Subcutaneous (SC) injection in cancer treatment is an emerging administration method, carrying with it both benefits and challenges for patients and health care providers. The evolution of intravenous (IV) to subcutaneous (SC) chemotherapy has resulted in significant cost savings for patients and reduced administration times, easing hospital burden and helping improve resource allocation. Despite these benefits, regulatory and payer challenges remain. In a presentation at the ACCC 51st Annual Meeting & Cancer Center Business Summit in Washington, DC, Raghava Induru, MD, thoracic oncologist and director of operations at Atrium Health Advocate Aurora, Levine Cancer Institute, emphasized the need for better drug development, clinical trials, and payer acceptance, as well as a multi-faceted approach to optimize SC administration and improve patient experience.
Woman self-administering a subcutaneous injection | Image Credit: © Ольга Шефер - stock.adobe.com
As medical science and the understanding of cancer pathology advance, treatments become more efficacious, safe, and precise, lending to a less invasive therapeutic experience for patients. The development of subcutaneous administration has been a long journey, built on centuries of accumulated knowledge and cancer treatment advancements. It marks a significant step forward in the pursuit of patient-centered care and treatment efficiency.1
“Cancer is not new,” Induru explained. “It's been there for centuries. In fact, it's described in Egyptian and Greek civilizations. But for the longest time, the treatment was predominantly surgical or cauterization, and while that was the best that they could be offered at the time.”1
After surgery and the discovery of radiation in the 1800s, chemotherapy was eventually discovered, accidentally, during World War 2. Mustard gas, a chemical warfare agent, was known to cause severe damage to rapidly dividing cells, including white blood cells. This led researchers to investigate whether similar compounds could be used to target cancer cells, which also divide rapidly. In 1942, the first chemotherapy drug, nitrogen mustard (mechlorethamine), was administered intravenously in a 48-year-old man with radiation-resistant, terminal non-Hodgkin lymphoma, which resulted in the disappearance of his tumors by the end of treatment. Although he relapsed with each subsequent line of therapy, this was proof that chemicals could treat cancer.1,2
Targeted therapies and immunotherapies, such as immune checkpoint inhibitors, have virtually revolutionized cancer treatment, offering patients various agents that precisely and selectively target cancer cells to limit toxicities and adverse effects. Similar to chemotherapy, IV has been the standard method of administration for these agents. However, the emergence of SC infusion may be a solution to overcome financial and operational burdens associated with IV infusion, as well as expand patients’ treatment options.1
SC infusion offers several key benefits that can significantly improve patient experience, reduce operational burden, and potentially lower healthcare costs. From the patient perspective, SC administration yields reduced administration times, lending to less time spent in the hospital and more time engaging in everyday activities. For example, SC daratumumab (Darzalex; Janssen Biotech, Inc) saved 62 minutes in total patient treatment time, 54 minutes saved in total drug administration, 78 minutes saved in drug preparation, and 82 minutes saved in total patient treatment experience. Shorter treatment times significantly impact non-drug costs, reducing expenses related to clinic visits and administrative overhead.1
“What are the direct costs, and what are the indirect costs? The direct costs are something for the health care system, right? What is the cost of the drug, and what is the cost of preparation of this drug, and what is the cost of administration of this drug?” Induru said.1
SC is also beneficial from an operational perspective for clinics and health care staff. Improving efficiency of treatment delivery helps reduce clinic burden and burnout, as well as optimize workforce operations and enable better resource allocation. Induru brought specific attention to the operational and financial costs of drug preparation times, noting that the drug preparation time can cost both the patient and the health care provider time and money. He also proposed the potential for in-home administration of SC infusions, further reducing treatment burdens for staff and expenses for patients.1
Woman receiving chemotherapy treatment in hospital | Image Credit: © Monkey Business - stock.adobe.com
“Some patients would prefer [SC] injection,” Induru stated. “In fact, they might even prefer actually [receiving it] at home. Is that a reality? It could be.”1
Despite these benefits, SC infusion methods do present significant clinical, patient-related, operational, and systemic challenges. Clinically, although the effectiveness of subcutaneous administration is promising, the skin's abundance of antigen-presenting cells could increase the likelihood of immune reactions, which may lead to drug resistance. Moreover, the bioavailability of drugs delivered subcutaneously, particularly when combined with chemotherapy, remains under-researched, necessitating further studies to fully understand how these drugs are absorbed and how they perform.1
From a patient perspective, the transition from IV to SC administration can be daunting, and patients may be uncertain about self-injection. Many may also find comfort in the established method of IV administration. On the operational side, the integration of SC infusion into existing healthcare systems poses challenges, including the need for updated electronic medical record (EMR) systems and formulary approval. Additionally, regulatory hurdles remain, with complex approval processes and a lack of clear reimbursement models complicating the financial feasibility of SC infusions.1
There is no clear solution to addressing these problems. It will require a comprehensive, collaborative approach involving manufacturers, health care providers, payers, and patients rather than a unilateral strategy.1
“The solutions are challenging,” Induru explained. “The solution requires a collaboration between every single party that's involved in taking care of the patient.”1
Some approaches may include improving formulation design, optimizing delivery devices, as well as addressing patient preferences. Additionally, a shift in payer perspectives, considering both direct and indirect costs, could support more flexible treatment models, including home injections. By integrating patient experience, focusing on quality of life, and fostering collaboration across stakeholders, the health care system can move towards more effective and patient-centered cancer care.
REFERENCES
1. Induru S. The Value of Subcutaneous Injection in Community Oncology. Presented at: ACCC 51st Annual Meeting & Cancer Center Business Summit. Wednesday, March 5, 2025 to Friday, March 7, 2025. Washington, DC.
2. Chemotherapy: From the trenches of warfare a weapon to fight cancer. Yale Medicine. Accessed March 6, 2025. https://medicine.yale.edu/ycci/clinicaltrials/learnmore/tradition/chemotherapy/