Key messages
1. Compared to receiving intravenous (directly into a vein (IV)) anti-cancer therapy in hospital outpatient clinics, we are uncertain whether receiving the same therapy at home affects the management of unwanted effects, admission to hospital or visits to the emergency department after therapy, and IV line complications.
2. People receiving treatment at home may be more likely to prefer future treatments at home after receiving treatment there, compared to participants' preference for future treatments in hospital outpatient clinics after receiving treatment there.
3. Delivering IV anti-cancer therapy at home, compared to in hospital outpatient clinics, may make little or no difference to the cost of the treatment, from the healthcare system perspective.
What is anti-cancer therapy, and how is it delivered?
Anti-cancer therapy is medical treatment to stop or slow the spread of cancer or to treat pain and cancer symptoms and improve quality of life. Chemotherapy and immunotherapy are common anti-cancer treatments for adults with cancer. They can be delivered by mouth or under the skin (subcutaneously), or 'intravenously' (IV), directly into the vein using a needle or a tube. IV anti-cancer therapy is usually administered weekly to 4-weekly for 4 to 24 months. Treatment sessions last between 20 minutes and several hours. They are usually delivered in hospital outpatient departments. Undergoing multiple rounds of IV therapy is burdensome for people with cancer.
What did we want to find out?
We wanted to know if delivering IV anti-cancer therapy at home or in the community instead of in hospital makes it harder to manage unwanted effects (like allergic reaction), leads to more people being admitted to hospital or visiting the emergency department in the 48 hours after treatment, and if there are more problems with the 'IV line' - the tube used to deliver the medication - such as infections. We were also interested in which location for treatment patients, carers and clinicians prefer, and whether it is more expensive to give the same treatment at home instead of in hospital.
What did we do?
We searched for studies that compared the delivery of the same IV anti-cancer therapy at home, in a hospital outpatient clinic, or in the community (for example, a general practice (GP) surgery). Studies did not have to provide information about the costs of treatment. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and effect sizes.
What did we find?
We found 7 studies with 401 participants with various types of cancer, aged between 60 and 70 years. All 7 studies compared treatment at home with treatment in a hospital outpatient clinic, and 1 trial also included treatment in a local GP surgery.
Main results
Compared to delivering IV anti-cancer therapy in hospital outpatient clinics, we are uncertain of the effect of delivering the same therapy at home on unwanted effects, being admitted to hospital and visiting the emergency department during the 48 hours after treatment, and on problems with the IV line.
People who were treated at home may be more likely to prefer future treatments at home than those treated in hospital are to prefer future treatments in hospital. Out of 100 participants treated in hospital, 57 preferred future treatments in hospital, while 92 people out of 100 treated at home preferred future treatments at home (based on data from 1 study).
Home compared to hospital treatment may make little or no difference to costs for healthcare providers. Studies reported costs in their local currency, which we converted to 2022 Australian dollars (AUD) to compare them. The mean cost per hospital treatment was AUD 3419; the same treatment at home cost AUD 126 less (data from 2 studies with 80 people).
One study also investigated treatment in a local GP surgery. We are uncertain whether home treatment compared to in a local GP surgery affects management of unwanted effects and emergency department attendance in the 48 hours after treatment. Continued home treatment may or may not be preferred by people first treated at home compared to continued treatment in a GP surgery being preferred by those first treated there. Home treatment compared to the local GP surgery may make little or no difference to the cost of the treatment. This study did not provide data on admission to hospital or problems with the IV line.
What are the limitations of the evidence?
We have little confidence in the evidence because the studies we found are more than 10 years old and may not be relevant to current practice. People in the studies knew which treatment they were getting, and not everyone who started it completed the trial. Not all the trials provided data about everything that we were interested in, and sometimes the available evidence was not directly relevant. Overall, the evidence is based on a few, relatively small trials.
How up-to-date is this evidence?
The evidence is up-to-date to 16 October 2024.
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.
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.
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.
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.
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.
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.
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.