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Delivering a patient-centred high-quality homecare prostate cancer service

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A pilot looking at treating prostate cancer away from cancer centres and at home had a major impact on capacity, cost, patient satisfaction and experience

ADVERTORIAL

The cancer team at Plymouth Hospital NHS Trust (PHNT) aims to provide the best possible standards of cancer treatment, care and support to the patients they serve. In addition to overcoming capacity issues, developing a homecare prostate cancer service will align with the Trust’s overarching quality ambition to improve patient and staff experience, and use its resources more efficiently.

Recent innovations in anticancer therapy mean that many of the treatments for cancer can now be safely delivered away from major cancer centres. This pilot reflects on the provision of abiraterone, an oral anticancer therapy closer to home via a homecare delivery service supported by PHNT. It examines the need for this service, reviews the prostate cancer homecare patient pathway, and considers what impact this service has had on capacity, cost, patient satisfaction and experience.

Full case study available on the Plymouth Hospitals NHS Trust website

Delivering abiraterone through a homecare provider

During the pilot, for the first three months of treatment, patients would receive a telephone call from a pharmacist to coincide with every medication delivery. At day 13, a phone call is made to remind the patient of their scheduled home visit by an oncology nurse for full assessment and blood tests. Thereafter (month four and beyond) patients will receive one new monthly nursing visit.

Homecare nurse monitoring details:

Methodology

  • Market research was conducted by GfK’s UK Health Industry team
  • The research was focused on patients who are currently receiving abiraterone pre or post docetaxel and their caregivers
  • Patients and their caregivers were recruited in two arms pilot site at Derriford Hospital where patients were receiving abiraterone via the homecare pilot two sites in neighbouring hospitals where the patients were receiving abiraterone direct from the hospital (acting as the control arm)

The research was administered via pen and paper questionnaires of 20 minutes in duration, with four separate questionnaires designed for each target group:

  1. Patients in pilot
  2. Caregivers of patients in pilot
  3. Patients in control arm
  4. Caregivers of patients in control arm

In addition to the patient experience survey, a satisfaction survey was conducted by the homecare provider.

Benefits and research results

Benefits to patients

  • Increases patient choice
  • Supports the message that their treatment is important
  • Lessens the burden of treatment
  • Adds additional channels of communication

Benefits to significant others

  • Gives reassurance that there is continuity of high quality care from the hospital
  • Allows them to feel more engaged in the treatment process in general

Benefits to nurses

  • Allows a more holistic view of the patient
  • Gives the opportunity to see the reality of patients’ lives
  • Increased patient interactions

Benefits to the consultant

  • Creates extra capacity for the lead consultant to focus on other areas of their role
  • Increases physician’s personal satisfaction with the role they perform
  • Increases the number of touch points the patient experiences during their care

Benefits to the overall healthcare system

  • No negative effects on the hospital’s financial position, service fully sustainable by the Trust.
  • Lessens the pressure on phlebotomy services
  • Greater interactions allow for earlier interventions

Conclusion

Feedback and experience indicates that the homecare pilot has been well received by patients and clinical team. It shows signs of alleviating the strain on capacity in clinic. Part of the success of this pilot was due to the communication matrix between the homecare company and consultant, which was tightly controlled.

The pilot has led to an improvement in the patients’ and caregivers’ experience:

  • Less time is spent in clinic having to manage the aspects of the disease related to treatment
  • Despite the team’s initial concerns about healthcare professional interactions, they were shown to be more frequent and elicit greater satisfaction
  • Satisfaction ratings with treatment overall was higher, with the organisation of treatment delivery and nurse visits at the same time being the only key area identified for improvement

Due to the success of the pilot, a business case for care closer to home has been submitted and is under review.

Key learning points

Understand commissioning arrangements before the service is implemented. Every locality will have commissioning nuances and any joint working with primary care should be mapped out, addressed and agreed before starting a project.

A homecare service for the treatment of mCRPC has been shown to improve the experience of patients and caregivers. This pilot suggests that wider adoption of homecare services for oral anticancer treatments could benefit the NHS.

 

NHS uro-oncology services continue to be challenged with the emergence of new treatments for metastatic castration-resistant prostate cancer (mCRPC), with a growing requirement for increased supervision for these patients. This initiative, fully funded and project managed by Janssen, represents how Plymouth Hospital NHS Trust (PHNT) has risen to this challenge, not simply in piloting a prostate cancer homecare service to enable the current service to be more efficient, but in offering patients a high-quality homecare service for abiraterone (Zytiga®), Janssen’s oral anticancer therapy, on the NHS, delivered in the privacy of their home.

A market research study was conducted 12 months on from the pilot initiation to identify to what extent the homecare pilot had improved the patients’ and caregivers’ experience when receiving abiraterone, either pre or post docetaxel chemotherapy in the home setting.

The results have demonstrated high levels of patient adherence to treatment, positive patient satisfaction for the service provided, and reduced pressure on existing hospital capacity, allowing the centre to accommodate and manage new and more complex patients.

 

Delivering abiraterone through a homecare provider

During the pilot, for the first three months of treatment, patients would receive a telephone call from a pharmacist to coincide with every medication delivery. At day 13, a phone call is made to remind the patient of their scheduled home visit by an oncology nurse for full assessment and blood tests. Thereafter (month four and beyond) patients will receive one new monthly nursing visit.

 

 

 

ZYTIGA® 250 mg Tablets PRESCRIBING INFORMATION

ACTIVE INGREDIENT(S): Abiraterone acetate

Please refer to Summary of Product Characteristics (SmPC) before prescribing.

INDICATION(S):

Taken with prednisone or prednisolone for the treatment of metastatic castration resistant prostate cancer in adult men who are asymptomatic or mildly symptomatic after failure of androgen deprivation therapy in whom chemotherapy is not yet clinically indicated. The treatment of metastatic castration resistant prostate cancer in adult men whose disease has progressed on or after a docetaxel-based chemotherapy regimen.

DOSAGE & ADMINISTRATION:

Adults: 1000 mg (4 tablets) single daily dose. Not with food as this increases the systemic exposure (take dose at least two hours after eating; no food for at least one hour post-dose). Swallow whole with water. Take with recommended dose of prednisone or prednisolone of 10 mg daily. Medical castration with LHRH analogue should be continued during treatment in patients not surgically castrated.

Children: No relevant use.

Hypokalaemia: In patients with pre-existing, or who develop hypokalaemia during treatment with Zytiga, consider maintaining potassium level at ≥4.0 mM. Patients who develop Grade ≥ 3 toxicities (hypertension, hypokalaemia, oedema and other non-mineralocorticoid toxicities) stop treatment and start appropriate medical management. Do not restart Zytiga until symptoms of the toxicity have resolved to Grade 1 or baseline.

Renal impairment: No dose adjustment, however no experience in patients with prostate cancer and severe renal impairment; caution advised.

Hepatotoxicity: If hepatotoxicity develops (ALT or AST >5x upper limit of normal - ULN), stop treatment immediately until liver function returns to baseline; restart Zytiga at 500 mg

(2 tablets) once daily and monitor serum transaminases at least every 2 weeks for 3 months and monthly thereafter (see Special warnings & precautions). If hepatotoxicity recurs on reduced dose, stop treatment. If severe hepatotoxicity develops (ALT or AST 20xULN), discontinue Zytiga and do not restart.

Hepatic impairment: Mild (Child-Pugh class A) - no dose adjustment required. Moderate (Child-Pugh class B) - approximately 4x increased systemic exposure after single oral doses of 1,000 mg. Moderate/Severe (Child-Pugh class B or C) - no clinical data for multiple doses. Use with caution in moderate impairment, benefit should clearly outweigh risk.

CONTRAINDICATIONS:

Pregnancy or potential to be pregnant. Hypersensitivity to active substance or any excipients. Severe hepatic impairment (Child-Pugh Class C).

SPECIAL WARNINGS & PRECAUTIONS:

Zytiga may cause hypertension, hypokalaemia and fluid retention due to increased mineralocorticoid levels.

Cardiovascular: Caution in patients with history of cardiovascular disease. In patients with a significant risk for congestive heart failure (history of cardiac failure, uncontrolled hypertension, ischaemic heart disease) consider an assessment of cardiac function before treating (echocardiogram). Safety not established in patients with left ventricular ejection fraction < 50% or NYHA Class II to IV (pre-chemotherapy) and III or IV (post-chemotherapy) heart failure. Before treatment cardiac failure should be treated and cardiac function optimised. Correct and control Hypertension, hypokalaemia and fluid retention pre-treatment. Caution in patients whose medical conditions might be compromised by hypertension, hypokalaemia or fluid retention e.g. heart failure, severe or unstable angina pectoris, recent myocardial infarction or ventricular arrhythmia, severe renal impairment. Monitor blood pressure, serum potassium and fluid retention and other signs and symptoms of congestive heart failure before treatment, then every two weeks for 3 months, and monthly thereafter. Consider discontinuation if there is a clinically significant decrease in cardiac function. Hepatotoxicity & Hepatic impairment: Measure serum transaminases pre-treatment and every two weeks for first three months, then monthly. If symptoms/signs suggest hepatotoxicity, immediately measure serum transaminases. If ALT or AST > 5x ULN, stop treatment and monitor liver function. Restart treatment after liver function returns to baseline; use reduced dose (see dosage and administration). No clinical data in patients with active or symptomatic viral hepatitis. Corticosteroid withdrawal: Monitor for adrenocortical insufficiency if prednisone or prednisolone is withdrawn. Monitor for mineralocorticoid excess if Zytiga continued after corticosteroids withdrawn. Bone density: Decreased bone density may be accentuated by Zytiga plus glucocorticoid. Prior use of ketoconazole: Lower response rates may occur in patients previously treated with ketoconazole for prostate cancer. Hyperglycaemia: Use of glucocorticoids could increase hyperglycaemia, measure blood sugar frequently in patients with diabetes. Use with chemotherapy: Safety and efficacy of concomitant use of Zytiga with cytotoxic chemotherapy not established. Intolerance to excipients: Not to be taken by patients with galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption. Take sodium content into account for those on controlled sodium diet. Potential risks: Anaemia and sexual dysfunction may occur in men with metastatic castration resistant prostate cancer including those taking Zytiga. Skeletal Muscle Effects: Cases of myopathy reported. Some patients had rhabdomyolysis with renal failure. Caution is recommended in patients concomitantly treated with drugs known to be associated with myopathy/rhabdomyolysis.

SIDE EFFECTS:

Very common: urinary tract infection, hypokalaemia, hypertension, diarrhoea, peripheral oedema.

Common: sepsis, hypertriglyceridaemia, cardiac failure (including congestive heart failure, left ventricular dysfunction and decreased ejection fraction), angina pectoris, arrhythmia, atrial fibrillation, tachycardia, dyspepsia, increased alanine aminotransferase, increased aspartate aminotransferase, rash, haematuria, fractures (includes all fractures with the exception of pathological fracture).

Other side effects: adrenal insufficiency, myopathy, rhabdomyolysis.

Refer to SmPC for other side effects.

FERTILITY/PREGNANCY/LACTATION:

Not for use in women. Not known whether abiraterone or its metabolites are present in semen. A condom is required if the patient is engaged in sexual activity with a pregnant woman. If the patient is engaged in sexual activity with a woman of childbearing potential, a condom is required along with another effective contraceptive method. Studies have shown that abiraterone affected fertility in male and female rats, but these effects were fully reversible.

INTERACTIONS:

Caution with drugs activated by or metabolised by CYP2D6 particularly when there is a narrow therapeutic index e.g. metoprolol, propranolol, desipramine, venlafaxine, haloperidol, risperidone, propafenone, flecanide, codeine, oxycodone and tramadol. Avoid strong inducers of CYP3A4 (e.g. phenytoin, carbamazepine, rifampicin, rifabutin, rifapentine, phenobarbital, St John’s wort). Zytiga is a CYP2C8 inhibitor (in vitro data). Examples of medicinal products metabolised by CYP2C8 incl paclitaxel, repaglinide. No clinical data are available on the use of Zytiga with CYP2C8 substrates. May increase concentrations of drugs eliminated by OATP1B1. Food (see Dosage & Administration).

Refer to SmPC for full details of interactions.

LEGAL CATEGORY: POM

PRESENTATIONS, PACK SIZES, MARKETING AUTHORISATION NUMBERS & BASIC NHS COSTS EU/1/11/714/001; 120 tablets: £2930.

MARKETING AUTHORISATION HOLDER: JANSSEN-CILAG INTERNATIONAL NV, Turnhoutseweg 30, B-2340 Beerse, Belgium.

FURTHER INFORMATION IS AVAILABLE FROM: Janssen-Cilag Ltd, 50-100 Holmers Farm Way, High Wycombe, Buckinghamshire, HP12 4EG, UK.

© Janssen-Cilag Ltd 2014

Adverse events should be reported. This medicinal product is subject to additional monitoring and it is therefore important to report any suspected adverse reactions related to this medicinal product. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Janssen-Cilag Ltd on 01494 567447.

Prescribing information last revised: May 2014

PHGB/ZYT/0514/0026a Date of preparation: July 2014

Zinf

 

 

 

 

 

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