Despite benefits, subcutaneous delivery of drugs underused in US for patients with cancer
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Despite the benefits and accessibility of administering cancer medications and fluids subcutaneously vs. intravenously, U.S. facilities appear to underuse this delivery method, according to a research letter published in JAMA Oncology.
“Subcutaneous delivery of medications and fluids presents an opportunity for an easier route of administration,” Michael Tang, MD, assistant professor of palliative, rehabilitation and integrative medicine at The University of Texas MD Anderson Cancer Center, told Healio. “To use intravenous routes, some technical ability is required — nurses are trained in this. Subcutaneous routes essentially require placing the needle beneath the skin in certain locations; it’s easier to do. So, I think it presents an opportunity to allow for care in the home environment.”
Tang and colleagues compared the frequency of subcutaneous administration in the acute palliative care units of two cancer centers with similar end-of-life care practices: MD Anderson Cancer Center in Houston and Princess Margaret Cancer Centre in Toronto.
Tang spoke with Healio about why subcutaneous administration is underused in the United States and how it might be increased in the future.
Healio: What inspired you to study subcutaneous medication and fluid administration in the U.S. cancer setting?
Tang: Our chair of the department of supportive medicine previously practiced in Canada, where things are much different in terms of how they administer fluids and medications, especially in the palliative care realm. So, he thought of the idea to compare specific practices in the United States and Canada, rather than just comparing one country to another.
Healio: How did you conduct this study?
Tang: We have contacts in Canada, such as Jenny Lau, MD, director of the palliative care unit at Princess Margaret Hospital in Toronto. That’s a comparable tertiary care center to where I work at MD Anderson in Houston. We asked if she would be willing to do this study with us. She was excited to do the project.
The study was a simple design — we looked at our palliative care unit here at MD Anderson and their palliative care unit at Princess Margaret Hospital in Toronto. We did a chart review of 200 patients per location last year. We found that when we had to administer fluids and medications here in the United States, we used IV essentially 100% of the time. They used subcutaneous administration about 95% of the time.
Healio: Were there any differences in outcomes between these two routes of administration?
Tang: We tried to find associations with certain outcomes like location of discharge and whether the patient died in the palliative care unit or was able to go home with hospice. We found no significant associations between any of those variables. It was simply the location of the practice — whether it was in the United States or Canada.
Healio: Why do you think there is such a difference between the United States and Canada in this regard?
Tang: In my research for this paper, I found it fascinating that subcutaneous use was widespread in the United States up until the 1940s and 1950s. Then, a series of case reports showed some harm with the subcutaneous fluid route. I found one case report about an infant who died that a lot of the literature cites. However, when you look more closely at the case, you see they actually administered the wrong type of fluid — hypertonic saline instead of saline. Nevertheless, this information spread and a lot of people did not want to use a subcutaneous route after that, believing the IV route would allow for better titration in those types of events.
The second thing we found is that physicians and nurses today are not really trained in using the subcutaneous route. So, culturally, we are more comfortable using IV.
Another thing we found is that here in the United States, a lot of institutions have a buy-and-bill model. We buy an IV pump, and in order to pay for the pump and all the services, we charge for it. With the subcutaneous model, medications can be given without pumps or infusions. There is no associated charge with that. But if an institution buys a thousand IV pumps and they aren’t able to charge for them anymore, they begin to lose money. Of course, that money pays for the nursing staff and the right ancillary staff. So, it’s a different business model.
I had a lecture with a palliative care group from Oxford University, and they were shocked that we do 100% IV administration here. I think countries that have a single-payer model are incentivized to save money. They are more apt to use this method of delivery.
Healio: What do you think will be the implications of your findings?
Tang: One of the reasons I was so fascinated to be doing this study is because it shows an opportunity in health care. I talked to someone who asked me, “Does this mean it would be best to transition to all subcutaneous routes of administration?” I would say there are definitely some limitations. For example, correcting large volume deficiencies, electrolyte imbalances and colloids such as blood products can’t be done subcutaneously.
I don’t think this has to be an all-or-nothing proposition — this knowledge can lead to opportunities in locations where this can be given to save money.
For more information:
Michael Tang, MD, can be reached at The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030; email: mjtang@mdanderson.org.
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