Justin E. Bekelman, MD
For many cancer patients, the arc of care resembles that of any chronic disease. After a brief, acute interlude, the patient experiences a long period of recovery, with intermittent returns to the hospital or clinic for follow-up care. During this later period, chemotherapy is often a key element of cancer care.
Chemotherapy has long been available in the home for topical and oral agents. In recent years, a few injectable and infusion therapies have joined the transition to home care. Typically, however, these drugs are administered in hospitals or clinics — an imposition on cancer patients and their caregivers. Ideally, this is offset by the increased safety, quality assurance and lower cost in these settings.
However, according to Justin Bekelman, MD, of the Abramson Cancer Center at Penn Medicine, the current multidisciplinary, multi-setting disposition of cancer care can also be a source of financial burden and fragmented, unnecessary, or sub-optimal care for patients.
Establishing Penn Cancer Care at Home
A radiation oncologist and Director of the Penn Center for Cancer Care Innovation (PC3I), Dr. Bekelman stated his views on home cancer care in a series of articles and interviews that predate the COVID-19 pandemic.
In these reports, Dr. Bekelman makes the case for transitioning cancer care, including home infusion, away from the hospital. He argues convincingly that such care could achieve equal or higher quality than traditional inpatient oncology care and greater patient satisfaction at lower cost.
"Just as telemedicine is dramatically changing how primary care is delivered, much of cancer treatment can be delivered safely, effectively, and less expensively at home."
Justin E Bekelman, MD, in STAT February 2019
Introduced in February 2020, Cancer Care at Home is an exemplar of this perspective. A joint initiative of the PC3I, the Center for Healthcare Innovation and the Division of Hematology and Oncology at Penn, the program offers patients the services of a multidisciplinary care team and access to a dozen chemotherapeutics. These include leuprolide, dose-adjusted EPOCH (etoposide, vincristine, doxorubicin, cyclophosphamide and prednisone), rituximab and bortezomib, among others, for the treatment of breast and prostate cancers, lymphoma, and multiple myeloma.
At-Home Cancer Care: Overcoming Barriers
Although Cancer Care at Home now seems a prescient and invaluable addition to the community, the program was not widely embraced when it first appeared.
"Early on, we found that oncologists and patients were understandably resistant to the idea of receiving treatment at home," Dr. Bekelman said in a recent interview with ASCO Post. Early reluctance is a familiar barrier to home-based cancer care among patients and their providers, who cite concerns about safety, quality and resource availability.
To ensure that Cancer Care at Home would gain traction and to address these concerns, Dr. Bekelman and his staff established a series of far-reaching procedures:
- The process for ordering and administration of home infusions was streamlined and all equipment delivered directly to patients' homes;
- Injections and infusions are conducted using safety and quality protocols that match what patients would experience in the hospital or clinic facility; and
- Physicians and patients receive careful explanation to ensure that they understand the safety procedures in place and the credentialing criteria for the nurses who deliver infusion therapy.
The reception among patients was particularly positive for women with breast cancer.
"These women often have to take leuprolide monthly, sometimes for 5 to 10 years — a significant burden that often means taking time off from work," Dr. Bekelman explained. "Now, they can receive their injections in their home at their convenience."
Home Infusion and COVID-19: Driving Cancer Home Care
The planning and innovation devoted to the program's introductory phase allowed Cancer Care at Home the flexibility to scale up when the COVID-19 pandemic arrived in Philadelphia in early 2020. From a base of 39 patients in early March, the program catapulted to 310 patients by the end of April — a more than 700% rise in patient participation.
Home Infusion Therapy
The immediate explanation for the sudden success of Cancer at Home can be attributed to safety. Simply put, the program removes patients from a source of potential infection. Administrators soon discovered that Cancer at Home had a practical advantage in the pandemic, too: it increased hospital capacity by diminishing patient density in the infusion suites at Penn Medicine.
Will Cancer Care Be at Home in the Future?
There will be challenges ahead for Cancer at Home, of course. Making the program economically sustainable for providers beyond the current pandemic crisis will require significant changes in insurance reimbursement policy and benefit design, according to Dr. Bekelman. And he notes that the goal of the program is not to transfer all cancer care to the home setting.
But, he adds, the present success of Cancer Care at Home provides a great example of why the staff at PC3I are so passionate about the work they do.
"I believe the measures we're taking to provide cancer care during the pandemic will make our health-care system stronger and will make cancer care better," he continued. "We know there will continue to be challenges to scaling the program. But providing cancer care at home is here to stay."