Key takeaways:

• Patients and oncologists recommended a program supporting home-injection of gonadotropin-releasing hormone agonists for breast cancer.
• Insurance barriers prevented many interested patients from participating.

A home-injection approach for certain cancer therapies, such as gonadotropin-releasing hormone agonists for breast cancer, could substantially benefit patients, but barriers linked to insurance coverage could hinder program implementation.

A pilot program for patients with breast cancer, funded by the NCI Telehealth Reacher Centers of Excellence (TRACE) initiative, receiving intramuscular leuprolide at Memorial Sloan Kettering Cancer Center showed participants could quickly learn to inject the medications themselves and most preferred to continue administration at home in the future.

Data derived from Malling CD, et al. JAMA Netw Open. 2026;doi:10.1001/jamanetworkopen.2026.29406.

However, more than half of interested patients could not join the study due to medication costs, insurance denials or delays.

“My hope is that we’ll continue to see innovation and creativity as we think about how we deliver cancer care, utilizing emerging tools like telehealth and remote monitoring to better connect the home and clinic,” Erin M. Bange, MD, MSCE, genitourinary medical oncologist at Memorial Sloan Kettering Cancer Center, told Healio.

“How can we minimize the number of times that patients have to come into the clinic, and can we successfully deliver high quality of care in their home?”

‘Enhanced telehealth’

Hormone-positive malignancies account for approximately 80% of all breast cancer cases, according to NCI.

Premenopausal patients commonly receive injectable gonadotropin-releasing hormone agonists (GnRHas) to suppress ovarian function, which research has shown improves DFS when combined with aromatase inhibitors or tamoxifen, according to study background.

Some patients receive GnRHas injections monthly, and they can be on treatment for years as ovarian ablation is recommended for both early-stage and metastatic malignancies.

“Logistical and time burdens associated with cancer care can be quite burdensome on patients,” Bange said. “We know from other fields, such as IVF and even with GLP-1s, that patients can frequently self-administer many of these subcutaneous and intramuscular injections themselves.”

Bange and colleagues conducted a pilot study to see if a telemedicine-supported home-injection program could alleviate some of those logistical troubles.

Bange described it as “enhanced telehealth.”

Researchers approached 105 patients with breast cancer receiving leuprolide at a regional Memorial Sloan Kettering Cancer Center site about joining the study, 54 agreed, but only 24 (median age, 44 years; range, 33-53; 83.3% white) could obtain insurance coverage with affordable copay to participate.

“That was really striking to us, that 50% of patients wanted to participate in the pilot,” Bange said. “This showed us that there is a sizable cohort of women who were interested in this approach.”

Nurses trained patients and/or their caregivers how to administer the medication during their next scheduled injection appointment after enrollment.

“Either they would self-administer that day, or they would use it on a practice model,” Bange said. “Patients were also provided both written and video-based educational material that we worked with the MSK patient education department to build and make sure that it was patient-friendly and understandable for all different skill levels. The nurses made sure that the patient and/or their caregiver felt competent and confident in doing the administration.”

Patients also had the option of telemedicine visits with a nurse for their first two home injections.

Researchers followed patients for 6 months and up to two home-administrations.

Home-injection completion rates served as the primary endpoint.

‘Very impressed’

Among patients who completed a baseline assessment (n = 19), 12 (63.2%) resided within 25 miles of a clinic and five (26.3%) lived more than 50 miles away. Patients had a median door-to-door time for a clinic injection of 2 hours (range, 1-15) and a median of three visits (range, 0-30) in a 3-month span.

Among 20 patients who finished intake, half had never self-administered injections.

All 24 participants completed the education appointment, 23 (95.8%) completed at least one injection, 19 (79.2%) finished two, and 13 (54.2%) had a telemedicine visit with a nurse for their first self-administration. Only two patients requested a second telehealth appointment.

Most participants (n = 18; 75%) continued home-administration following the trial’s conclusion, and one stopped due to difficulties with injection and scheduling telemedicine appointments.

“We were very impressed with the numbers,” Bange said. “We were particularly impressed with the proportion of patients who continued on with the injection post the pilot, which was a real signal to us that this was something that was really beneficial to patients, and there was a real desire for the program.”

Survey data following the intervention supported that conclusion.

Most participants who completed the survey (n = 17) cited time savings (n = 15; 88.2%), control over scheduling (n = 15; 88.2%) and convenience (n = 13; 76.5%) as the best parts of the program. Additionally, four of six patients who had a qualitative interview said they would pay extra to stay on home-injections.

Bange and colleagues described willingness to recommend the program from patients and oncologists as “high.”

Researchers acknowledged study limitations, including lack of diversity and limited number of participating practices.

Insurance a hinderance

Despite the positive results, barriers persist in broader implementation, mainly around insurance.

Of the 30 individuals who wanted to participate but could not get coverage, 19 could not join because insurance denied the medication and five withdrew because the approval process took too long.

Additionally, 18 had a copayment when the injection moved to the home setting, which ranged from $3 to $2,000. This caused six patients to decline participation, although four others did join after receiving financial assistance.

“These injections, when they’re done in clinic, are typically paid for under the patient’s clinical or hospital benefit from their insurance,” Bange said. “When we move the injection out of the clinic, it goes under their pharmacy benefit. There could be different copays associated with the drug.”

Bange said she and colleagues are currently conducting an institution-wide pragmatic trial, which has enrolled around 11,000 patients with breast and prostate cancer, to further evaluate the program, and are using lessons from the pilot to facilitate higher involvement.

“One is having pre-drafted letters of appeal that are very easy for staff to just adapt to the specific patient,” Bange said. “Two, we have a dedicated pharmacy team that knows about the program, knows about the use of these drugs in the home setting, and they can help us get these medications filled. We also have built a dedicated line to talk with our patient financial services team. By doing these, we have seen a substantial improvement in terms of helping connect patients with copay assistance programs and find grant support. There was a case that we saw that the team didn’t realize the patient had access to the World Trade Center Fund, and after they pursued that program the patient was able to participate.”

Federal and state policies would make the biggest difference, though.

“We’re going to need to work with policymakers and think about how we pay for these types of approaches,” Bange said. “Think about reimbursement strategies that help to incorporate the work and interpretation of data that is collected in a remote way, thinking about, how do we pay for these drugs when they move from the clinic to home, and how do we do this in a way that doesn’t silo people? What I would hate to see happen is this has to be delivered at home, or it has to be delivered in clinic. To create patient-centered models of care, we need to allow the clinician and the patient together to decide what is the right approach for them.”

In an accompanying editorial, Vishal R. Patel, MD, MPH, physician at Brigham and Women’s Hospital and researcher at Harvard Medical School, and Arjun Gupta, MD, medical oncologist at City of Hope Cancer Center Phoenix, also highlighted the importance of supporting home-based care.

“We have built a system in which the more efficient site of care is more costly for the patient and have made the patient pay the difference for the privilege of staying home,” they wrote. “This inversion matters because the entire rationale for home injection is the value of a patient’s time.

“When the same molecule costs the patient more at home than in clinic, we are looking at a policy artifact, not a medical fact. The most pertinent question this pilot study really poses, and exposes, is whether we are willing to stop charging patients for the time we claim we want to give back.”

For more information:

Erin M. Bange, MD, MSCE, can be reached at bangee@mskcc.org.