A Telemedicine-Supported Home-Injection Model for Patients With Breast Cancer.

This pilot study, conducted between October 2024 and August 2025, was reviewed by the Memorial Sloan Kettering (MSK) Cancer Center institutional review board and determined not to constitute human subjects research; instead, it was designated as a quality improvement study. Because this study was deemed quality improvement, patients were offered the opportunity to participate and were permitted to decline without signing a formal informed consent document. This study is reported in accordance with the Standards for Quality Improvement Reporting Excellence ( SQUIRE ) 2.0 reporting guideline. 13 Patients with a diagnosis of breast cancer were recruited from 4 outpatient medical oncology practices at MSK Cancer Center’s Westchester County regional site. Eligible patients were adults actively receiving leuprolide and enrolled in the patient portal. Patients with an upcoming appointment within 2 weeks and an active order for leuprolide within the last 6 months were identified through a weekly automated report. Using a broad opt-out–style recruitment approach, a research coordinator (K.M.) verified the report with each treating medical oncologist (D.L., C.D., J.S., and R.S.) to identify participants. After oncologist assent to initiate contact, potential participants were invited by telephone and secure portal messaging and provided information about the pilot. Patients who confirmed interest in GnRHa self-administration were onboarded by the research coordinator and completed an intake survey assessing demographics, time and cost burden associated with usual clinic visits, and prior injection-administration experience and telemedicine use. Data on age, sex, and race and ethnicity were obtained from the electronic medical record. Race categories included Asian, Black, and White participants; ethnicity categories included Hispanic or Latino and non-Hispanic or non-Latino. Race and ethnicity were included in the study to characterize the demographics of patients who engaged in home injections. The patient’s oncologist was notified of participation, completed a brief survey, and submitted prior authorization requests to obtain insurance approval for dispensing and delivering medication for administration at home. Both insurance authorization and patient willingness to pay any associated drug copayment were required prior to at-home drug administration. Results from recruitment attempts, including reasons for lack of participation, were tracked to characterize the reach of the program ( Figure 1 ). After obtaining insurance authorization, the next scheduled injection visit was converted to a dedicated teaching appointment with a registered nurse (RN), who adhered to a training program (designed and taught by RNs S.P., J.A., K. Bonenfant, and K. Budrock). The RN provided hands-on instruction in injection preparation and administration using clinic-supplied medication and/or an injection-training simulation pad. Written educational materials regarding self-administration of leuprolide were provided at the conclusion of the visit. 14 , 15 Patients were also offered optional telemedicine nursing visits for their first 2 at-home injections to provide additional real-time teaching and/or supervision. Following each home injection, patients were required to confirm administration via secure patient-portal messaging, allowing nursing staff to document the treatment date in the medical record (per the training program designed and taught by RNs S.P., J.A., K. Bonenfant, and K. Budrock). Patients were also sent surveys after each of their first 2 home injections via the patient portal to capture their experiences and perspectives. Patients were followed up for up to 6 months following their injection-education visit. At the conclusion of the pilot, patients were offered the option to continue home-based injection administration at the discretion of the treating clinician. Each participant’s medical oncologist was invited to complete a survey assessing their views on home-based treatment. Patients were also invited to participate in an optional qualitative telephone interview, and those who completed the interview received a $50 gift card as a token of appreciation. Study data were abstracted from MSK’s electronic medical record, and self-reported surveys were administered using REDCap electronic data capture. 16 , 17 Patients completed up to 2 satisfaction surveys following home injections; only the most recent response was included in the analysis. Net promoter scores (NPSs) were calculated as the percentage of promoters minus the percentage of detractors, with detractors defined as scores of 0 to 6, passives as 7 to 8, and promoters as 9 to 10 based on the survey response. 18 The NPS and other survey measures are included in the eMethods in Supplement 1 ). Descriptive statistics were used to characterize quantitative outcomes and variables of interest. Qualitative patient interviews were conducted via videoconferencing by a qualitative research methodologist (S.C.). The goal of interviews was to delve more deeply into patients’ experiences with the program, including factors that may have influenced participation and satisfaction. Interviews were recorded, transcribed, and analyzed using grounded theory methods to explore experience with the home-injection care model. 19

Of 105 eligible patients, 54 patients were interested in participation, and after insurance approval, 24 subsequently participated. Between October 2024 and January 2025, 24 women with breast cancer (median [range] age, 44 [33-53] years) participated in the home-injection pilot; 2 (8.3%) were Asian, 2 (8.3%) were Black, and 20 (83.3%) were White; ethnicity categories included 1 participant (4.2%) who was Hispanic or Latino and 23 (95.8%) who were non-Hispanic or non-Latino. The majority of patients (15 [62.5%]) were receiving monthly leuprolide, whereas the remaining 9 (37.5%) received doses every 3 months. Most of those patients (23 [95.8%]) were receiving therapy in the adjuvant or neoadjuvant setting; 1 patient (4.2%) received treatment for metastatic disease ( Table 1 ). For the 23 patients whose oncologist completed a medical-intake survey (95.8%) the median (range) Eastern Cooperative Oncology Group Performance Status was 0 (0-1), in which scores range from 0 to 5, with higher scores indicating more disability and inability to carry on any self-care, and the median (range) time from breast cancer diagnosis was 2 (0-13) years. Among 20 participants, 19 (95.0%) were college-educated, and 13 (65.0%) had an annual household income of more than $100 000. Abbreviation: ECOG, Eastern Cooperative Oncology Group. Data are reported as No. (%) of patients unless otherwise indicated. Scores range from 0 to 5, with higher scores indicating more disability and inability to carry on any self-care. Respondents could select more than 1 option. Nineteen of 24 patients (79.2%) completed the baseline assessment of time and cost burden associated with usual cancer care. Most participants (12 of 19 [63.2%]) lived within 0 to 25 miles of the clinic, although 5 of 19 (26.3%) resided greater than 50 miles away. Patients reported a median (range) door-to-door visit time of 2 (1-15) hours and a median (range) of 3 (0-30) clinic visits during a typical 3-month period. Among the 6 of 24 patients (25.0%) who agreed to participate in qualitative interviews at the end of the study, the time and financial burden associated with clinic-administered injections emerged as the primary concern and key motivator for enrolling in the pilot (eTable in Supplement 1 ). Of the 20 patients who completed the intake, half of respondents (50.0%) reported no prior experience with injection administration; among the 10 (50.0%) with prior experience, nearly all (9 [90.0%]) had previously self-administered injections, mostly requiring a vial or syringe (7 [70.0%]). Most of those patients (14 [70.0%]) reported using telemedicine some of the time, and the majority (19 [95.0%]) reported no challenges with telemedicine use. Further details are outlined in Table 1 . All 24 patients referred for injection education successfully completed a teaching visit for intramuscular leuprolide. Following the education visit, 23 of 24 patients (95.8%) completed at least 1 home injection of intramuscular leuprolide. The single patient who did not proceed was unable to do so because a change in their insurance copayment created a financial barrier to obtaining the take-home prescription. Thirteen of 24 patients (54.2%) had a telemedicine visit with an oncology RN for support during their first home injection. Overall, 19 of 24 participants (79.2%) completed 2 injections, but only 2 opted for further telemedicine support. Of the 4 patients who did not complete a second injection, 1 transferred care to another institution, 1 discontinued leuprolide, and 2 elected to return to in-clinic administration due to the copayment costs and simpler coordination. Overall, 18 of 24 pilot study participants (75.0%) continued home-injection administration beyond study completion. One patient (4.2%) discontinued home injections because of challenges with both administration technique and coordinating telemedicine visits. Details regarding home-injection completion are presented in Figure 2 . Among the 17 of 24 patients who completed a study survey (70.8%), the most frequently cited benefits of home injections were associated with the time savings (15 [88.2%]), greater control over scheduling (15 [88.2%]), and overall convenience (13 [76.5%]) ( Table 2 and Figure 3 ). These themes were echoed in qualitative interviews, in which patients described how home administration reduced disruption to daily life (eTable in Supplement 1 ). Notably, 4 of 6 patients who agreed to participate in a qualitative interview (66.7%) indicated willingness to pay a convenience fee to continue home injections (eTable in Supplement 1 ). Abbreviation: MSK, Memorial Sloan Kettering. The number of respondents was 17 unless otherwise indicated. Reported barriers among the 17 patients who completed a satisfaction survey were less common but included challenges with communication or coordination with the care team (such as getting help or scheduling visits) (3 [17.6%]) and difficulties obtaining necessary equipment or medication (5 [29.4%]) (eFigure in Supplement 1 ). These issues were also reflected in semi-structured interviews (eTable in Supplement 1 ). Despite these challenges, most patients indicated that they would be likely to complete another home injection if offered (13 [76.5%]), that they strongly preferred home injection for their next dose (11 [64.7%]), and that home injection was less stressful than an in-person clinic visit (11 [64.7%]) ( Table 2 and eTable in Supplement 1 ). Overall, the willingness to recommend home self-administration to similar patients was high, corresponding to an NPS of 69. Among 15 of 17 patients (88.2%), who used telemedicine support during the time of home injection, most found it very helpful (12 [80.0%]), and 3 (20.0%) found it somewhat helpful ( Table 2 ). In interviews, patients emphasized that telemedicine support provided real-time guidance, training, and other support remotely (eTable in Supplement 1 ). Four medical oncologists completed surveys pertaining to 18 of 24 (75.0%) participants. Oncologists were asked whether they would recommend self-administration of injection medications to future patients with breast cancer. Their level of endorsement was high, with an NPS of 61. Oncologists’ comments on surveys highlighted perceived benefits such as improved patient engagement and reduced missed doses of treatment (eTable in Supplement 1 ). One hundred and seventeen patients were screened for eligibility; the most common reason for ineligibility was discontinuation of leuprolide. Notably, oncologists in only 2 cases advised that their patients were not appropriate candidates for home-based treatment administration. Of the 105 eligible patients approached by the research coordinator, 54 (51.4%) agreed to participate in the pilot. The primary reason for declining participation (28 of 51 [54.9%]) was lack of interest in self-injection. Among the 54 patients who agreed to participate, 19 (35.2%) were unable to proceed due to a lack of insurance approval for home administration of the eligible medication, and 5 (9.3%) were initially interested but due to the prolonged insurance authorization process, chose to continue with clinic-based treatment. Among the 30 patients (55.6%) who were interested in participation and received insurance authorization, 18 (60.0%) incurred a copayment for leuprolide when injection coverage shifted from their medical benefit covering clinic-based administrations to their pharmacy benefits covering home-based administrations (median [range], $61 [$3-$2000]). Of these 18 patients, 6 (33.3%) declined to participate after learning about the high out-of-pocket costs, while 4 (22.2%) obtained financial assistance through their specialty pharmacy that reduced the copayment and enabled participation. After application of financial assistance, the median (range) participant’s copayment per dose of leuprolide was $38 ($3-$100). Recruitment details are described in Figure 1 .

In this quality improvement study, premenopausal patients with breast cancer receiving GnRHa therapy were invited to self-administer intramuscular injections at home and found that at-home administration was both feasible and highly acceptable. The goal was to offset the logistical and time burdens involved with travel to clinics for nurse-administered injections, particularly for patients residing at a distance and/or with competing personal and professional responsibilities. Among interested patients, the most substantial barrier to participation was insurance related. Specifically, prior authorization requirements and higher out-of-pocket costs for home-administered medications limited uptake compared with clinic-administered therapies, which typically resulted in lower patient cost-sharing. Overall, 95.8% successfully administered intramuscular GnRHa at home, with 75.0% continuing self-administration beyond study completion. The feasibility, high completion rates, and strong patient satisfaction observed in this pilot have broad implications, suggesting that telehealth-supported home-injection models may be adaptable to other patient populations facing similar treatment duration, frequency, and access-related challenges, such as women receiving GnRHa therapy for endometriosis 20 or patients with neuroendocrine tumors treated with subcutaneous lanreotide. 21 These findings complement prior work by Laughlin et al, 22 who demonstrated the success of a home GnRHa program primarily delivered by registered nurses, as well as earlier work by Hamm et al 23 in a pilot study conducted in the UK, which demonstrated that patients with prostate cancer were able to successfully self-administer therapy over the course of 1 year. Together, these studies support the feasibility of home-based treatment models and suggest potential for broader implementation across care settings. Clinician screening identified only 1.7% potentially eligible patients as unsuitable for participation, further supporting the feasibility of this approach. Overall, interest in home-injection administration was moderate, with 51.4% of approached patients agreeing to participate. A research coordinator–led approach to patient recruitment enabled broader reach while minimizing additional burden on clinicians in an already resource-constrained outpatient setting. Similar opt-out recruitment strategies have been shown to improve participation and reduce inequities in pragmatic research. 24 , 25 , 26 However, because the most common reason for declining participation was lack of interest in self-administration, uptake may have differed if the intervention had been introduced by a trusted member of the clinical care team. Insurance coverage emerged as the primary barrier to participation. Denials, prolonged approval processes, and new copayment obligations associated with shifting coverage from medical to pharmacy benefits deterred more than half of interested patients (55.6%) from participation. The only patient who underwent injection training but did not complete a home injection cited rising copayment costs as their primary reason. Among patients who proceeded to training, the median (range) copayment was $38 ($3-$100). Exit interviews indicated patient openness to paying a modest convenience fee to continue home injections, suggesting that patients may accept some out-of-pocket costs in exchange for meaningful time savings. Cost tradeoffs may be particularly salient for the 6 of 24 participants (25%; 5 self-reported and 1 obtained from EHR review) who lived 50 to 300 miles from the MSK clinic (all of whom continued with home injections beyond the second administration), including those in rural or semirural areas with limited access to oncology specialty care. For these individuals, telehealth-supported home administration may substantially reduce travel burden, time away from work or caregiving responsibilities, and reliance on transportation assistance. Given that patients were a median (range) of 2 (0-13) years from diagnosis and reported spending a median (range) of 2 (1-15) hours per monthly clinic visit, the cumulative time savings over years of adjuvant endocrine therapy may be substantial, with the potential to improve treatment adherence, patient satisfaction, and quality of life. 27 , 28 These findings underscore the importance of early payer engagement and policy alignment to support implementation of home-injection models, particularly for patients for whom frequent in-person visits impose substantial logistical and financial burdens. From a hospital or clinic perspective, randomized clinical trials have demonstrated comparable costs between home-based and facility-based cancer treatment, with outpatient costs largely associated with nursing labor, travel time, and equipment needs, many of which may be reduced through patient self-administration approaches. 29 However, the potential loss of revenue from facility-based administration represents an important barrier for clinical practices, particularly smaller community-based groups that may have fewer opportunities to offset these losses through other infusion services. Reimbursement mechanisms for home monitoring and care coordination may represent 1 strategy to address this challenge. From the payer perspective, an additional barrier is the separation of pharmacy and medical benefits. Although home administration may reduce facility-based expenditures, including administration and facility fees, additional efforts are needed to address patient cost-sharing, copayment structures, and assistance programs to ensure that home-administration models remain feasible and equitable. Notably, half of participants had no prior experience with self-injection. Nevertheless, a nurse-led, in-clinic education model was found to be highly effective among the 24 patients based on subsequent high home-injection completion rates. Furthermore, patient interviews aligned with survey findings, indicating largely positive experiences with home injection, with numerous perceived benefits and relatively few short-term barriers. Continued use beyond the pilot period, coupled with high NPSs, suggests strong support from both patients and their clinical care team for this home-injection care-delivery model. 30 The use of standardized written educational materials and optional telemedicine support during initial home-administered injections, which provided real-time reassurance while maintaining patient safety, may have been key facilitators for the model’s support. 14 , 15 Allowing telemedicine visits to remain optional may have balanced patients’ support while avoiding unnecessary increases in health care utilization. Beyond breast cancer, GnRHa therapy is widely used across solid tumor types, including prostate and selected gynecologic cancers, in which patients similarly receive long-term, regularly scheduled injections in clinic-based settings. 31 As oncology care increasingly shifts toward prolonged outpatient management and survivorship-focused approaches, scalable strategies integrating telemedicine and patient self-management should play a key role in improving access, convenience, and the patient experience. In parallel, with prior efforts to decentralize chemotherapy delivery, 22 , 32 , 33 these approaches may also help expand access to immunotherapies as treatment administration evolves from intravenous to subcutaneous formulations, 34 , 35 , 36 an active area of ongoing research. 37 Notably, these developments are occurring within a broader health care landscape, in which patients have increasing familiarity with self-administered–injectable therapies for chronic disease management (eg, diabetes, fertility, obesity, and autoimmune disease). 9 , 38 , 39 , 40 In this context, oncology care must continue evolving beyond the traditional clinic setting, not only to support more patient-centric models of care but also to address growing workforce, financial, and operational constraints 41 , 42 , 43 while meeting the needs of an expanding population with cancer. This study has several limitations including a small number of participating medical oncology practices (n = 4) and relatively homogenous patient demographics (eg, 83.3% who were White, 95.0% who were college-educated, 65.0% with >$100 000 income, and with a median Eastern Cooperative Oncology Group Performance Status of 0). Furthermore, it was conducted at a free-standing comprehensive cancer center, which may limit generalizability. This work represents preliminary evidence of feasibility and acceptability; further research is needed to evaluate clinical, safety, and utilization outcomes in a broader population.

In this quality improvement study of a telemedicine-supported home-injection care-delivery model, the findings suggest that it is a viable, patient-centered alternative to clinic-based administration of long-term injectable therapies. High rates of successful home administration, strong patient and clinician endorsement, and sustained continuation beyond the initial pilot period underscored the potential of this model to meaningfully reduce treatment burden without compromising safety or adherence. Although insurance coverage remains a critical barrier to equitable implementation, the high willingness of patients to engage in home administration, including among those without prior injection experience, highlights an important opportunity to modernize the delivery of commonly used injectable medications. Future work should focus on policy alignment, cost-effectiveness, and implementation across more diverse populations and treatment settings to inform broader adoption. This care-delivery model is currently being extended as part of an enhanced telehealth intervention within an ongoing larger pragmatic trial among patients with breast or prostate cancer. 44

Endocrine therapy is the cornerstone of treatment for hormone receptor–positive breast cancer and is associated with substantial improvements in breast cancer–specific mortality. 1 In premenopausal patients, optimal endocrine therapy requires pharmacologic ovarian function suppression to reduce estrogen production, most commonly achieved through injectable gonadotropin-releasing hormone agonists (GnRHas) such as leuprolide. 2 When combined with tamoxifen or aromatase inhibitors, ovarian suppression has demonstrated improved disease-free survival, particularly among younger patients and those with higher-risk disease. 3 In contemporary oncology practice, GnRHas are typically administered as intramuscular injections in outpatient clinic settings at monthly or quarterly intervals. 4 Given that ovarian suppression is recommended for patients with both early-stage and metastatic disease, treatment may extend over many years, resulting in frequent clinic visits. 5 , 6 , 7 Although effective, GnRHa treatment places burdens on patients, including time away from work and family and travel demands. 8 These challenges are particularly salient for parents and younger working patients who are otherwise often clinically well and may derive minimal incremental value from in-person visits beyond medication administration. Home-injection programs in the in vitro fertilization setting have demonstrated that patients can safely and effectively self-administer injectable medications via intramuscular or subcutaneous routes, with home administration as the standard of care. 9 , 10 However, in the context of cancer treatment, clinic administration remains the norm. Combining telehealth with at-home administration of GnRHa therapy has the potential to maintain safety and effectiveness while minimizing treatment burdens for patients. 11 , 12 We sought to assess the feasibility of a telemedicine-supported home-injection care-delivery model for premenopausal patients with breast cancer.