Supportive oncology care at home interventions: protocols for clinical trials to shift the paradigm of care for patients with cancer.

BACKGROUND: Patients with cancer often endure substantial symptoms and treatment toxicities leading to high healthcare utilization, including hospitalizations and emergency department visits, throughout the continuum of their illness. Innovative oncology care models are needed to improve patient outcomes and reduce their healthcare utilization. Using a novel hospital at home care platform, we developed a Supportive Oncology Care at Home intervention to address the needs of patients with cancer. METHODS: We are conducting three trials to delineate the role of Supportive Oncology Care at Home for patients with cancer. The Supportive Oncology Care at Home intervention includes: (1) a hospital at home care model for symptom assessment and management; (2) remote monitoring of daily patient-reported symptoms, vital signs, and body weight; and (3) structured communication with the oncology team. Our first study is a randomized controlled trial to test the efficacy of Supportive Oncology Care at Home versus standard oncology care for improving healthcare utilization, cancer treatment interruptions, and patient-reported outcomes in patients with cancer receiving definitive treatment of their cancer. Participants include adult patients with gastrointestinal and head and neck cancer, as well as lymphoma, receiving definitive treatment (e.g., treatment with curative intent). The second study is a single-arm trial assessing the feasibility and acceptability of the Supportive Oncology Care at Home intervention for hospitalized patients with advanced cancer. Eligible participants include adult patients with incurable cancer who are admitted with an unplanned hospitalization. The third study is a single-arm trial assessing the feasibility and acceptability of the Supportive Oncology Care at Home intervention to enhance the end-of-life care for patients with advanced hematologic malignancies. Eligible participants include adult patients with relapsed or refractory hematologic malignancy receiving palliative therapy or supportive care alone. DISCUSSION: These studies are approved by the Dana-Farber/Harvard Cancer Center Institutional Review Board and are being conducted in accordance with the Consolidated Standards of Reporting Trials statement for non-pharmacological trials. This work has the potential to transform the paradigm of care for patients with cancer by providing them with the necessary support at home to improve their health outcomes and care delivery. TRIAL REGISTRATIONS: NCT04544046, NCT04637035, NCT04690205.

Healthcare Utilization and End-of-Life Outcomes in Patients Receiving CAR T-Cell Therapy.

BACKGROUND: CAR T-cell therapy has revolutionized the treatment of patients with hematologic malignancies, but it can result in prolonged hospitalizations and serious toxicities. However, data on the impact of CAR T-cell therapy on healthcare utilization and end-of-life (EoL) outcomes are lacking. METHODS: We conducted a retrospective analysis of 236 patients who received CAR T-cell therapy at 2 tertiary care centers from February 2016 through December 2019. We abstracted healthcare utilization and EoL outcomes from the electronic health record, including hospitalizations, receipt of ICU care, hospitalization and receipt of systemic therapy in the last 30 days of life, palliative care, and hospice referrals. RESULTS: Most patients (81.4%; n=192) received axicabtagene ciloleucel. Overall, 28.1% of patients experienced a hospital readmission and 15.5% required admission to the ICU within 3 months of CAR T-cell therapy. Among the deceased cohort, 58.3% (49/84) were hospitalized and 32.5% (26/80) received systemic therapy in the last 30 days of life. Rates of palliative care and hospice referrals were 47.6% and 30.9%, respectively. In multivariable logistic regression, receipt of bridging therapy (odds ratio [OR], 3.15; P=.041), index CAR-T hospitalization length of stay >14 days (OR, 4.76; P=.009), hospital admission within 3 months of CAR T-cell infusion (OR, 4.29; P=.013), and indolent lymphoma transformed to diffuse large B-cell lymphoma (OR, 9.83; P=.012) were associated with likelihood of hospitalization in the last 30 days of life. CONCLUSIONS: A substantial minority of patients receiving CAR T-cell therapy experienced hospital readmission or ICU utilization in the first 3 months after CAR T-cell therapy, and most deceased recipients of CAR T-cell therapy received intensive EoL care. These findings underscore the need for interventions to optimize healthcare delivery and EoL care for this population.