Delivery of intravenous anti-cancer therapy at home versus in hospital or community settings for adults with cancer.

Abstract

Background: Intravenous (IV) chemotherapy and immunotherapy are administered at frequent, regular intervals (weekly to four-weekly) for 4 to 24 months, with treatment sessions lasting between 20 minutes and several hours for adults with cancer. These treatments are usually given in chemotherapy day units in hospitals as same-day treatments. However, less complex anti-cancer therapy regimens may be administered in the participant's home.

Objectives: To assess the safety, patient preference for, and cost of IV (including subcutaneous) anti-cancer therapy (chemotherapy or immunotherapy) delivered at home as an alternative to the same IV anti-cancer therapy regimen delivered in a hospital or community setting in adults with cancer.

Search methods: We searched CENTRAL, Cochrane Database of Systematic Reviews, MEDLINE, Embase, CINAHL, NHS Economic Evaluation Database, Cost-Effectiveness Analysis Registry and trial registries (ClinicalTrials.gov and WHO-ICTRP) from inception until 16 October 2024. We also searched PDQ Evidence and Epistemonikos for related systematic reviews. We screened reference lists of included studies and relevant systematic reviews.

Selection criteria: We included randomised parallel and cross-over trials, conducted in adults (aged 18 years and over) diagnosed with any type and stage of cancer requiring IV anti-cancer chemotherapy or immunotherapy. Eligible studies compared delivery of IV anti-cancer therapy at home with delivery of the same therapy in a hospital setting (as an inpatient or outpatient), or in the community setting (e.g. GP practice, community clinic). We included economic evaluation studies (i.e. cost-effectiveness analyses, cost-utility analyses, cost-benefit analyses) conducted alongside eligible effectiveness studies. Primary outcomes were adverse events, hospital inpatient admission and additional hospital attendance (e.g. emergency department visit) within 48 hours of administration of anti-cancer therapy, IV line complications, participant preference, and cost of delivering IV anti-cancer therapy from a healthcare system perspective.

Data collection and analysis: Two review authors selected studies for inclusion, extracted trial characteristics and numerical data, assessed risk of bias, and judged the certainty of evidence using the GRADE approach. The main comparison was delivery of IV anti-cancer therapy at home versus in a hospital outpatient clinic. The primary time points of interest for outcomes related to serious adverse events, complications and cost were those collected at the longest follow-up postintervention. For outcomes such as participant preference, participant quality of life, participant and caregiver satisfaction, and non-adherence to the treatment regimen, data collected at time points as soon as possible after the intervention were of primary interest.

Main results: We identified seven eligible trials (three parallel RCTs, four randomised cross-over trials; 401 randomised participants, with 272 participants included in the final analyses) and five ongoing trials. Five included trials were performed prior to the 2000s and two were performed between 2007 and 2011. Trial participants' mean age ranged from 60 to 70 years. Four trials recruited a mix of cancer patients, including breast, colon, rectum, pancreatic, pancreaticobiliary, non-Hodgkin's lymphoma, lung, and head and neck cancer. Three trials focused on specific cancers (i.e. colorectal cancer, breast cancer, colon cancer). Seven trials compared delivery of IV anti-cancer therapy at home versus in a hospital outpatient clinic. One trial compared delivery of IV anti-cancer therapy in the participant's home, in the hospital outpatient clinic, and in local general practice surgery. All participants were assessed either by a physician or trained chemotherapy nurse prior to receiving each treatment cycle, and trained chemotherapy nurses administered the therapy, as per standard clinical practice, in all settings in all trials. We judged three trials as having low overall risk of bias. In four trials, the overall risk of bias was unclear due to poorly reported study methods, failing to report assessed data points and inaccessible study protocols. Due to the very low certainty of the evidence, we are uncertain of the effect of delivering IV anti-cancer therapy at home versus in the hospital outpatient clinic on the response to and management of adverse events, on both hospital inpatient admission and additional hospital attendance within 48 hours of administration of anti-cancer therapy, and on IV line complications (including infection and thrombosis). Based on low-certainty evidence, participants receiving therapy at home may be more likely to prefer future treatments at home, after receiving treatment in this setting (35 more per 100, 10 to 70 more; data from 1 RCT with 65 participants). Based on low-certainty evidence, delivering IV anti-cancer therapy at home may make little or no difference to the cost of the treatment from the healthcare system perspective in comparison to delivering it in the hospital outpatient clinic (mean cost (in 2022 Australian dollars (AUD)) per treatment at home: 126 AUD less; 1798 AUD less to 1546 AUD more; data from 2 RCTs with 80 participants). We are uncertain of the effect of delivering IV anti-cancer therapy at home, versus a local GP surgery, on the response to and management of adverse events. No studies reported on hospital inpatient admission. Evidence on additional hospital attendance within 48 hours of administration of anti-cancer therapy is of very low certainty. Low-certainty evidence suggests that compared to receiving treatment in a local GP surgery, participants may or may not be more likely to prefer future treatments at home, and delivering anti-cancer therapy at home may make little or no difference to the cost of the treatment.

Authors' conclusions: Evidence on the safety and cost-effectiveness of IV anti-cancer therapy at home is scarce and outdated. IV anti-cancer regimens have evolved; the findings of studies performed more than a decade ago may lack applicability to current practice. However, key considerations when considering suitability for home treatment remain unchanged: safety, duration of treatment and geographic catchment area. The finding that patients may prefer future treatments at home after receiving treatment in this setting, albeit based upon low-certainty evidence, is consistent with the widespread current practice of delivering IV anti-cancer therapy, including immunotherapies, at home when judged safe and preferred by the patient. Appropriate selection of patients and regimens is a key consideration for ensuring the safety of delivering IV anti-cancer therapy at home.