Introduction

Cancer is a disease that devastates patients psychologically from the very first moment after the diagnosis. Furthermore, the treatment phase can be just as wearing. Today, there are various cancer treatment methods such as surgery, radiotherapy, and chemotherapy, and each of these treatments has its own complications. In surgical operations, since a certain part of the organ containing cancerous cells is generally removed, the integrity of the patients' organs is impaired. Patients receiving radiotherapy and chemotherapy may experience skin problems, loss of appetite, nausea, fatigue, hair loss, and many other side effects in this process. Therefore, as much as cancer itself, its treatment has the potential to cause trauma in patients.

Colon cancer, which has a higher incidence than many other types of cancer, is also one disease that can cause trauma in patients. According to the 2019 Turkey Health Statistics Yearbook, the incidence of colorectal cancer, which ranks 3rd among the most common cancer types in both men and women, is 21 per 100,000 population. In addition, colon cancer is the cancer type with the highest incidence among the cancer types that occur in the digestive organs [1]. However, significant progress has been made in the treatment of colon cancer in recent years. In terms of chemotherapy treatment, which is one of the cancer treatment methods, new chemotherapy drugs, and new drug administration methods are being developed with each passing day. Chemotherapy treatment through venous port catheters is one of these methods. Traditionally, peripheral vascular access can be established, and chemotherapy treatment can be administered through cannulas, while the venous port catheter application, which has been widely used in recent years, provides considerable comfort, especially in terms of aesthetic appearance and ease of application. The use of appropriate venous access ports in the early period of treatment in oncology patients reduces the risk of extravasation, ensures the safe administration of vesicant and irritant drugs, ensures the continuity of peripheral access, and reduces the patient's anxiety due to refraining from establishing venous access frequently [2].

There are many studies in the literature on patients with colorectal cancer. Most of these are clinical studies [3,4,5,6,7,8] study cancer treatments effects on quality of life [9,10,11,12], their costs [13, 14] or both parameters simultaneously [15, 16]. However, studies were mostly carried out on subjects such as comparison of institutions, pre-op and post-op results, and chemotherapy drug effects. We did not come across any literature examining the quality-of-life differences between cancer patients receiving chemotherapy via the new venous port catheter application and the traditional peripheral vascular access method and adding a cost variable to the study as well. Therefore, we consider this study unique since evaluates the quality of life from the perspective of the patient by using the EORTC QLQ-30 scale developed for cancer patients and calculates costs from the perspective of the institution by inspecting the invoices issued to the Social Security Institution (SSI).

Methods

The study aims to compare the administration of chemotherapy treatment through a venous port catheter or peripheral vascular access to metastatic colon cancer patients in terms of quality of life and treatment costs.

This study has a quantitative research design and includes descriptive findings. The study is cross-sectional since the data were collected between specific dates, and the patients were interviewed once. In addition, this study is a causal-comparative research because it examines the differences between the quality of life and treatment costs according to the chemotherapy application method used.

Population and sampling

The research population comprises 130 patients with metastatic colon cancer who received chemotherapy treatment at Necmettin Erbakan University Meram Medical Faculty Hospital Medical Oncology Unit between 01.06.2020 and 31.12.2020. We aimed to reach the entire population, so no sampling was done in the study. Since there were patients unwilling to participate in the study, unable to continue treatment regularly due to the concurrent COVID-19 pandemic, or deceased during the treatment, we reached 79.2% of the population. Therefore, the sample of the study comprises 103 people.

Data collecting tools

The demographic information form, the EORTC QLQ-30 quality of life scale, and treatment invoices were the data collection tools used in the study.

The demographic information form comprises 19 questions that include information about the socio-demographic characteristics of the participants, their treatments and the obstacles caused by their treatment, and the out-of-pocket expenses of the treatment.

The EORTC QLQ C-30 Quality of Life Scale was developed by Aaronson et al. [17] to measure the quality of life of cancer patients and adapted to Turkish by Beşer and Öz [18]. The EORTC QLQ C-30 Quality of Life Scale comprises 30 questions and three sections: functioning scales, symptom scales, and global quality of life. We used the EORTC QLQ-C30 Scoring Manual (3rd Edition) created by Fayers et al. [19] to calculate the results from the EORTC QLQ C-30 Quality of Life Scale. One can score between 0 to 100 points in each section of the scale. High scores from the global quality of life and functional scales sections indicate improved general quality of life and functional status. High scores from the symptom scales section indicate more symptoms in the individual. The internal consistency coefficient of the scale was found to be 0.90 in the study conducted by Beşer and Öz [18]. In the study conducted by Aaronson et al. [17], the internal consistency coefficients of the scale ranged from 0.54 to 0.86. When the cronbach alpha values of the scale were examined in this study, the total scale was 0.84; global quality of life scale was 0.99; functional scale was 0.87 and symptom scale was 0.81. In addition, the cronbach alpha values of the subscales range from 0.55 to 0.91. In the research, it was initially envisaged to conduct a cost-effectiveness analysis using the EQ-5D scale. However, in the exchange of information with oncology physicians, the physicians gave feedback that it would be more accurate to use The EORTC QLQ C-30 scale developed specifically for cancer. Since this scale is not suitable for cost-effectiveness analysis, the research design was designed to consider cost and quality of life separately.

On the other hand, we used invoices issued by the institution to SSI regarding the processes in which patients received chemotherapy treatment to calculate the costs. In the invoices used in the calculation of costs, service, medicine and medical consumption amounts and the total cost are handled under separate headings. In addition, according to the information given by the physicians, the choice of drug to be given to the patient varies according to the condition of the disease, not according to the chemotherapy application method. Therefore, when calculating the costs of chemotherapy treatment application methods, five different cost amounts are considered, including services, medicines, medical consumables, total including medicines, and total excluding medicines. These costs were calculated as the cost per cycle of chemotherapy. In addition, when calculating the treatment costs of patients receiving chemotherapy treatment with a venous access port, the cost of port insertion was divided by the total number of chemotherapy treatments received by the patient, and the cost per cure of port insertion was calculated and added to the cost of chemotherapy treatment. Because port insertion is performed to give chemotherapy treatment, and since all costs were calculated per chemotherapy cycle in the study, the cost of port insertion was calculated as the cost per chemotherapy. The calculation was made according to the formulas created by the researchers in Table 1.

Table 1 Formulas used in calculating costs
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Data collection took place between 01.06.2020 and 31.12.2020 at Necmettin Erbakan University Meram Medical Faculty Hospital Medical Oncology Clinic. Data collection from the participants was carried out using the face-to-face interview method. The cost data were obtained by interviewing the personnel in the Medical Oncology Billing department.

Inclusion/exclusion criteria

The criteria for inclusion or exclusion of the participants are as follows:

  • The participants were selected from patients with the diagnosis code of ICD-10 “C18-Malignant neoplasm of the colon” in the patient registry system.

  • Patients with primary colon malignancy and metastases, regardless of their site, were included in the study.

  • Receiving chemotherapy treatment during the research period and receiving at least two cycles of chemotherapy before the interview was a requirement for participation.

  • Patients with primary cecum or rectum cancer were not included in the population and sampling.

The criteria for inclusion or exclusion of the invoices are as follows:

  • Service, medicine, and medical consumable cost items are included in the research.

  • Since additional diseases in patients and related tests/examinations may be different, analysis and examination costs are not included in the cost calculations.

  • In addition, since the medicines used did not differ according to the chemotherapy application method, two different total costs were calculated while calculating the total cost, one excluding the medicine and one including the medicine.

Statistical analysis

The Microsoft Office Excel program was used to make cost calculations in the analysis of the research data. Other analyzes were made using the IBM SPSS 20 package program. Before analyzing the data, it was tested whether both scale dimensions and cost data showed normal distribution. According to Plichta and Kelvin [20], the fact that the skewness and kurtosis values are in the range of ± 1.96 indicates a normal distribution. After examining the skewness and kurtosis values of the scale and cost data in the study, we determined that the data showed a normal distribution. In alignment, in addition to descriptive statistics, we used the parametric tests (independent sample t-test and multivariate linear regression analysis).

Results

In this section, we included the descriptive findings of the participants and the comparison of the quality of life and treatment costs according to the chemotherapy administration method.

Table 2 shows the findings regarding socio-demographic characteristics and treatment of the participants. When the distribution of the whole sample is examined, 61.2% of the participants are male, and 78.6% are married. In addition, 54.4% of the participants were above the mean age (62.45 ± 12.17 years), and the ages ranged from 32 to 85 years. The average monthly income of the participants is 2854.85 ± 1767.42 ₺, and 65% of them stated that they have an income below the average. According to the findings on the treatments of the participants, 64.1% of the participants have been receiving chemotherapy treatment for 6 months or less. 71.8% of the participants receive chemotherapy treatment via a venous port catheter, and 56.3% as an outpatient. 82.5% of the participants see colon cancer as a disease that requires long-term treatment but can be treated.

Table 2 Findings regarding socio-demographic characteristics and treatment of the participants
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Table 3 shows the results of the analysis we performed with the independent sample t-test to test whether there was a difference in the quality of life according to the chemotherapy administration methods.

Table 3 Examination of the quality of life of the participants according to the chemotherapy application method
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After examining the functioning scales, we did not observe any statistically significant differences in the total scores, physical functions, role functions, emotional functions, and cognitive functions according to the chemotherapy treatment application methods (p > 0.05). However, we observed that there was a statistically significant difference in the social functions. (p < 0.05). Accordingly, we determined that the social functions of the participants who received chemotherapy treatment with a venous port catheter were significantly lower than the participants who received treatment with a peripheral vein.

After examining the symptom scales, we did not observe any statistically significant difference in the total scores of the participants' symptom status, fatigue, nausea and vomiting, pain, dyspnea, sleep disturbance, loss of appetite, constipation, diarrhea and financial impact (p > 0.05). However, although the difference was not significant, patients who received chemotherapy with a venous port catheter showed relatively more symptoms (except for the symptom of constipation). It is thought that good symptom management is effective in the treatments of those who receive chemotherapy via peripheral vein since they are completely monitored.

After examining the global quality of life, we did not observe any statistically significant difference in the global quality of life scores according to the chemotherapy treatment application methods (p > 0.05). However, we observed that patients who received chemotherapy with a venous port catheter had a relatively higher overall quality of life score, although not at a significant level. It is thought that this is due to the relatively less isolation of patients receiving chemotherapy with a venous port catheter from daily life.

Multivariate linear regression analysis was performed to predict participants' quality of life variables using the independent variables shown in Table 4. As a result of the analysis, a significant regression model (F(5,97) = 3.082, p = 0.013) was found, which explained 9% of the variance in functioning (R2adjusted = 0.093) by the independent variables. Accordingly, seeing colon cancer as easily treatable predicts functioning positively and significantly (β = 0.259, t(97) = 2.662, p < 0.01, pr2 = 0.07). A significant regression model (F(5,97) = 2.695, p = 0.025) was found to explain approximately 8% of the variance in symptom (R2adjusted = 0.077) by independent variables. Accordingly, seeing colon cancer as easily treatable predicted symptom negatively and significantly (β = − 0.321, t(97) = − 3.267, p < 0.01, pr2 = 0.10). Finally, a significant regression model (F(5,97) = 2.877, p = 0.018) was found to explain 8% of the variance in global quality of life (R2adjusted = 0.084) by independent variables. Accordingly, seeing colon cancer as easily treatable predicts global quality of life positively and significantly (β = 0.343, t(97) = 3.508, p < 0.001, pr2 = 0.11). In addition, the independent variables of chemotherapy method, age, duration of chemotherapy and monthly income do not significantly predict functioning, symptom and global quality of life.

Table 4 Quality of life multivariate linear regression analysis findings
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After examining Table 5, we did not observe any significant difference in the total treatment costs of the participants, excluding drugs, according to the chemotherapy administration method (p > 0.05). We observed a statistically significant difference in the service cost, total cost including medicine, medical consumable cost, and medicine cost (p < 0.05). Accordingly, the cost of service for patients who received chemotherapy with peripheral vascular access was found to be significantly higher than for patients who received chemotherapy via a venous port catheter. In terms of medicine cost, medical consumable cost, and total cost including medication, we determined that patients who received chemotherapy via a venous port catheter had higher costs than those who received chemotherapy via peripheral vascular access.

Table 5 Findings on the comparison of treatment costs according to chemotherapy administration method and treatment department (₺)
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Multivariate linear regression analysis was performed to predict the treatment costs of the participants using the independent variables shown in Table 6. As a result of the analysis, a significant regression model (F(4,98) = 4.105, p < 0.01) was found in which 11% of the variance in the service cost (R2adjusted = 0.109) was explained by the independent variables. Accordingly, using the port as a chemotherapy method negatively and significantly predicts the service cost (β = − 0.215, t(98) = − 2.217, p = 0.029, pr2 = 0.05). It was determined that the age variable predicted service cost positively and significantly (β = 0.217, t(98) = 2.256, p = 0.026, pr2 = 0.05). In addition, the independent variables of chemotherapy duration and monthly income do not significantly predict the cost of service. A significant regression model (F(4,98) = 16.195, p < 0.001) was found in which 37% of the variance in medical consumable costs (R2adjusted = 0.373) was explained by the independent variables. Accordingly, using the port as a chemotherapy method positively and significantly predicts the medical consumables costs (β = 0.549, t(98) = 6.757, p < 0.001, pr2 = 0.32). The duration of chemotherapy was found to negatively and significantly predict the medical consumables costs (β = − 0.423, t(98) = − 5.307, p < 0.001, pr2 = 0.22). Finally, a significant regression model (F(4,98) = 4.504, p < 0.01) was found in which 12% of the variance (R2adjusted = 0.121) in total cost excluding medicine was explained by the independent variables. Accordingly, using the port as a chemotherapy method positively and significantly predicts the total cost excluding medicine (β = 0.219, t(98) = 2.279, p = 0.025, pr2 = 0.05). The duration of chemotherapy was found to negatively and significantly predict the total cost excluding medicine (β = − 0.305, t(98) = − 3.237, p < 0.01, pr2 = 0.10). In addition, the independent variables of age and monthly income do not significantly predict the medical consumable costs and the total cost excluding medicine. On the other hand, as a result of multivariate regression analysis, it was seen that the independent variables of chemotherapy method, age, duration of chemotherapy and monthly income did not significantly explain the medicine cost (F = 1.644, p = 0.169) and the total cost including medicine (F = 1.837, p = 0.128).

Table 6 Treatment costs multivariate linear regression analysis findings
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Discussion

The research team thinks that this study, which aims to compare the administration of chemotherapy drugs via a venous port catheter and peripheral vascular access in metastatic colon cancer patients in terms of both quality of life and chemotherapy treatment costs, will contribute significantly to the literature in terms of considering chemotherapy treatment from both the perspective of the patient and the provider institution. Previous studies focused on the quality of life and cost of chemotherapy treatment in outpatient and inpatient or at home and in hospital rather than comparing the quality of life and cost of chemotherapy treatment via a direct venous port catheter and peripheral vascular access. However, in some cases, patients can receive chemotherapy treatment both outpatient and inpatient or both at home and in the hospital via a venous port catheter or peripheral vein. This study differs from other studies in the literature in this respect. In addition, the fact that the scale used in this study to measure the quality of life was developed for cancer patients, and the inclusion of port costs in patients with venous port catheters in the calculation of treatment costs are among the factors that make the research important. On the other hand, the presence of 29 patients in the peripheral vascular access group is an important limitation of the study.

Traditionally, home-based chemotherapy required the treatment to be given under the supervision of a specialist nurse. With ambulatory devices, the term has evolved to include outpatient chemotherapy today. Devices used for this, also known as infusion pumps, allow patients to safely receive unattended long-term infusions at home [21].

In the light of this preliminary information, after examining the quality of life of the participants according to the chemotherapy application methods, the social function means of patients who received chemotherapy via peripheral vascular access are significantly higher than those who received chemotherapy via a venous port catheter. Patients treated via peripheral vascular access require more social support because of reasons such as the treatment in the inpatient unit, the need for hospital attending, or the need for support at home. This is provided by their family members or close circle, and also because of their social relations with their peers during hospitalization, they have higher means of social function scores. On the other hand, as a result of multiple regression analysis, it was seen that the chemotherapy method did not significantly predict the quality of life. Hall and Lloyd [22] emphasized that the home environment increases opportunities for privacy, but the hospital environment also provides the opportunity to meet people with similar illnesses and feelings. Home treatment deprives patients of this. Mcllfatrick et al. [23] also noted in their study that the relationships that patients develop with each other have an impact on their general experience in the hospital environment. However, this effect can be positive as well as negative. Isaksen and Gjengedal [24] emphasized that the positive effects of contact with other patients, such as the exchange of experiences, are most discussed, but some negative experiences (for example, the possibility of experiencing the distress and sadness of others) can have a negative effect. In addition, although not at a significant level, the mean role function (ability to continue work or daily responsibilities and hobby or leisure activities) of patients who received chemotherapy via a venous port was relatively higher than those of peripheral vascular access patients. Anderson et al. [25] also measured whether there was a difference in the quality of life of 16 patients when the chemotherapy drug Gemcitabine was administered at home and in the hospital, respectively. Accordingly, it was determined that when patients received chemotherapy at home, their role functions were significantly higher. In another study, hospitalized patients were much less active in daily tasks than were those treated at home [26]. Stevens et al. [27], who conducted research on children, revealed that home-based chemotherapy provides a better quality of life than chemotherapy in the hospital in a physical aspect. In this study, we think that the higher role function in patients with a venous port is because patients with a venous port are less handicapped by the port. They can continue their daily lives, and they can stand on their own feet better. Although it was not at a significant level in terms of symptom scales score, we observed that patients with venous ports had a relatively higher mean. This is thought to be because most of the treatment in individuals with a venous port is continued at home under the control of the individual, whereas in patients who receive chemotherapy via peripheral vascular access, the treatment continues under monitoring in the hospital. In other words, it is thought to be due to better symptom management in the hospital setting. Vokes et al. [28] stated in their study that patients who refused outpatient treatment reported fear of pump failure, restriction in daily routine activities, frequency of clinic visits, and experiencing side effects of chemotherapy at home as the main reasons. The same patients expressed the reassurance of receiving chemotherapy under supervision as the greatest advantage of receiving chemotherapy in the hospital. In the study of Hall and Lloyd [22], some patients stated that they feel great comfort from receiving chemotherapy in the hospital environment with the confidence of being in the hospital in case of a mishap. On the other hand, studies have reported that there is no significant difference in the rates of side effects between chemotherapy given in the hospital or under surveillance and home-based chemotherapy, although complications related to the devices at home are common [29,30,31,32,33]. These data also support the current research. Finally, when examined in terms of the global quality of life, the mean global quality of life scores of patients who received chemotherapy treatment via a venous port catheter is relatively higher, although it is not at a significant level. It is widely believed that chemotherapy administered in the hospital is perceived as more stressful and has a greater impact on lifestyle [26]. When the studies on this subject in the literature are examined, Anderson et al. [25] draw attention to the fact that although there is no significant difference in the global quality of life, the mean quality of life of the patients is higher when they receive chemotherapy at home. In addition, a previous comparison between home-based and hospital treatment for patients with advanced cancer suggested that home treatment requires fewer analgesics, better survival rate, and less psychosocial morbidity [34]. In the study by Payne [26], it was found that palliative chemotherapy given at home was consistent with a better quality of life than hospital-based chemotherapy. In addition, some studies reported that, the difference in the effectiveness of home-based and outpatient chemotherapy [35, 36] and quality of life scores [37, 38] was not significant. Treatment of patients receiving chemotherapy with a venous port catheter is generally started in the hospital and continues at home. Therefore, in this study, it is thought that the relatively higher quality of life score of patients who received chemotherapy with a venous port catheter was because they were more comfortable in the home environment and received the treatment without any serious restrictions. Studies have shown that patients receiving chemotherapy at home have higher satisfaction rates [35, 39] and feel more comfortable and safer [22].

After comparing the treatment costs according to the chemotherapy application method, we found that the service cost of the chemotherapy application via a venous port catheter was significantly lower than the peripheral vascular access, while the cost of medicines and medical consumables were found to be significantly higher. In addition, chemotherapy via a venous port catheter has a significantly higher cost in terms of total cost including medicine. It is thought that the difference in the service's cost is because patients receiving treatment via peripheral vascular access generally receive treatment in inpatient unit for about 3 days (bed fee, companion fee, etc.). In terms of medical consumable costs, it is known that patients with a venous port catheter normally have lower medical consumable costs (51.46 ± 18.81 ₺) than those who receive treatment via peripheral vascular access. However, as stated in the method section, the cost of inserting a port before the first treatment was also considered when calculating the costs of patients with a venous port catheter. After examining the port costs, we observed that there is no drug cost in the port insertion process, but there is an average service cost of 149.07 ₺ and a medical consumable cost of 682.37 ₺. Moreover, since approximately 65% of the participants in the study have received treatment for less than 6 months, a high average cost per session emerges when the port costs are distributed over the number of sessions. Although a significant difference was found in the medicine's cost and the total cost including the medicines, the insertion of the port does not create any extra costs on the drugs used. Because we confirmed by interviewing the physicians that the drugs were determined entirely according to the disease status of the participants. Based on all these, it is thought that the main reason for the difference in comparisons involving drug costs is not due to the chemotherapy administration methods and that this is due to the use of different drugs according to the treatment of the patients. In fact, in the multiple regression analysis, it was observed that the chemotherapy method significantly predicted the service and medical consumable costs and the total cost excluding medicine, but did not significantly predict the medicine costs and the total cost including medicine. Evidence suggests that home-based chemotherapy costs are similar to or slightly higher than hospital chemotherapy [40]. The results of the study conducted by Remonnay et al. [41] also show that the marginal cost of home-based chemotherapy is significantly higher than that of hospital chemotherapy. Rischin et al. [33] noted that home-based treatment resulted in a cost increase of $83 for each chemotherapy treatment compared to hospital-based treatment. The results of the research conducted by King et al. [36] show that there is an additional cost of 68.81 US dollars per visit for home treatment. However, there are also studies stating the opposite of these findings and that the costs of home-based chemotherapy treatment are lower [29, 35, 38, 42]. In addition to these two perspectives, two different studies conducted in the United Kingdom showed that there is no difference in cost between the hospital, outpatient, and home-based chemotherapy administration [22, 43]. Hirtzlin and Préaubert Hayes [44], on the other hand, with a different perspective from all of these, stated that the cost of outpatient chemotherapy treatment is higher than the cost of home-based treatment. Moreover, it has been stated that the cost of the treatment is even higher when the inpatient treatment in the hospital lasts for a few days. On the other hand, calculations have shown that when home-based treatment continues for 7–8 days, home care becomes more costly than hospitalization [44]. Based on all these data, studies conducted in this area have revealed different results. One of the biggest factors in this is that the methods used for cost calculations are different from each other.

In this study, the costs were calculated over the invoices issued to the SSI, in other words, the direct costs and the costs were handled from the perspective of the hospital that provides services. However, in some studies, calculations were made based on out-of-pocket costs from the perspective of the patient, and in some studies, indirect costs were included for the institution. In addition, while port insertion costs were included in the cost calculations in this study, no statement was found that port insertion costs were included in the cost calculations in any of the other studies in this area. Therefore, it is thought that the fact that the patients receiving treatment with a venous port catheter in this study have higher amounts in cost items other than the cost of service is due to the inclusion of port insertion costs in the calculations.

After considering the results of quality of life and cost of treatment regarding treatment methods simultaneously, it is important to consider some factors when choosing this method, since the use of a venous port catheter does not significantly increase the quality of life in general and the treatment costs are relatively higher. Although chemotherapy via a venous port catheter is a relatively new method, trying to apply this method to every patient may cause difficulties for both the patient and the institution. For this reason, it is recommended that the group of patients who will be using venous port catheters consist of people whose chemotherapy treatment will continue for a long time, people with problems in peripheral vascular access (such as children and elderly patients), people with advanced disease and that these people prefer this method voluntarily is thought to be more beneficial. In other words, the main criterion in the selection of the chemotherapy method to be used should be the selection of the method to be used according to the patient and treatment characteristics, rather than the understanding of applying the new method to each patient. In addition, even if a venous port catheter is inserted, the hospital inpatient treatment of patients whose disease has progressed significantly, who cannot manage their symptoms, and who are in a vulnerable condition, is another important factor that needs to be emphasized.