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Chemotherapy At Home: A Case ReportBy: Helen J. Taylor, DipClinPharm, MRPharmS
The Whittington Cancer Unit at the Whittington Hospital recently provided funding so that a patient could receive home chemotherapy. In this article the author reports on this experience with reference to the existing published data
Patients with cancer who require chemotherapy experience major lifestyle changes. Some intravenous chemotherapy regimens require frequent visits to hospital and this can be time consuming and inconvenient for the patient, family members and carers. These problems can be addressed by treating chemotherapy patients at home.
Despite there being some experience in the private sector there are few reports on home chemotherapy programmes. A recent Australian study1 reported the results of a randomised crossover trial where patients preferred to have their chemotherapy at home. Of the 20 patients in the trial, most patients preferred home treatment for reasons of convenience, avoidance of traffic and parking, a reduction in treatment associated anxiety, not burdening carers and being able to care for their dependants.
Another recent paper,2 describing a randomised controlled trial of cancer patients receiving treatment either at home or as outpatients, showed no change or increase in the number of patients using emergency medicine resources, ie, casualty admissions for chemotherapy associated complications. The authors claimed that although giving the patient their chemotherapy at home increased compliance there were no positive effects on quality of life or adverse effects. However, the paper stated that global satisfaction was higher in the home group than the hospital group but the difference was not statistically significant. The overall conclusions of the study were that administering this type of chemotherapy at home is safe and does not require extra use of emergency services.
Patient DetailsOur patient presented with a change of bowel habit over the past year and bright red rectal bleeding. She also experienced anal discomfort on defecation but did not have any abdominal pain. Occasionally she experienced the feeling of not having emptied her bowels properly. There had been no weight loss over the past three months. She was not aware of any family history of bowel cancer.
On examination the patient was found to have a palpable growth at 6cm. The tumour was a peripheral polypoid tumour with central bleeding and ulceration. After biopsy and surgery the patient was confirmed to have adenocarcinoma of the rectum stage III. On CT scan no metastatic disease was seen. All the resected margins were clear.
This patient had a history of depression and cancer of the breast two and a half years ago, which had been treated with radiotherapy and tamoxifen.
The patient lived alone, had no close family and spoke limited English. After discussion with her medical oncology consultant the patient chose to receive the chemotherapy that he recommended. This chemotherapy was weekly fluorouracil and folinic acid. The patient was physically fit and well and motivated to undertake chemotherapy making her a good candidate for this treatment.
Stages II and III colorectal cancer are at high risk of recurrence and research has shown that there is an increased time to recurrence with chemotherapy but no increase in overall survival.
Patient ProblemsThe patient received her first course of chemotherapy in the outpatient suite at the hospital but subsequently became anxious about coming to the hospital for treatment and coping with the journey on public transport and had missed several appointments in the chemotherapy suite. She did not have anyone to help her get to the hospital.
SolutionThe options available for this patient were:
• To be treated with anxiolytics and use hospital transport to take her to and from the hospital
• To have a community nurse visit her and administer the chemotherapy
• To deliver the chemotherapy to her in her home
The first option was not acceptable due to the associated problems with giving anxiolytics, such as dependence and withdrawal. In addition, the journey would still be adding anxiety and stress to the process, making it difficult for her to cope.
The community nurse option proved not to be viable because the nurses were not all trained to administer chemotherapy and it was not clear if they were insured to carry out such a procedure.
The final option of providing the chemotherapy at home was chosen since it was preferred by the patient and would cause her the least distress.
A home chemotherapy company was contacted and the necessary arrangements made. The home care company provided nursing care, administration of chemotherapy and blood sampling. The hospital pharmacy continued to provide the drugs to the chemotherapy suite where they were collected by the home care service each week and taken to the patient's home for administration.
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