The value of time savings in breast cancer therapy for patients and healthcare providers: the subcutaneous injection of pertuzumab and trastuzumab fixed-dose combination at a tertiary care center in the UAE

The objective of the study was to measure time saving and indirect cost saving associated with using PH FDC SC compared with IV infusion of pertuzumab and trastuzumab in patients with HER2-positive breast cancer. The SC FDC was associated with a significantly shorter duration of treatment administration by nurses and patient length of stay, as well as shorter pharmacist preparation time with the SC formulation. This was in line with a substantial body of evidence demonstrating the time-saving aspect of PH FDC SC [8]. In addition to reduced administration time, the SC formulation has offered several advantages including more patient convenience, improved health-related quality of life, optimized healthcare resource utilization (HCRU) and minimizing costs of cancer treatments [8,12–14].

In the present study, optimizing HCRU was achieved through reduced patient chair occupancy and saving healthcare providers’ time (nurses and pharmacists). Similar findings were demonstrated in the time-and-motion substudy of the PrefHer trial as well as in other studies [8,9,15]. To accurately understand the operational impact, it is important to distinguish between ‘active nursing workload’ and total ‘chair occupancy duration’. Even though a nurse only spends a few minutes active at the start and end of an IV, the patient continues to occupy a treatment chair for the entire duration of the infusion. Specifically, the duration of nurse administration of treatment was significantly shorter in the SC arm (5.0 ± 0.4 vs 109.7 ± 27.7 min; p < 0.001), representing a 95.4% reduction in active nursing workload. The mean nurse time saved per cycle (104.7 min) represents a comprehensive reduction in workload across the entire patient encounter (encompassing preparation, administration and monitoring). Assuming a 100% switching rate of all IV patients to the SC formulation for the study cohort of 75 patients undergoing 18 cycles per year (1350 annual visits), this would result in a total of 2355.75 annual nursing hours saved (equivalent approximately to 294.5 full working days based on an 8 h workday). The true institutional advantage is that the SC formulation frees up chair capacity much faster and clears those chairs for other patients almost immediately. Furthermore, total chair occupancy was significantly shorter in the SC arm (50.2 ± 37.0 vs 154.8 ± 37.8 min; p < 0.001), reclaiming 104.5 min (~1.75 h) of physical chair capacity per patient visit. For the annual cohort of 1350 visits, this represents 2351.25 reclaimed chair hours. Based on an average chemotherapy infusion duration of 1.5 h as per the oncology pharmacy manual of the institution, this saved chair capacity would allow the center to accommodate approximately 1567 additional chemotherapy infusions annually (calculated as 2351.25 h/1.5 h). This significant increase in throughput equates to roughly 8 ± 2 additional daily patient appointments, providing actionable evidence for hospital administrators to optimize existing treatment space and reduce patient waiting lists in the oncology service. For pharmacist preparation time, time spent by the pharmacist to prepare three IV infusions was also the same time they will spend to prepare five SC injections. Applying the same 100% switching rate, the institution would save 112.5 pharmacist hours every year (~14 full working days of pharmacy productivity).

Consequently, enhanced patient throughput and shorter waiting lists would be expected. Alternatively, time saved by healthcare providers could be redirected to other patient care activities, thereby improving overall staff efficiency in treatment centers and optimizing HCRU within the treatment center. The difference between IV and SC formulations represents the closest estimation of annual indirect cost savings. In this study, the per-visit savings in nurse administration (87.25–174.5 AED, equivalent to 23.8–47.6 USD) and pharmacist preparation (8.3–12.5 AED, equivalent to 2.3–3.4 USD) were multiplied by the annual cohort of 75 patients undergoing 18 cycles (1350 visits). This extrapolation yielded nurse administration time savings of 117,787 to 235,575 AED (equivalent to 32,094 to 64,189 USD) annually, while pharmacist preparation time savings corresponded to 11,250 to 16,875 AED (equivalent to 3065 to 4598 USD) annually. Together, these extrapolated figures reflect a total potential annual indirect cost saving of 129,037 to 252,450 AED (equivalent to 35,160 to 68,787 USD), derived from a total of 2468.25 clinical hours recovered annually across nursing and pharmacy services. These are potential savings based on assumed hourly rates, as actual institutional rates are confidential. According to internal analyses conducted in 2022 and 2023 at Tawam Hospital (preliminary internal audit), eliminating drug preparation and infusion time because of switching from IV to SC formulation resulted in substantial labor savings: 99,855 min (≈1664 h) in 2022 and 105,650 min (≈1761 h) in 2023 from combined pharmacy and nursing time. While these internal figures confirm the overall trend of institutional efficiency, they were derived using a different calculation methodology and sample size than the current study; nonetheless, both datasets underscore the consistent operational gains achieved through SC administration. These figures highlight the operational efficiency gains in terms of labor hours saved when switching from IV to SC administration, without reference to drug acquisition cost differences or individual drug costs, which remain confidential.

Nondrug costs were reduced after switching from IV to SC formulation. A cost-minimization analysis reported similar findings; PH FDC SC was estimated to reduce nondrug costs by 73–80% in Western Europe, and 75% in the USA [16]. The findings at Tawam Hospital mirror these international trends; as the locally observed 95.4% reduction in active nursing workload and significant chair-time recovery (104.5 min per visit) confirms the massive efficiency gains seen in hospitals worldwide. This reduced nondrug cost was mainly in terms of savings in patient chair time and to a lesser extent patients' productivity loss. Moreover, similar analyses reported that PH FDC SC was associated with significant reduction in the cost of nondrug consumables [9,17]. PH FDC SC contributes to considerable healthcare cost savings, consequently, reducing the overall financial burden on healthcare systems. Such reduction would contribute to the long-term sustainability of the healthcare spending, while still providing a safe and effective therapy.

From a patient’s perspective, PH FDC SC was preferred over the conventional IV formulation [4,11]. This preference was driven by the shorter administration time, the convenient and comfortable administration process, and positive impact on patients’ quality of life [4,8,11]. While these benefits have been well-documented for other SC oncology formulations, they are particularly relevant to PH FDC SC, which further optimizes the treatment process by combining pertuzumab and trastuzumab into a single injection. In terms of patient convenience and preference, the concept of flexible care has been an attractive alternative to traditional therapy administration in hospital settings. By taking advantage of these established SC formulations in cancer therapy, flexible care allows patients to receive their cancer therapy at home or in primary care settings. Consequently, patients would be able to maintain their regular daily activities regularly, while reducing healthcare system costs in terms of healthcare providers time and hospitals occupancy. Present findings suggest this move toward flexible care is a perfect fit for PH FDC SC, mainly because the drug is so much faster and easier to give than traditional IV infusions.

Notably, while prescribing information recommends a post-treatment monitoring period of only 15–30 min for the SC formulation [6], a duration of 45 min was observed in the current real-world study. This discrepancy suggests that actual clinical practice at the center currently includes additional observation time beyond the minimum requirements, likely due to institutional workflows, concurrent nursing assessments, or the initial implementation phase where nursing staff exercised additional caution while becoming familiar with the new FDC formulation. In real-world settings, recorded monitoring times often deviate from strict guidelines due to practical variables such as coordinated patient discharge, transport logistics or administrative documentation. By strictly adhering to the 15 min observation protocol once the formulation is fully integrated into routine practice, the center could realize even greater time-saving benefits. Our data confirms that monitoring time savings were indeed captured and contributed to the total mean nurse time saved, though the magnitude of the difference reflects real-world institutional practice at Tawam Hospital rather than a controlled trial environment. Additionally, the time needed by the pharmacist to prepare a SC dose is estimated at 5 min, compared with the 8 min recorded in the present study. This 3 min variance is largely attributed to the required period for the FDC formulation to reach room temperature after being removed from refrigeration, as well as institutional logistical steps such as order verification, batching and internal delivery, rather than a lack of efficiency in the technical preparation itself. This indicates that the time-saving potential with the SC formulation is still to be fully achieved by minimizing both the pharmacist preparation time of SC injection and the post-treatment monitoring to match what is recommended in the summary of product characteristics. Aligning local workflows with these 5 min preparation and 15 min monitoring targets will be reflected in relevant cost saving greater than what was achieved so far. The data also did not take into consideration the direct cost saving from reduced use of consumables (IV infusion bag, infusion line and catheter are needed for the IV formulation vs a 10–15 ml syringe, a transfer needle and a 25–27G injection needle needed for the SC). Factoring in the differential cost of consumables between formulations would further increase the estimated economic benefit of SC administration.

The first limitation in this study is that it was conducted in a single center. Healthcare practices and resources may not represent those in other hospitals across the UAE; thus, the findings may not be generalizable to other hospitals where resource allocation, clinical practice, and treatment processes differ. However, the alignment of our data with global findings suggests these efficiencies are achievable in similar settings. Second, time efficiency observed in this study may be influenced by the specific workflow and infrastructure of the study site. Third, cost savings were calculated based on local costs of the center, which may vary widely between institutions and countries. In addition, the cost of medical supplies/consumables (e.g., IV infusion bags and lines for the IV arm vs syringes and needles for the SC arm) were not included in the analysis. Given that SC administration significantly reduces the volume and complexity of required materials, the current figures likely represent a conservative underestimation of the true total economic benefit of the SC formulation.

In conclusion, PH FDC SC was associated with significant time savings for both patients and healthcare providers, including shorter nurse administration and pharmacist preparation times. Switching from IV to SC administration reclaimed a total of 2468.25 clinical hours annually (equivalent to ~308.5 full working days) across nursing and pharmacy services for a cohort of 75 patients undergoing 18 cycles (1350 visits). These time savings translated into notable indirect cost reductions ranging between 129,037 AED and 252,450 AED (equivalent to 35,160 to 68,787 USD) annually, derived from nurse and pharmacist labor time and assumed hourly rates. Also, this transition provided indirect benefits such as shorter patient stays, reduced chair occupancy and increased chair capacity, leading to improved workflow efficiency. These findings highlight the potential of PH FDC SC to improve operational efficiency, optimize resource utilization and enhance patient experience within cancer treatment centers. Further multicenter studies are needed to confirm the generalizability of these results across different healthcare settings.

The author contributed to the conception and/or design of the study, acquisition of data, and data analysis. The author agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

The author would like to acknowledge Phoenix Clinical Research for the support in the preparation of this manuscript. This assistance was carried out in accordance with Good Publication Practice (GPP 2022) and the ICMJE requirements. The author also acknowledges the senior clinical pharmacists at Tawam Hospital, Dr Lina Wahba, and pharmacy supervisor, Dr Syam Varghese, at Sheikh Tahnoon Bin Mohammad Medical City for providing data from internal cost saving and quality improvement projects. The views and opinions expressed are those of the author.

Funding this manuscript was provided through a grant from Roche Pharmaceuticals Middle East FZCO to SEHA, UAE.

The authors have no competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Funding for medical writing was provided through a grant from Roche Pharmaceuticals Middle East FZCO to SEHA.

This retrospective study was conducted in accordance with the Declaration of Helsinki, the study protocol, and in compliance with the applicable regulatory authority requirements in the participating site. It was also conducted in accordance with scientific purpose, value and rigor, and follow generally accepted research practices such as Good Pharmacoepidemiology Practices (GPP) issued by the International Society for Pharmacoepidemiology (ISPE). A documented waiver of the informed consent was granted in accordance with local regulatory authorities and IRB/IEC.

The authors certify that this manuscript reports the original results of a real-world evidence study. A prespecified study protocol was developed, which is not publicly available. Data underlying the findings of this study are available upon request, and is to be checked locally on site – cannot be shared online. The study was reported in accordance with STROBE.

This work is licensed under the Creative Commons Attribution 4.0 License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/