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Chemotherapy At Home: A Case Report

By: 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 Details

Our 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 Problems

The 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.

Solution

The 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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Patient Experience

The patient continued to attend consultant appointments and approximately half way through her treatment she was interviewed in the clinic about her experiences.

On direct questioning it was established that the home care company had contacted her before coming to her home for the first dose and discussed what they would be doing. The patient was happy with the service. She found the nurses friendly and believed she was "getting to know them well". The nurses always came on time to administer her chemotherapy. There had been no problems with venous access. The administrations had all gone smoothly and the treatment had been tolerated well; the only symptom of note was fatigue.

The patient still feels nervous about visits to hospital but can cope with consultant appointments for assessment while having her chemotherapy at home. The home care team co-ordinate blood count monitoring with the patient's consultant appointments enabling hospital blood monitoring and maintaining a minimum number of hospital visits. Overall the patient is satisfied with the service.

Whittington Clinician And Nurse Experience

When discussing the option of administering the patient's chemotherapy at home the hospital chemotherapy nurses expressed concern that they may lose track of where the patient was in her treatment and how she was coping. The mechanism of monitoring the patient and her general well-being were also of concern.

These issues were satisfactorily addressed by using a system where the home care nurses collected the drugs weekly from the chemotherapy suite. This allowed the Whittington chemotherapy nurse and the home chemotherapy nurse to check through the prescription together. The home care nurse also recorded all her findings and administration details in the patient's notes providing a good communication system and a well-documented record of treatment. All aspects of care have run smoothly and the relationship between the hospital and the home care company has been excellent.

Pharmacy Experience

The Whittington pharmacy continued to produce the doses and provide all the supplementary drugs and infusions. The clinical screening and monitoring continued in line with the normal recognised risk management role of the oncology pharmacist.

Conclusion

To provide this service for the patient, the hospital had to bear an increased cost of Ł2,500. However the alternative transport cost was Ł750 and the increased anxiety that this may have caused to the patient could have resulted in her being less compliant with treatment.

One of the fundamental aims of the National Health Service cancer plan is to provide equity of treatment. This must include equity of access. In the majority of cases this has been interpreted as equity of access to expensive drugs and the end of postcode prescribing. However in this case a patient, who would clearly benefit from chemotherapy but could not access the site where the service could be provided, was being let down by the system. The solution to this was to provide her with equity of care.

The cost of equity is high since outpatient treatment is the cheaper option for the NHS but the individual is not always being best served by such a system. For the future this may be a service other patients will need and one approach would be to provide the nursing service from the trust nurses or to train community nurses rather than to use a home care company.

References

1. Rischin D, White MA, Matthews JP, Toner GC, Watty K, Sulkowski AJ et al. A randomised controlled trial of chemotherapy in the home: patient preferences and cost analysis. Med J Australia 2000;173: 125–7.

2. Borras JM, Sanchez-Hernandez A, Navarro M, Martinez M, Mendez E, Poton JLI et al. Compliance, satisfaction, and quality of life of patients with colorectal cancer receiving home chemotherapy or outpatient treatment: a randomised controlled trial. BMJ 2001;322: 826–8.