Advertisement

Home is best. Self-administration of subcutaneous Bortezomib at home in patients with multiple myeloma - A mixed method study

  • Jannie Kirkegaard
    Affiliations
    Department of Hematology, Odense University Hospital, Kloevervaenget 10, 12th floor, 5000, Odense C, Denmark
    Search for articles by this author
  • Birgitte Wolf Lundholm
    Affiliations
    Department of Hematology, Odense University Hospital, Kloevervaenget 10, 12th floor, 5000, Odense C, Denmark
    Search for articles by this author
  • Tine Rosenberg
    Correspondence
    Corresponding author. Odense University Hospital, Kloevervaenget 10, 12th floor, 5000, Odense C, Denmark.
    Affiliations
    Department of Hematology, Odense University Hospital, Kloevervaenget 10, 12th floor, 5000, Odense C, Denmark

    Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19.3, DK-5000, Odense C, Denmark
    Search for articles by this author
  • Thomas Lund
    Affiliations
    Department of Hematology, Odense University Hospital, Kloevervaenget 10, 12th floor, 5000, Odense C, Denmark

    Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19.3, DK-5000, Odense C, Denmark
    Search for articles by this author
  • Michael Tveden Gundesen
    Affiliations
    Department of Hematology, Odense University Hospital, Kloevervaenget 10, 12th floor, 5000, Odense C, Denmark

    Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19.3, DK-5000, Odense C, Denmark
    Search for articles by this author
  • Karin Brochstedt Dieperink
    Affiliations
    Research Unit of Oncology, The Academy of Geriatric Cancer Research Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark

    Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19.3, DK-5000, Odense C, Denmark

    Family Focused Healthcare Research Center (FaCe), University of Southern Denmark, J.B. Winsløws Vej 19.3, DK-5000, Odense C, Denmark
    Search for articles by this author
Open AccessPublished:September 06, 2022DOI:https://doi.org/10.1016/j.ejon.2022.102199

      Highlights

      • Self-administration of SC Bortezomib at home is advantageous for both patients with MM and healthcare professionals.
      • Self-administration is timesaving for patients and healthcare professionals.
      • Treatment relocation is feasible and safe.

      Abstract

      Objectives

      To examine the perspectives of patients and healthcare professionals of self-administration of subcutaneous (SC) injection of Bortezomib in the homes of patients with Multiple Myeloma (MM), and to assess organizational aspects.

      Methods

      A prospective, clinical, parallel mixed-method design with a qualitative core and a quantitative supplementary component was conducted at a single hematological centre in Denmark. Qualitative data were obtained from individual, semi-structured interviews with patients (n = 10) and a focus group interview with healthcare professionals (n = 5); data were analyzed using a hermeneutic approach. Quantitative data were acquired from time registrations performed by patients and nurses and descriptively analyzed applying a micro-costing approach, using cost data per individual.

      Results

      In general, patients and healthcare professionals were pleased with self-administration as patient empowerment increased. Qualitative findings yielded three themes: “Home is best”, “Everyone is different”, and “Safety first”. Quantitative data were confirmative and revealed self-administration to be time saving for patients and nurses. In a Danish context, delivery of the medicine to the patient's home was slightly more expensive than administration at the hospital.

      Conclusions

      Self-administration of SC Bortezomib in the homes of patients with MM is advantageous for patients and healthcare professionals. It is feasible, safe, and timesaving. These advantages come with a negligible increase in expenses.

      Keywords

      1. Introduction

      Multiple Myeloma (MM) is the second most common hematological cancer, with a world-wide incidence of 174,404 in 2020 () and a median age at diagnosis of 66–70 years (
      • Kazandjian D.
      Multiple myeloma epidemiology and survival: a unique malignancy.
      ). Though great improvements have been achieved in the treatment of MM, there is still no curative treatment. However, usually the disease is very sensitive to treatment, and patients can have periods, where they do not require treatment (
      • Kumar S.K.
      • Dimopoulos M.A.
      • Kastritis E.
      • Terpos E.
      • Nahi H.
      • Goldschmidt H.
      • Hillengass J.
      • Leleu X.
      • Beksac M.
      • Alsina M.
      • Oriol A.
      • Cavo M.
      • Ocio E.M.
      • Mateos M.V.
      • O'donnell E.K.
      • Vij R.
      • Lokhorst H.M.
      • Van De Donk N.
      • Min C.
      • Mark T.
      • Turesson I.
      • Hansson M.
      • Ludwig H.
      • Jagannath S.
      • Delforge M.
      • Kyriakou C.
      • Hari P.
      • Mellqvist U.
      • Usmani S.Z.
      • Dytfeld D.
      • Badros A.Z.
      • Moreau P.
      • Kim K.
      • Otero P.R.
      • Lee J.H.
      • Shustik C.
      • Waller D.
      • Chng W.J.
      • Ozaki S.
      • Lee J.J.
      • De La Rubia J.
      • Eom H.S.
      • Rosinol L.
      • Lahuerta J.J.
      • Sureda A.
      • Kim J.S.
      • Durie B.G.M.
      Natural history of relapsed myeloma, refractory to immunomodulatory drugs and proteasome inhibitors: a multicenter IMWG study.
      ;
      • Costa L.J.
      • Chhabra S.
      • Medvedova E.
      • Dholaria B.R.
      • Schmidt T.M.
      • Godby K.N.
      • Silbermann R.
      • Dhakal B.
      • Bal S.
      • Giri S.
      • D’souza A.
      • Hall A.
      • Hardwick P.
      • Omel J.
      • Cornell R.F.
      • Hari P.
      • Callander N.S.
      Daratumumab, carfilzomib, lenalidomide, and dexamethasone with minimal residual disease response-adapted therapy in newly diagnosed multiple myeloma.
      ).
      With improved survival, it is relevant to focus on initiatives for improving quality of life and independence for the patients. In some countries, including Denmark, treatment of MM is centralized at few, specialized hematology departments and many patients spend a lot of time on transportation. Consequently, it can be difficult to return to a normal everyday life (
      • Fitch M.I.
      • Nicoll I.
      Returning to work after cancer: survivors', caregivers', and employers' perspectives.
      ). Thus, it seems relevant to evaluate the possibility of reducing patients' visits to the hospital, e.g. by relocating treatment from the hospital to the patients’ homes (
      • Johansson E.
      • Langius-Eklof A.
      • Engervall P.
      • Wredling R.
      Patients' experience of ambulatory self-administration of pamidronate in multiple myeloma.
      ;
      • Greenhalgh T.
      • Shaw S.
      • Wherton J.
      • Vijayaraghavan S.
      • Morris J.
      • Bhattacharya S.
      • Hanson P.
      • Campbell-Richards D.
      • Ramoutar S.
      • Collard A.
      • Hodkinson I.
      Real-world implementation of video outpatient consultations at macro, meso, and micro levels: mixed-method study.
      ). This seems particularly important for treatments given frequently over a long period of time, such as subcutaneous (SC) Bortezomib that is used in several MM treatment combinations in patients with newly diagnosed as well as relapsed MM (
      • Durie B.G.M.
      • Hoering A.
      • Abidi M.H.
      • Rajkumar S.V.
      • Epstein J.
      • Kahani S.P.
      • Thakuri M.
      • Reu F.
      • Reynolds C.M.
      • Sexton R.
      • Orlowski R.Z.
      • Barlogie B.
      • Dispenzieri A.
      Bortezomib with lenalidomide and dexamethasone versus lenalidomide and dexamethasone alone in patients with newly diagnosed myeloma without intent for immediate autologous stem-cell transplant (SWOG S0777): a randomised, open-label, phase 3 trial.
      ,
      • Richardson P.G.
      • Oriol A.
      • Beksac M.
      • Liberati A.M.
      • Galli M.
      • Schjesvold F.
      • Lindsay J.
      • Weisel K.
      • White D.
      • Facon T.
      • San Miguel J.
      • Sunami K.
      • O’gorman P.
      • Sonneveld P.
      • Robak P.
      • Semochkin S.
      • Schey S.
      • Yu X.
      • Doerr T.
      • Bensmaine A.
      • Biyukov T.
      • Peluso T.
      • Zaki M.
      • Anderson K.
      • Dimopoulos M.
      Pomalidomide, bortezomib, and dexamethasone for patients with relapsed or refractory multiple myeloma previously treated with lenalidomide (OPTIMISMM): a randomised, open-label, phase 3 trial.
      ;
      • San Miguel J.F.
      • Schlag R.
      • Khuageva N.K.
      • Dimopoulos M.A.
      • Shpilberg O.
      • Kropff M.
      • Spicka I.
      • Petrucci M.T.
      • Palumbo A.
      • Samoilova O.S.
      • Dmoszynska A.
      • Abdulkadyrov K.M.
      • Schots R.
      • Jiang B.
      • Mateos M.-V.
      • Anderson K.C.
      • Esseltine D.L.
      • Liu K.
      • Cakana A.
      • Van De Velde H.
      • Richardson P.G.
      ;
      • Spencer A.
      • Lentzsch S.
      • Weisel K.
      • Avet-Loiseau H.
      • Mark T.M.
      • Spicka I.
      • Masszi T.
      • Lauri B.
      • Levin M.-D.
      • Bosi A.
      • Hungria V.
      • Cavo M.
      • Lee J.-J.
      • Nooka A.K.
      • Quach H.
      • Lee C.
      • Bareto W.
      • Corradini P.
      • Min C.-K.
      • Scott E.M.
      • Chanan-Khan A.A.
      • Horvath N.
      • Capra M.
      • Beksac M.
      • Ovilla R.
      • Jo J.-C.
      • Shin H.-J.
      • Sonneveld P.
      • Soong D.
      • Casneuf T.
      • Chiu C.
      • Amin H.
      • Qi M.
      • Thiyagarajah P.
      • Sasser A.K.
      • Schecter J.M.
      • Mateos M.-V.
      Daratumumab plus bortezomib and dexamethasone versus bortezomib and dexamethasone in relapsed or refractory multiple myeloma: updated analysis of CASTOR.
      ). Studies have shown that it is well-tolerated and only associated with few side effects (
      • Cerchione C.
      • Nappi D.
      • Pareto A.E.
      • Di Perna M.
      • Zacheo I.
      • Picardi M.
      • Pane F.
      • Catalano L.
      Safety and comfort of domestic bortezomib injection in real-life experience.
      ;
      • Gentilini F.
      • Levi A.
      • Federico V.
      • Russo E.
      • Foa R.
      • Petrucci M.T.
      Bortezomib a safe treatment for patients with multiple myeloma and cystic fibrosis.
      ;
      • Vogl D.T.
      • Raje N.
      • Jagannath S.
      • Richardson P.
      • Hari P.
      • Orlowski R.
      • Supko J.G.
      • Tamang D.
      • Yang M.
      • Jones S.S.
      • Wheeler C.
      • Markelewicz R.J.
      • Lonial S.
      Ricolinostat, the first selective histone deacetylase 6 inhibitor, in combination with bortezomib and dexamethasone for relapsed or refractory multiple myeloma.
      ). Thus, it seems safe to offer patients self-administration of SC Bortezomib at home after thorough training.
      Cancer treatment is very cost-intensive both in relation to price and time spent in the healthcare system (
      • Meropol N.J.
      • Schulman K.A.
      Cost of cancer care: issues and implications.
      ). Previous studies showed great economic savings when converting traditional treatment at the hospital to self-administered treatment at the patients’ homes (
      • Lassalle A.
      • Thomare P.
      • Fronteau C.
      • Mahe B.
      • Jube C.
      • Blin N.
      • Voldoire M.
      • Dubruille V.
      • Tessoulin B.
      • Touzeau C.
      • Chauvin C.
      • Loirat M.
      • Lok A.
      • Bourcier J.
      • Lestang E.
      • Mocquet R.
      • Barbarot V.
      • Moreau P.
      Home administration of bortezomib in multiple myeloma is cost-effective and is preferred by patients compared with hospital administration: results of a prospective single-center study.
      ;
      • Touati M.
      • Lamarsalle L.
      • Moreau S.
      • Vergnenegre F.
      • Lefort S.
      • Brillat C.
      • Jeannet L.
      • Lagarde A.
      • Daulange A.
      • Jaccard A.
      • Vergnenegre A.
      • Bordessoule D.
      Cost savings of home bortezomib injection in patients with multiple myeloma treated by a combination care in Outpatient Hospital and Hospital care at Home.
      ). Due to increased pressure on the healthcare system, rethinking the organization of future anti-cancer treatment seems particularly important, benefitting both patients and society as a whole (
      • Challinor J.M.
      • Alqudimat M.R.
      • Teixeira T.O.A.
      • Oldenmenger W.H.
      Oncology nursing workforce: challenges, solutions, and future strategies.
      ).
      However, although it seems beneficial and safe to relocate the treatment (
      • Cerchione C.
      • Nappi D.
      • Pareto A.E.
      • Di Perna M.
      • Zacheo I.
      • Picardi M.
      • Pane F.
      • Catalano L.
      Safety and comfort of domestic bortezomib injection in real-life experience.
      ;
      • Gentilini F.
      • Levi A.
      • Federico V.
      • Russo E.
      • Foa R.
      • Petrucci M.T.
      Bortezomib a safe treatment for patients with multiple myeloma and cystic fibrosis.
      ;
      • Vogl D.T.
      • Raje N.
      • Jagannath S.
      • Richardson P.
      • Hari P.
      • Orlowski R.
      • Supko J.G.
      • Tamang D.
      • Yang M.
      • Jones S.S.
      • Wheeler C.
      • Markelewicz R.J.
      • Lonial S.
      Ricolinostat, the first selective histone deacetylase 6 inhibitor, in combination with bortezomib and dexamethasone for relapsed or refractory multiple myeloma.
      ;
      • Lassalle A.
      • Thomare P.
      • Fronteau C.
      • Mahe B.
      • Jube C.
      • Blin N.
      • Voldoire M.
      • Dubruille V.
      • Tessoulin B.
      • Touzeau C.
      • Chauvin C.
      • Loirat M.
      • Lok A.
      • Bourcier J.
      • Lestang E.
      • Mocquet R.
      • Barbarot V.
      • Moreau P.
      Home administration of bortezomib in multiple myeloma is cost-effective and is preferred by patients compared with hospital administration: results of a prospective single-center study.
      ;
      • Touati M.
      • Lamarsalle L.
      • Moreau S.
      • Vergnenegre F.
      • Lefort S.
      • Brillat C.
      • Jeannet L.
      • Lagarde A.
      • Daulange A.
      • Jaccard A.
      • Vergnenegre A.
      • Bordessoule D.
      Cost savings of home bortezomib injection in patients with multiple myeloma treated by a combination care in Outpatient Hospital and Hospital care at Home.
      ), success highly depends on the patients' and the healthcare professionals’ experience of the initiative. Therefore, we find it of the utmost importance to examine their perspectives, which, to the best of our knowledge, has not yet been done in combination with an analysis of their time spent. Therefore, the aims of the present study were primarily to examine the experiences of patients and healthcare professionals, highlighting the benefits and challenges of treatment relocation, and secondly to assess organizational aspects.

      2. Methods

      2.1 Design

      We used a prospective, clinical, parallel mixed-method design with a qualitative core and a quantitative supplementary component (
      • Chiang-Hanisko N.D., L.
      • Dyess S.
      • Piyakong D.
      • Liehr P.
      Guidance for using mixed methods design in nursing practice research.
      ). This design was chosen intentionally to combine qualitative and quantitative data, to maximize the strengths and minimize the weaknesses of each, using systematic integrative procedures.
      This paper is reported according the EQUATOR's Standards for Reporting Qualitative Research (SRQR) 21-item guideline (

      Journals.Lww.Com The EQUATOR's Standards for Reporting Qualitative Research (SRQR) 21-item Guideline.

      ).

      2.2 Setting and study population

      The study was conducted at the Department of Hematology at Odense University Hospital (OUH), Denmark, between January 2020 and May 2021. For the interviews, we expected to include 8–10 patients, depending on data saturation (
      • Moser A.
      • Korstjens I.
      Series: practical guidance to qualitative research. Part 3: sampling, data collection and analysis.
      ;
      • Francis J.J.
      • Johnston M.
      • Robertson C.
      • Glidewell L.
      • Entwistle V.
      • Eccles M.P.
      • Grimshaw J.M.
      What is an adequate sample size? Operationalising data saturation for theory-based interview studies.
      ). If new perspectives had emerged during the last two interviews, further two patients would have been included.
      Inclusion criteria comprised physical and cognitive ability to self-administer SC Bortezomib at home and willingness to participate in two semi-structured interviews. Patients could not be included if they were enrolled in other clinical trials. Physicians and nurses in the outpatient clinic identified patients eligible for inclusion and thereafter, a study nurse with no prior knowledge of the patients, informed them about the study, obtained their written informed consent, and performed the inclusion.
      The patients were followed for two treatment cycles. Bortezomib was administered four times in each 28-day cycle. In the first treatment cycle, patients were trained in self-administration at the hospital, while in cycle two, they alternated between treatment at home and at the hospital (Fig. 1). Before each administration, a nurse called the patients to ensure that they were physically fit for treatment. Once confirmed, the syringe with Bortezomib ready for SC administration was ordered from the hospital Pharmacy and sent by courier to the patient's home address or delivered to the outpatient clinic the next day.
      The study population also included healthcare professionals involved in prescribing or administering the treatment courses. Inclusion criterion for healthcare professionals was minimum two years of experience in hematology. Both doctors and nurses were eligible for inclusion.

      2.3 Data collection

      Qualitative data were obtained from two individual, semi-structured interviews with patients and one focus group interview with healthcare professionals. To clarify expectations and possible concerns, patients were interviewed before starting study treatment. Further, patients were interviewed after two treatment cycles to elucidate advantages and disadvantages of self-administration at home. Patient interviews were conducted on the telephone at a time point chosen by the patient.
      To obtain the perspectives of healthcare professionals, a focus group interview was conducted at the end of the study.
      All interviews were conducted in Danish by J.K. and B.W.L. To ensure a complete dataset, all interviews were recorded and transcribed verbatim. Based on an in-depth literature review and discussions with the User Council and former patients at the Department of Hematology, OUH, semi-structured interview guides were prepared for the interviews (Supplementary File 1). Interview guides contained mainly open-ended questions covering demographics, course of disease, experience of being a patient at the department, expectations of self-administration of SC Bortezomib at home (first patient interview) advantages, and disadvantages of self-administration at home (second patient interview and focus group interview).
      Quantitative data were obtained from time registrations performed by patients and healthcare professionals. Both parties registered time spent on treatment in cycle two. For patients, this included time spent on transport, waiting at the clinic, receiving the medicine at home, and the actual treatment time. Nurses registered time spent with the patients and administrative activities, such as phone calls and preparation. Finally, time spent on distributing the medicine to the patients’ homes was estimated by the hospital pharmacy.

      2.4 Data analysis

      First, with the purpose to understand patient and health care professionals perspectives of home treatment, qualitative data were analyzed applying a hermeneutic approach through the use of systematic text condensation (
      • Malterud K.
      Systematic text condensation: a strategy for qualitative analysis.
      ).
      Second, quantitative data were descriptively analyzed applying a micro-costing approach, using cost data per individual (
      • Vestergaard A.S.
      • Hansen L.
      • Sorensen S.S.
      • Jensen M.B.
      • Ehlers L.H.
      Is telehealthcare for heart failure patients cost-effective? An economic evaluation alongside the Danish TeleCare North heart failure trial.
      ;
      • Sorensen C.A.
      • De Thurah A.
      • Lisby M.
      • Olesen C.
      • Sorensen S.B.
      • Enemark U.
      Cost-consequence analysis of self-administration of medication during hospitalization: a pragmatic randomized controlled trial in a Danish hospital setting.
      ). The total costs consisted of the patients' travel costs and nurses' time spent on treatment. Travel costs were set at EUR 0.3 per KM from the patient's home address to the hospital and back. In Denmark, travel expenses are covered for the entire distance for retired patients, while for employed patients, regardless of sick leave, travel expenses are covered from 50 KM. The hourly wage for nurses was set at EUR 32.3, in 2020 prices. Numerical variables were presented as mean (range) and categorical variables as numbers and percentages. Data were analyzed using Stata BE 17.
      Last, meta-inference between the two analyses was explored through explicit and thorough discussion of qualitative and quantitative findings, leading to a more nuanced understanding of the different perspectives on self-administration of SC Bortezomib (
      • Klassen A.C.
      • Creswell J.
      • Plano Clark V.L.
      • Smith K.C.
      • Meissner H.I.
      Best practices in mixed methods for quality of life research.
      ,
      • Chiang-Hanisko N.D., L.
      • Dyess S.
      • Piyakong D.
      • Liehr P.
      Guidance for using mixed methods design in nursing practice research.
      ).

      2.5 Ethics

      According to the Danish National Research Ethics Committee, the study did not require approval. The study was registered at the Danish Data Protection Agency with no. 19/41516 and at ClinicalTrials.gov, ID: NCT05163405.

      3. Results

      3.1 Participants

      Between December 2019 and May 2021, 20 patients with MM were invited to participate in this study. Of these, 13 were included, and 10 (4 female) with a median age of 71.4 years completed the study (Table 1). Reasons for dropout were side effects (n = 2) and start of new intravenous treatment (n = 1). Reasons for non-inclusion were lack of energy to participate in the interviews (n = 6) and lack of time due to employment (n = 1). For half of the patients (n = 5), Bortezomib was part of first-line treatment, while for the other half, it was part of relapse treatment. Seventy-two injections were administered; 24 at home and 48 at the hospital. No injections were discarded. Full data were available for 9/10 patients and 8/10 nurse-registrations. Two patients were still in the work force. 4/10 patients lived ˂25 KM from the hospital, 2/10 patients lived 25–100 KM, and 4/10 patients lived >100 KM from the hospital.
      Table 1Patient characteristics. Patients marked with * had Bortezomib as their first-line of treatment.
      Patient no.Age (years)SexEmploymentYears since diagnosis
      173MFarmer. Retired10
      281MElectrician, mechanic. Retired5
      379MFarmer. Retired6
      473MFarmer. Retired5
      559MOwn printing business.

      Early retirement
      2
      671FFarmer's wife.

      Still own the farm
      1*
      757FFormer lab technician; now accountant.

      On sick leave
      1*
      884FShop assistant. Retired0.5*
      969MHigh school teacher. Retired1*
      1068FFactory worker. Retired0.5*
      In the focus group interview, two physicians with an average experience in hematology of 16.5 years and three nurses with an average experience of 6.7 years in hematology were included.

      3.2 Patient and healthcare perspectives

      The interviews revealed three key themes; “Home is best”, “Everyone is different”, and “Safety first” (Fig. 2):

      3.3 Home is best

      Patients were pleased to avoid the transportation to and from the hospital; they specifically highlighted the time saved. They stated that they were tired of their many visits to the hospital. Furthermore, they reported challenges in connection with receiving treatment at the hospital regarding their general condition and their ability to drive home after the treatment, finding parking, driving in bad conditions, walking from the parking space to the clinic, having to show up at a certain time, and the drive being expensive. They said that treatment at home had increased their quality of life and given them more flexibility.“ … it means more peace and quiet in my everyday life, because it takes an entire morning to drive to the hospital and back again, so there will be some more peace and quiet." (male, patient, 74 years)“It's the transportation and it's the time consumption. You have to get there, and the wait that is out there - because there is a wait. So I think, here you get it at home and you can inject yourself within 3–4 minutes, and I think that works fine, and I don’t have to drive anywhere." (female, patient, 71 years)
      In spite of general satisfaction, one patient stated that if he could choose freely, he would rather receive the treatment at the local hospital than administer it himself. The healthcare professionals’ statements supported this:“It is very individual how each experience is. The vast majority think it's freedom not to have to drive all the way over here. Especially those who come a really long way." "Yes, they still have to be home at the time the syringe arrives, but they don't have to spend time on the road." (female, nurse, 11 years experience)
      Patients were equally confident in self-administration as going to the hospital. They had no concerns about injecting themselves. In case of any questions or doubt, patients were aware that they could contact the hospital. However, no patients made use of this, but the option made them feel safe.
      Some patients felt that they would easily be able to self-administer the medicine at home more frequently. However, they understood that the healthcare professionals needed to see them. The patients’ need for feedback decreased with time, as they became more confident with the treatment and the situation.

      3.4 Everyone is different

      The healthcare professionals found it challenging to inform newly diagnosed patients about the possibility of self-administration, as some patients shut down when receiving a cancer diagnosis and cannot relate to additional information.
      The healthcare professionals suggested that patients be informed about self-administration after the first treatment-cycle. By then, patients have observed how to administer the treatment, and the healthcare professionals have gotten to know the patients.
      One patient rejected to participate due to general malaise the first time she was asked, but was included later on. She recommended re-inviting patients who rejected participation at the first invitation. She also mentioned the importance of timing the invitation.“Yes, when I was hospitalized and felt bad, and it just didn't suit me at all because I was bad-bad, so it’s OK to ask again, because it's not like you don't want to, but it's because you don’t have the capacity to consider these things at such a time." (female, patient, 58 years)
      No patients had to go to the hospital for treatment instead of administering it at home as scheduled. The healthcare professionals reported that the patients were compliant; only minor problems arose once the patients had started treatment. Physicians found it helpful that the nurses identified possible candidates before consultations. This, they said, brought the opportunity of self-administration into focus at the consultation. They suggested turning self-administration into standard treatment with the possibility of opting out.
      Initially, the physicians were concerned if patients scheduled for self-administration would be converted to administration at the hospital on the day of administration, as these would come “on top” of the planned program. However, they pointed out that self-administration in fact released time for new patients and patients with specific needs, since no doses were reconverted.

      3.4.1 Safety first

      The majority of patients considered the training period to be optimal and stated that they became confident in self-administration. The training period also allowed the healthcare professionals to observe the patients’ abilities to manage self-administration. Several of the patients (n = 5) had experience with Bortezomib from previous treatment at the hospital, which made self-administration easier for them.“Whether it's one location or another, it doesn’t really matter, but it's easy because it comes packed and ready, and I'm not nervous about doing it wrong". “I feel as safe, as when I'm at the hospital" (female, patient, 85 years)
      Patients perceived the healthcare professionals as nice and welcoming. Overall, patients felt well-informed and safe.“I have also experienced some who say no until I explain very clearly that it is our responsibility because they feel, wow, that is a big responsibility. But I say to them; "It's not your responsibility, it's still our responsibility." (female, nurse, 4 years experience)
      All treatments were delivered and administered as scheduled, and all except one were delivered on time. One patient pointed out that he was surprised that he was not required to sign for receipt of the medicine at delivery.
      Despite fewer appointments at the hospital, none of the patients expressed a need for extra contact to the healthcare system. Nor did the healthcare professionals experience that the patients had a greater need for contact or sparing at their planned visits.

      3.5 Organizational aspects

      The organizational aspects were evaluated by time spent on administration – for patients and nurses. Also, the total socio-economic expenses for self-administration and total expenses for hospital administration were calculated.
      On average, patients spent 245 min, 95% confidence interval (CI) (172.9–317), on each administration at the hospital. By comparison, they spent on average 17.6 min, 95% CI (4.8–30.4) on each self-administration at home (p = 0.0000). This means an average savings of 235.4 min per administration (Fig. 3).
      Fig. 3
      Fig. 3Nurses' time spent on SC Bortezomib administration. The dot at the self-administration represents an outlier.
      On average, nurses spent 34.8 min, 95% CI (23.4–46.2) per administration at the hospital and 13.9 min, 95% CI (9.9–17.6) per patient self-administration at home (p = 0.0012). This is an average savings of 20.4 min per administration. Further, the pharmacy estimated a time consumption of 3–5 min on each distribution, regardless of treatment location (Fig. 4).
      Fig. 4
      Fig. 4Patients' time spent on SC Bortezomib administration. The dot at self-administration represents an outlier.

      3.6 Economy

      The cost of Bortezomib (EUR 352.9/dose) and expenses at the hospital pharmacy distribution were the same regardless of location (EUR 49.7/dose). The average cost of delivering the medicine to patients' homes was EUR 53.8/delivery, whereas the average cost for transporting the patients to the hospital was EUR 34.3/visit. Expenses for nursing salary were on average EUR 20.8 during an outpatient visit; for self-administration in the patients' own homes, it was EUR 7.8. This means a total socio-economic cost of EUR 464.3 for self-administration and EUR 457.8 for hospital administration, leading to an additional expenditure of EUR 6.5 per administration at home (Fig. 5).
      Fig. 5
      Fig. 5Total hospital expenses for administration of SC Bortezomib.

      3.7 Meta-inference between qualitative and quantitative data

      The remarkable timesavings revealed by our quantitative analysis confirmed the findings from the qualitative interviews, in which patients and healthcare professionals reported great satisfaction with self-administration, primarily due to timesavings and increased flexibility.

      4. Discussion

      To our knowledge, this is the first study concurrently examining the perspectives of patients and healthcare professionals, timesaving, and socio-economic aspects when relocating SC Bortezomib from an outpatient clinic to self-administration in the patients’ homes. Previous studies have primarily focused on safety (
      • Leveque D.
      Subcutaneous administration of anticancer agents.
      ;
      • Cerchione C.
      • Nappi D.
      • Pareto A.E.
      • Di Perna M.
      • Zacheo I.
      • Picardi M.
      • Pane F.
      • Catalano L.
      Safety and comfort of domestic bortezomib injection in real-life experience.
      ;
      • Lamm W.
      • Drach-Schauer B.
      • Eder S.
      • Drach J.
      Bortezomib administered subcutaneously is well tolerated in bortezomib-based combination regimens used in patients with multiple myeloma.
      ;
      • Waight C.C.
      • Cain R.
      Authorising bortezomib treatment prior to reviewing haematology results: a step toward home administration.
      ), and patient perspectives have been evaluated using quality of life questionnaires (
      • Lassalle A.
      • Thomare P.
      • Fronteau C.
      • Mahe B.
      • Jube C.
      • Blin N.
      • Voldoire M.
      • Dubruille V.
      • Tessoulin B.
      • Touzeau C.
      • Chauvin C.
      • Loirat M.
      • Lok A.
      • Bourcier J.
      • Lestang E.
      • Mocquet R.
      • Barbarot V.
      • Moreau P.
      Home administration of bortezomib in multiple myeloma is cost-effective and is preferred by patients compared with hospital administration: results of a prospective single-center study.
      ), while in our study, individual interviews have been conducted to ensure comprehensive evaluation. Previous economic analyses have assessed cost differences when comparing SC Bortezomib administration at the hospital to home administration performed by a visiting nurse (
      • Lassalle A.
      • Thomare P.
      • Fronteau C.
      • Mahe B.
      • Jube C.
      • Blin N.
      • Voldoire M.
      • Dubruille V.
      • Tessoulin B.
      • Touzeau C.
      • Chauvin C.
      • Loirat M.
      • Lok A.
      • Bourcier J.
      • Lestang E.
      • Mocquet R.
      • Barbarot V.
      • Moreau P.
      Home administration of bortezomib in multiple myeloma is cost-effective and is preferred by patients compared with hospital administration: results of a prospective single-center study.
      ).
      Patients reported increased empowerment and co-responsibility. They did not feel burdened by having the responsibility for their own treatment; on the contrary, they liked taking responsibility for themselves in a situation where they were otherwise highly dependent on others. This is in keeping with previous studies showing that patients experienced increased quality of life and well-being along with heightened daily activity levels and that they appreciated a sense of increased freedom and independence when using home treatment (
      • Johansson E.
      • Langius-Eklof A.
      • Engervall P.
      • Wredling R.
      Patients' experience of ambulatory self-administration of pamidronate in multiple myeloma.
      ;
      • Hendricks A.M.
      • Loggers E.T.
      • Talcott J.A.
      Costs of home versus inpatient treatment for fever and neutropenia: analysis of a multicenter randomized trial.
      ). However, though patients were generally pleased with self-administration, one patient put the peace of mind she experienced when going to the hospital for every second administration into words: if she could choose freely, she would prefer continuing this schedule to maintain close contact with the hospital. This highlights the importance of open dialogue between patients and healthcare professionals to ensure the best possible treatment course for the individual patient (
      • Partridge A.H.
      • Avorn J.
      • Wang P.S.
      • Winer E.P.
      Adherence to therapy with oral antineoplastic agents.
      ;
      • Ruddy K.
      • Mayer E.
      • Partridge A.
      Patient adherence and persistence with oral anticancer treatment.
      ).
      In order to ensure safe self-administration, identifying the right candidates is paramount. In our study, nurses and physicians generally agreed on possible candidates, and there was no need for relocating any treatments to the hospital. We found the timing of the invitation to participate to be of the utmost importance for both patients and healthcare professionals. From the patients' perspectives, their general condition at the time of the invitation was important for their decision. For the healthcare professionals, knowledge of the individual patient was crucial. This emphasizes the importance of the training program at the hospital during the first treatment-cycle. Rodin et al. have previously demonstrated that receiving a cancer diagnosis might induce traumatic stress (
      • Rodin G.
      • Yuen D.
      • Mischitelle A.
      • Minden M.D.
      • Brandwein J.
      • Schimmer A.
      • Marmar C.
      • Gagliese L.
      • Lo C.
      • Rydall A.
      • Zimmermann C.
      Traumatic stress in acute leukemia.
      ). This is consistent with the physicians’ description of patients shutting down when receiving their diagnosis. However, though physicians found it challenging to inform newly diagnosed patients about the possibility of self-administration, half of the patients in our study were newly diagnosed. They had no need for treatment relocation and were generally satisfied with the treatment course, indicating that despite a very stressful situation, they possess the resources needed for self-administration. In parallel, it can be questioned if the patients who were not considered suitable for self-administration, in fact were the patients with the greatest need for home treatment, and if further initiatives could be organized to provide them the opportunity of home treatment.
      To the best of our knowledge, no studies have evaluated if one category of patients is better than another in self-administering their medication. In the present study, we found that all patients; men and women, young and old, were able to complete the self-administration, so despite the group of patients predominantly being old, self-administration was successful. We therefore believe that it is possible to expand self-administration to more patient groups, but future studies are needed to clarify this.
      As the study was conducted during the Covid-19 pandemic, we expected patients to mention feeling safer not being exposed to infectious diseases such as Covid-19 at the hospital. However, though it seems particularly important for patients with MM who are at increased risk of infection due to immunosuppression (
      • Terpos E.
      • Engelhardt M.
      • Cook G.
      • Gay F.
      • Mateos M.V.
      • Ntanasis-Stathopoulos I.
      • Van De Donk N.
      • Avet-Loiseau H.
      • Hajek R.
      • Vangsted A.J.
      • Ludwig H.
      • Zweegman S.
      • Moreau P.
      • Einsele H.
      • Boccadoro M.
      • San Miguel J.
      • Dimopoulos M.A.
      • Sonneveld P.
      Management of patients with multiple myeloma in the era of COVID-19 pandemic: a consensus paper from the European Myeloma Network (EMN).
      ), no patients addressed this; not even those who were asked directly.
      When any medication is given at the hospital, the identity of the patient is double-checked. Therefore, it is worrying that patients report having the medication delivered without their identity being checked and without signing for receipt. To ensure that the right person receives the medication, it is advisable that standard operating procedures for medication delivery are prepared and implemented.

      4.1 Organizational aspects

      We found self-administration to be timesaving for both patients and nurses (
      • Broetje S.
      • Jenny G.J.
      • Bauer G.F.
      The key job demands and resources of nursing staff: an integrative review of reviews.
      ). However, unexpectedly, we saw great variation in the time registrations, which might have biased the results. Especially for the patients, timesavings were remarkable, but also nurses had extra time released. This must be considered a great gain in light of the current shortage of nurses (
      • Turale S.
      • Meechamnan C.
      • Kunaviktikul W.
      Challenging times: ethics, nursing and the COVID-19 pandemic.
      ).
      Further, our analysis revealed that delivering the medicine to the patients was slightly more expensive than administration at the hospital; primarily due to high delivery costs. Thus, to make home administration more viable, this expense must be reduced. This might be achieved by agreements on dispensing the medicine from hospitals or pharmacies closer to the patients. However, the issue of delivery costs must be interpreted in the specific Danish context.
      Since the majority of the patients included in our study were no longer on the labor market, their time spent was difficult to price; therefore their expenses were not included in the economic analysis. However, as the 5-year survival rate for MM is only 30.6% (), patients' timesaving seems very important and should be prioritized. Moreover, as quality of life has no fixed price, it is difficult to quantify, and it could be argued that the positive experiences of both patients and healthcare professionals compensate for the minor additional expenditure. Further, the analyses could have been expanded by the inclusion of physicians’ salaries, hospital overhead costs, indirect costs from lost earnings of the relatives required to drive the patients to the hospital etc. that could have affected the results of the analyses. However, in this study, focus has primarily been to examine the perspectives of patients and healthcare professionals, and therefore the socio-economic analyses have been made from this perspective.

      4.2 Strengths and limitations

      The most important strength of this study is that we simultaneously have elucidated different perspectives of relocating SC Bortezomib from the hospital to the patients’ homes. As such, our quantitative data back up our qualitative data, bringing great synergy to our results. However, the quantitative data brought our attention to the aspect of economy not being sufficiently covered in our qualitative interviews. This should be expanded on in future studies. During the analysis, we looked for nuances that could bring our preunderstanding into play. This included making great efforts to emphasize surprising findings, such as the finding of self-administration being slightly more expensive than administration at the hospital.
      We aimed for maximum variation in the group of participants, but as patients were continually included, being selective was not an option. With regard to age and gender, maximal variation was achieved (,
      • DMSG
      Diagnostik Og Behandling Af Myelomatose.
      ), but in the area of education, we saw a predominance of farmers and only few with a higher education (
      • Goodwin J.A.
      • Coleman E.A.
      • Sullivan E.
      • Easley R.
      • Mcnatt P.K.
      • Chowdhury N.
      • Stewart C.B.
      Personal financial effects of multiple myeloma and its treatment.
      ).
      Obviously, patients needing other simultaneous parenteral treatment at hospital, e.g. I.V. bisphosphonate, immunoglobulins, chemotherapy or S.C. Daratumumab, would not be selected for home-based Bortezomib on the same dates, but because Bortezomib in many regimens are given twice weekly, there is an obvious opportunity to give Bortezomib treatment alternating between the patients’ homes and in the clinic. Moreover, in several regimens, the partner drugs are administered orally, allowing even more use of home-based Bortezomib treatment (
      • Durie B.G.M.
      • Hoering A.
      • Abidi M.H.
      • Rajkumar S.V.
      • Epstein J.
      • Kahani S.P.
      • Thakuri M.
      • Reu F.
      • Reynolds C.M.
      • Sexton R.
      • Orlowski R.Z.
      • Barlogie B.
      • Dispenzieri A.
      Bortezomib with lenalidomide and dexamethasone versus lenalidomide and dexamethasone alone in patients with newly diagnosed myeloma without intent for immediate autologous stem-cell transplant (SWOG S0777): a randomised, open-label, phase 3 trial.
      ;
      • Richardson P.G.
      • Oriol A.
      • Beksac M.
      • Liberati A.M.
      • Galli M.
      • Schjesvold F.
      • Lindsay J.
      • Weisel K.
      • White D.
      • Facon T.
      • San Miguel J.
      • Sunami K.
      • O’gorman P.
      • Sonneveld P.
      • Robak P.
      • Semochkin S.
      • Schey S.
      • Yu X.
      • Doerr T.
      • Bensmaine A.
      • Biyukov T.
      • Peluso T.
      • Zaki M.
      • Anderson K.
      • Dimopoulos M.
      Pomalidomide, bortezomib, and dexamethasone for patients with relapsed or refractory multiple myeloma previously treated with lenalidomide (OPTIMISMM): a randomised, open-label, phase 3 trial.
      ;
      • San Miguel J.F.
      • Schlag R.
      • Khuageva N.K.
      • Dimopoulos M.A.
      • Shpilberg O.
      • Kropff M.
      • Spicka I.
      • Petrucci M.T.
      • Palumbo A.
      • Samoilova O.S.
      • Dmoszynska A.
      • Abdulkadyrov K.M.
      • Schots R.
      • Jiang B.
      • Mateos M.-V.
      • Anderson K.C.
      • Esseltine D.L.
      • Liu K.
      • Cakana A.
      • Van De Velde H.
      • Richardson P.G.
      ).
      The main limitation of the study is the relatively small number of participants. Potentially, this could have caused a lack of diversity in the patient group. During the interviews, we saw clear data saturation after seven patients, and nothing new was brought to light by interviewing further three patients.

      5. Conclusion

      Self-administration of SC Bortezomib in the homes of patients with MM is advantageous for patients and healthcare system alike. For both parties, self-administration is timesaving compared to traditional administration at the hospital. The logistics of home delivery and administration work flawlessly, as all administrations were performed as planned, and no extra visits to the hospital were required. In our Danish context, the cost of bringing the medicine to the patients was slightly higher than the cost of transporting the patients to the hospital, but the timesavings for seriously ill patients, their quality of life and well-being should reasonably be prioritized.

      CRediT authorship contribution statement

      Jannie Kirkegaard: Conceptualization, Methodology, Investigation, Data curation, Writing – original draft, Writing – review & editing, Visualization, Project administration. Birgitte Wolf Lundholm: Conceptualization, Methodology, Investigation, Data curation, Writing – original draft, Writing – review & editing. Tine Rosenberg: Data curation, Writing – review & editing, Funding acquisition. Thomas Lund: Conceptualization, Methodology, Resources, Supervision. Michael Tveden Gundesen: Formal analysis, Visualization. Karin Brochstedt Dieperink: Methodology, Supervision.

      Declaration of competing interest

      None declared.

      Acknowledgements

      The authors would like to thank the participating patients and their families for their trust and time spent on this project. We would furthermore like to thank participating nurses and physicians at the Hematological day clinic/department at OUH. Finally, the authors would like to thank Vickie Svane Kristensen for language assistance and pharmacist, Maria Nørgaard Lyhne for assisting with data from the pharmacy.
      The study was financially supported by The Danish Cancer Society (EUR 5400) and OUH's Council of Chief Physicians' Research Fund (EUR 5400).
      The project was executed using facilities at OPEN, Open Patient data Explorative Network facilities, Odense University Hospital.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

      References

        • Broetje S.
        • Jenny G.J.
        • Bauer G.F.
        The key job demands and resources of nursing staff: an integrative review of reviews.
        Front. Psychol. 2020; 11: 84
        • Cerchione C.
        • Nappi D.
        • Pareto A.E.
        • Di Perna M.
        • Zacheo I.
        • Picardi M.
        • Pane F.
        • Catalano L.
        Safety and comfort of domestic bortezomib injection in real-life experience.
        Support. Care Cancer. 2018; 26: 3111-3116
        • Challinor J.M.
        • Alqudimat M.R.
        • Teixeira T.O.A.
        • Oldenmenger W.H.
        Oncology nursing workforce: challenges, solutions, and future strategies.
        Lancet Oncol. 2020; 21: e564-e574
        • Chiang-Hanisko N.D., L.
        • Dyess S.
        • Piyakong D.
        • Liehr P.
        Guidance for using mixed methods design in nursing practice research.
        Appl. Nurs. Res. 2016; 31: 1-5
        • Costa L.J.
        • Chhabra S.
        • Medvedova E.
        • Dholaria B.R.
        • Schmidt T.M.
        • Godby K.N.
        • Silbermann R.
        • Dhakal B.
        • Bal S.
        • Giri S.
        • D’souza A.
        • Hall A.
        • Hardwick P.
        • Omel J.
        • Cornell R.F.
        • Hari P.
        • Callander N.S.
        Daratumumab, carfilzomib, lenalidomide, and dexamethasone with minimal residual disease response-adapted therapy in newly diagnosed multiple myeloma.
        J. Clin. Oncol. 2021; 40: 2901-2912
        • DMSG
        Diagnostik Og Behandling Af Myelomatose.
        2017 (Retningslinje 2017 [Online]. Dansk Myelomatose Studie Gruppe (DMSG). Available:)
        • Durie B.G.M.
        • Hoering A.
        • Abidi M.H.
        • Rajkumar S.V.
        • Epstein J.
        • Kahani S.P.
        • Thakuri M.
        • Reu F.
        • Reynolds C.M.
        • Sexton R.
        • Orlowski R.Z.
        • Barlogie B.
        • Dispenzieri A.
        Bortezomib with lenalidomide and dexamethasone versus lenalidomide and dexamethasone alone in patients with newly diagnosed myeloma without intent for immediate autologous stem-cell transplant (SWOG S0777): a randomised, open-label, phase 3 trial.
        Lancet. 2017; 389: 519-527
        • Fitch M.I.
        • Nicoll I.
        Returning to work after cancer: survivors', caregivers', and employers' perspectives.
        Psycho Oncol. 2019; 28: 792-798
        • Francis J.J.
        • Johnston M.
        • Robertson C.
        • Glidewell L.
        • Entwistle V.
        • Eccles M.P.
        • Grimshaw J.M.
        What is an adequate sample size? Operationalising data saturation for theory-based interview studies.
        Psychol. Health. 2010; 25: 1229-1245
        • GCO
        Multiple Myeloma Fact Sheet.
        2020 (Retrieved from)
        • Gentilini F.
        • Levi A.
        • Federico V.
        • Russo E.
        • Foa R.
        • Petrucci M.T.
        Bortezomib a safe treatment for patients with multiple myeloma and cystic fibrosis.
        Mediterr. J. Hematol. Infect. Dis. 2012; 4e2012035
        • Goodwin J.A.
        • Coleman E.A.
        • Sullivan E.
        • Easley R.
        • Mcnatt P.K.
        • Chowdhury N.
        • Stewart C.B.
        Personal financial effects of multiple myeloma and its treatment.
        Cancer Nurs. 2013; 36: 301-308
        • Greenhalgh T.
        • Shaw S.
        • Wherton J.
        • Vijayaraghavan S.
        • Morris J.
        • Bhattacharya S.
        • Hanson P.
        • Campbell-Richards D.
        • Ramoutar S.
        • Collard A.
        • Hodkinson I.
        Real-world implementation of video outpatient consultations at macro, meso, and micro levels: mixed-method study.
        J. Med. Internet Res. 2018; 20: e150
        • Hendricks A.M.
        • Loggers E.T.
        • Talcott J.A.
        Costs of home versus inpatient treatment for fever and neutropenia: analysis of a multicenter randomized trial.
        J. Clin. Oncol. 2011; 29: 3984-3989
        • Johansson E.
        • Langius-Eklof A.
        • Engervall P.
        • Wredling R.
        Patients' experience of ambulatory self-administration of pamidronate in multiple myeloma.
        Cancer Nurs. 2005; 28: 158-165
      1. Journals.Lww.Com The EQUATOR's Standards for Reporting Qualitative Research (SRQR) 21-item Guideline.

        • Kazandjian D.
        Multiple myeloma epidemiology and survival: a unique malignancy.
        Semin. Oncol. 2016; 43: 676-681
        • Klassen A.C.
        • Creswell J.
        • Plano Clark V.L.
        • Smith K.C.
        • Meissner H.I.
        Best practices in mixed methods for quality of life research.
        Qual. Life Res. 2012; 21: 377-380
        • Kumar S.K.
        • Dimopoulos M.A.
        • Kastritis E.
        • Terpos E.
        • Nahi H.
        • Goldschmidt H.
        • Hillengass J.
        • Leleu X.
        • Beksac M.
        • Alsina M.
        • Oriol A.
        • Cavo M.
        • Ocio E.M.
        • Mateos M.V.
        • O'donnell E.K.
        • Vij R.
        • Lokhorst H.M.
        • Van De Donk N.
        • Min C.
        • Mark T.
        • Turesson I.
        • Hansson M.
        • Ludwig H.
        • Jagannath S.
        • Delforge M.
        • Kyriakou C.
        • Hari P.
        • Mellqvist U.
        • Usmani S.Z.
        • Dytfeld D.
        • Badros A.Z.
        • Moreau P.
        • Kim K.
        • Otero P.R.
        • Lee J.H.
        • Shustik C.
        • Waller D.
        • Chng W.J.
        • Ozaki S.
        • Lee J.J.
        • De La Rubia J.
        • Eom H.S.
        • Rosinol L.
        • Lahuerta J.J.
        • Sureda A.
        • Kim J.S.
        • Durie B.G.M.
        Natural history of relapsed myeloma, refractory to immunomodulatory drugs and proteasome inhibitors: a multicenter IMWG study.
        Leukemia. 2017; 31: 2443-2448
        • Lamm W.
        • Drach-Schauer B.
        • Eder S.
        • Drach J.
        Bortezomib administered subcutaneously is well tolerated in bortezomib-based combination regimens used in patients with multiple myeloma.
        Oncology. 2013; 85: 223-227
        • Lassalle A.
        • Thomare P.
        • Fronteau C.
        • Mahe B.
        • Jube C.
        • Blin N.
        • Voldoire M.
        • Dubruille V.
        • Tessoulin B.
        • Touzeau C.
        • Chauvin C.
        • Loirat M.
        • Lok A.
        • Bourcier J.
        • Lestang E.
        • Mocquet R.
        • Barbarot V.
        • Moreau P.
        Home administration of bortezomib in multiple myeloma is cost-effective and is preferred by patients compared with hospital administration: results of a prospective single-center study.
        Ann. Oncol. 2016; 27: 314-318
        • Leveque D.
        Subcutaneous administration of anticancer agents.
        Anticancer Res. 2014; 34: 1579-1586
        • Malterud K.
        Systematic text condensation: a strategy for qualitative analysis.
        Scand. J. Publ. Health. 2012; 40: 795-805
        • Meropol N.J.
        • Schulman K.A.
        Cost of cancer care: issues and implications.
        J. Clin. Oncol. 2007; 25: 180-186
        • Moser A.
        • Korstjens I.
        Series: practical guidance to qualitative research. Part 3: sampling, data collection and analysis.
        Eur. J. Gen. Pract. 2018; 24: 9-18
        • Partridge A.H.
        • Avorn J.
        • Wang P.S.
        • Winer E.P.
        Adherence to therapy with oral antineoplastic agents.
        J. Natl. Cancer Inst. 2002; 94: 652-661
        • Richardson P.G.
        • Oriol A.
        • Beksac M.
        • Liberati A.M.
        • Galli M.
        • Schjesvold F.
        • Lindsay J.
        • Weisel K.
        • White D.
        • Facon T.
        • San Miguel J.
        • Sunami K.
        • O’gorman P.
        • Sonneveld P.
        • Robak P.
        • Semochkin S.
        • Schey S.
        • Yu X.
        • Doerr T.
        • Bensmaine A.
        • Biyukov T.
        • Peluso T.
        • Zaki M.
        • Anderson K.
        • Dimopoulos M.
        Pomalidomide, bortezomib, and dexamethasone for patients with relapsed or refractory multiple myeloma previously treated with lenalidomide (OPTIMISMM): a randomised, open-label, phase 3 trial.
        Lancet Oncol. 2019; 20: 781-794
        • Rodin G.
        • Yuen D.
        • Mischitelle A.
        • Minden M.D.
        • Brandwein J.
        • Schimmer A.
        • Marmar C.
        • Gagliese L.
        • Lo C.
        • Rydall A.
        • Zimmermann C.
        Traumatic stress in acute leukemia.
        Psycho Oncol. 2013; 22: 299-307
        • Ruddy K.
        • Mayer E.
        • Partridge A.
        Patient adherence and persistence with oral anticancer treatment.
        CA A Cancer J. Clin. 2009; 59: 56-66
        • San Miguel J.F.
        • Schlag R.
        • Khuageva N.K.
        • Dimopoulos M.A.
        • Shpilberg O.
        • Kropff M.
        • Spicka I.
        • Petrucci M.T.
        • Palumbo A.
        • Samoilova O.S.
        • Dmoszynska A.
        • Abdulkadyrov K.M.
        • Schots R.
        • Jiang B.
        • Mateos M.-V.
        • Anderson K.C.
        • Esseltine D.L.
        • Liu K.
        • Cakana A.
        • Van De Velde H.
        • Richardson P.G.
        N. Engl. J. Med. 2008; 359: 906-917
        • Sorensen C.A.
        • De Thurah A.
        • Lisby M.
        • Olesen C.
        • Sorensen S.B.
        • Enemark U.
        Cost-consequence analysis of self-administration of medication during hospitalization: a pragmatic randomized controlled trial in a Danish hospital setting.
        Ther. Adv. Drug Saf. 2020; 112042098620929921
        • Spencer A.
        • Lentzsch S.
        • Weisel K.
        • Avet-Loiseau H.
        • Mark T.M.
        • Spicka I.
        • Masszi T.
        • Lauri B.
        • Levin M.-D.
        • Bosi A.
        • Hungria V.
        • Cavo M.
        • Lee J.-J.
        • Nooka A.K.
        • Quach H.
        • Lee C.
        • Bareto W.
        • Corradini P.
        • Min C.-K.
        • Scott E.M.
        • Chanan-Khan A.A.
        • Horvath N.
        • Capra M.
        • Beksac M.
        • Ovilla R.
        • Jo J.-C.
        • Shin H.-J.
        • Sonneveld P.
        • Soong D.
        • Casneuf T.
        • Chiu C.
        • Amin H.
        • Qi M.
        • Thiyagarajah P.
        • Sasser A.K.
        • Schecter J.M.
        • Mateos M.-V.
        Daratumumab plus bortezomib and dexamethasone versus bortezomib and dexamethasone in relapsed or refractory multiple myeloma: updated analysis of CASTOR.
        Haematologica. 2018; 103: 2079-2087
        • Terpos E.
        • Engelhardt M.
        • Cook G.
        • Gay F.
        • Mateos M.V.
        • Ntanasis-Stathopoulos I.
        • Van De Donk N.
        • Avet-Loiseau H.
        • Hajek R.
        • Vangsted A.J.
        • Ludwig H.
        • Zweegman S.
        • Moreau P.
        • Einsele H.
        • Boccadoro M.
        • San Miguel J.
        • Dimopoulos M.A.
        • Sonneveld P.
        Management of patients with multiple myeloma in the era of COVID-19 pandemic: a consensus paper from the European Myeloma Network (EMN).
        Leukemia. 2020; 34: 2000-2011
        • Touati M.
        • Lamarsalle L.
        • Moreau S.
        • Vergnenegre F.
        • Lefort S.
        • Brillat C.
        • Jeannet L.
        • Lagarde A.
        • Daulange A.
        • Jaccard A.
        • Vergnenegre A.
        • Bordessoule D.
        Cost savings of home bortezomib injection in patients with multiple myeloma treated by a combination care in Outpatient Hospital and Hospital care at Home.
        Support. Care Cancer. 2016; 24: 5007-5014
        • Turale S.
        • Meechamnan C.
        • Kunaviktikul W.
        Challenging times: ethics, nursing and the COVID-19 pandemic.
        Int. Nurs. Rev. 2020; 67: 164-167
        • Vestergaard A.S.
        • Hansen L.
        • Sorensen S.S.
        • Jensen M.B.
        • Ehlers L.H.
        Is telehealthcare for heart failure patients cost-effective? An economic evaluation alongside the Danish TeleCare North heart failure trial.
        BMJ Open. 2020; 10e031670
        • Vogl D.T.
        • Raje N.
        • Jagannath S.
        • Richardson P.
        • Hari P.
        • Orlowski R.
        • Supko J.G.
        • Tamang D.
        • Yang M.
        • Jones S.S.
        • Wheeler C.
        • Markelewicz R.J.
        • Lonial S.
        Ricolinostat, the first selective histone deacetylase 6 inhibitor, in combination with bortezomib and dexamethasone for relapsed or refractory multiple myeloma.
        Clin. Cancer Res. 2017; 23: 3307-3315
        • Waight C.C.
        • Cain R.
        Authorising bortezomib treatment prior to reviewing haematology results: a step toward home administration.
        J. Oncol. Pharm. Pract. 2014; 20: 351-355