The potential for in-home intravesical therapy for NMIBC

Timothy D. Lyon, MD, FACS

In this interview, Timothy D. Lyon, MD, FACS, explains what led to the research discussed in his Journal of Urology letter¹ on the potential for in-home intravesical therapy for non–muscle-invasive bladder cancer (NMIBC). Lyon is a practicing urologic oncologist at Mayo Clinic in Jacksonville, Florida.

What spurred an interest in this research?

The idea for this paper really came from our patients. A couple of patients were asking about whether there would be an easier way for them to receive the treatments for their non–muscle-invasive bladder cancer. As you may know, bladder cancer generally happens to an older population. I think the median age of diagnosis is 73. Oftentimes, they have several other medical problems going on in addition to their bladder cancer, which might affect their mobility or the ease with which they can come back and forth from the health care system.

On top of that, intravesical therapy for non–muscle-invasive bladder cancer, is really time intensive. It's a high-touch treatment process. The patients need to come in once a week for 6 weeks in a row. So, they drive in from home, park in the parking lot, come up to the office, actually get the treatments or therapies, and then have to go home. That amount of travel with that frequency can be quite a burden to some of our older patients that are dealing with other medical conditions.

On top of that, in the past few years, with the COVID-19 pandemic, we've rapidly been moving a lot of health care to the patient's home. We increased virtual visits; we've increased the number of procedures that we're doing now on an outpatient basis. In many cases, we're now bringing the capabilities of the hospital into a patient's home. Things that used to need to be done in a brick-and-mortar hospital, such as getting IV antibiotics or having round-the-clock nursing care can now be done in the comfort of a patient's own home.

The collision of those 2 processes led us to think about this. As patients were asking, "is there an easier way, doc, than me having to come in quite a distance every week to get treatment?", we thought could we use some of the same processes and techniques that we're using to bring other aspects of health care to the patient's own, to allow them to get intravesical therapy in their own home?

What were some of the notable findings from looking at the existing literature?

Of course, the first thing we did is we went to the literature and tried to see whether anyone had done this before or what we could learn from it. We were quite surprised to see almost nothing in the literature describing this previously. We engaged the services of a research librarian to help us review, systematically, the literature that has existed over about the past 60 to 70 years from multiple databases. After culling through the identified studies [we] only found 2 papers that described doing this in any fashion in the past.

The first was from 1991 in the journal Home Healthcare Nurse² and was an instruction manual for home health care nurses about how to bring BCG into a patient's home, reconstitute it from powder, and then physically give it to the patient. It seems that this was being done at some point, but there were really no data in that paper about how many patients this was used on, how effective it was, [or] what the satisfaction was. It was just a recipe.

We found 1 other paper from the National Health Service in the United Kingdom,³ where they described giving intravesical therapies in Newcastle in a patient's home. A little over 300 BCG doses were given. I think it was 91 intravesical chemotherapy doses were given. Again, this wasn't a full article. It was kind of a news snippet. They mentioned that patient satisfaction was high, but no further information about the process or how much it cost or the benefits to a patient's quality of life. That's all we found. We left with as many questions as we came into the literature search with.

Could you discuss some of the current knowledge gaps on intravesical therapy in NMIBC?

I think there are a number of knowledge gaps that need to be thought about or addressed before testing out in-home intravesical therapy. The first of which is we don't have a good understanding of the burden that is placed on patients in the process of receiving intravesical therapy in the current structure, where it's given in the office. Lots has been written about quality of life, financial toxicity, [and] work and activity impairment in bladder cancer generally, but there's minimal information about intravesical therapy specifically.

Of course, those data are important to understand the baseline and some benchmarks of what patients are going through and how difficult it is for them to access intravesical care so we can understand whether any future changes are an improvement or not. In addition, it's important to understand patient attitudes towards this; whether patients are open to the idea of having a nurse come into their home and catheterize them in a non-hospital or non-clinic setting, [or] how patients feel about having biologic agents or chemotherapeutic agents brought into their home and delivered. It's important to make sure that this is something that is desired by our patients before pursuing further.

Is any further research on this topic planned? If so, what might that cover?

We've already performed a survey study of bladder cancer patients, specifically asking about some of those questions I just mentioned. What is the burden to you, both from a time and financial perspective of accessing and getting your intravesical therapies? What are your feelings, thoughts, and opinions on potentially receiving intravesical treatment in your home? Some of those data will be presented at the AUA meeting this year and are at least a first step towards better understanding some of these issues.

In addition, I think it'll be important to pilot test this idea and see what sort of operational challenges arise. I can tell you that some of the challenges that we've identified already are regulatory. Every state or country will have different rules regarding the safe transport of different classes of medications outside of health care settings in the patient's home. It will be important to identify appropriately trained personnel to transport those medications, as well as to perform catheterization and handling of the medications in the home. It will be important to make sure that payers are engaged, because the ultimate success of this idea depends upon reimbursement. Where there's a will, there's a way, and with further work and inquiry, we will be able to find a way to test this.

What is the take-home message for practicing urologists?

The overall take-home message is that in addition to thinking about new treatments and new agents that we can use to treat our bladder cancer patients, we should not forget about thinking about new ways to do things and new ways in which we may be able to deliver bladder cancer care in ways that are more patient-centered and make it easier and less burdensome for them to receive their therapies.

References

1. Lyon TD, Boorjian SA, Tyson MD. In-home intravesical therapy: the future of nonmuscle-invasive bladder cancer care delivery? J Urol. Published online January 13, 2023. Accessed February 3, 2023. doi:10.1097/JU.0000000000003176

2. Giglione L. Home bacillus Calmette-Guerin therapy for the treatment of superficial bladder cancer. Home Healthc Nurse. 1991;9(5):50-52.

3. Harrison S. DH praise for home chemotherapy patient services may lead to pilot projects across England and Wales. CancerNursPract. 2006;5(9):4