preferenceb | 43 | 100 |
| Death: PD | 8 | 19 |
a, referred to RECIST 1.1 criteria; b, patients were asked after two administrations to confirm their preference whether continuing with home- or hospital-based administrations. No. number; CR, complete response; PR, partial response; SD, stable disease; PD, progressive disease; NA, not assessable; irAE, immune-related adverse events; ICI, immune-checkpoint inhibitor.
This real-world experience proves that home-based administrations are feasible and convenient, particularly in patients with poor performance status, comorbidities and those with at-risk metastases (bone, brain). The strategy of delaying home-based administrations after at least two previous hospital-based doses appears sensible to reduce the risk of reactions.
Conclusions
Amid all the panic and suffering spread by COVID-19, a silver lining is that it has highlighted the added value of home treatment programs. Concerns remain about managing complications (22,23), but a review by van Tiel et al. shows that cytopenic patients could benefit from home chemotherapy without additional complications (24). Financial challenges remain, particularly on reimbursement by insurance companies and the loss of earnings for hospitals. The rules and impact will differ in each country. We know that these programs could benefit large recruitment centers that could provide more treatments to more patients than small recruitment centres that already lack patients and could suffer from over-staffing and financial woes without their patient base.
Home treatments also require the careful selection of eligible patients and training and organisation of specialised teams capable of managing the expected complications.
It would be interesting to assess the risk-reduction in terms of infections and potential survival gains obtained by these programmes during the COVID-19 pandemic. To do this accurately, prospective studies are warranted.
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the Guest Editors (Giuseppe Banna and Alfredo Addeo) for the series “Changes in Management of Mediastinal Tumours Following the Surge of COVID-19 Pandemic” published in Mediastinum. The article has undergone external peer review.
Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at: https://med.amegroups.com/article/view/10.21037/med-21-26/rc
Peer Review File: Available at https://med.amegroups.com/article/view/10.21037/med-21-26/prf
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at: https://med.amegroups.com/article/view/10.21037/med-21-26/coif). The series “Changes in Management of Mediastinal Tumours Following the Surge of COVID-19 Pandemic” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Mechahougui H, Yusof H, Baudoux N, Acharige S, Friedlaender A. Home-deliverable antitumoral treatments in the age of COVID-19: the Portsmouth experience and a narrative review. Mediastinum 2022;6:12.
