The field of oncology is ripe with new therapeutics with over 800 new medicines in development in 2015 and 80 percent of those representing new molecular entities (Medicines in development for cancer 2015; http://phrma-docs.phrma.org/sites/default/files/pdf/oncology-report-2015.pdf). Traditional chemotherapy agents are given intravenously for which the patient presents to an outpatient infusion center or inpatient hospital setting to receive their infusions. This paradigm has been shifting the last 10 years as many of the new agents in development are administered orally. Studies have shown that patients prefer oral over IV administration with convenience of administration being cited as a major reason (Ann Oncol 2006;17:205-210). One potential downside of oral administration is the patient is responsible for adhering to a chemotherapy regimen with known side effects and often a complex administration schedule.
Adherence as defined by the World Health Organization as the extent to which a person's behavior-taking a medication, following a diet, and/or executing lifestyle changes-corresponds with agreed recommendations from a health care provider (Adherence to long-term therapies: evidence for action 2003; http://www.who.int/chp/knowledge/publications/adherence_full_report.pdf). A troubling statistic is that adherence to oral chemotherapy can be less than optimal; ranging from 16 percent to 100 percent in some studies (Acta Clin Belg 2011; 66:85-96). Former Surgeon General C. Everett Koop once stated that medications don't work in patients who don't take them. This is especially true in cancer treatment because the consequences of non-adherence include disease progression or lack of efficacy, increased risk of toxicity, and increased health care costs.
The various factors that affect adherence have been described in the literature fall into one of five categories: patient-related; disease-related; therapy-related; social or economic-related; and health care team or system-related (Semin Oncol Nurs 2011;27(2):133-141). Patient and condition-related factors are closely intertwined and include the patient's cognitive ability and co-morbidities that may interfere with their ability to take their medications. Therapy-related factors include those inherent to the medication itself, such as adverse effects, dosing frequency, administration in relation to food and other drugs, and safe handling. Socioeconomic-related factors include the cost of treatment, distance to the treatment center, and social support. Health care team factors include the doctor-patient relationship, education prior to starting therapy, and the provision of appropriate follow-up.
To address these factors, one must understand the strategies most effective for improving adherence in this patient population. Pharmacists are uniquely positioned within the health care team to be able to address these factors, and ultimately ensure safe administration of oral oncology agents and management of adverse effects.
Strategies for Promoting Adherence
A multifaceted, patient-specific approach should be developed that addresses the particular barriers affecting medication adherence. The literature regarding the effectiveness of adherence interventions is sparse and often conflicting. Also, multiple factors affecting a patient's adherence are usually in play at any one time, thus a single strategy approach would likely be ineffective. The remainder of this article will discuss various strategies for promoting medication adherence.
Patient education is imperative for the provision of all types of health care, and each member of the health care team should provide patient education relevant to their expertise. Limited evidence exists on the effect of structured patient education on adherence to oral chemotherapy. However, there is a need for a more standardized approach to address medication teaching so patients receive the necessary information to safely and effectively administer their medication at home.
The Multinational Association of Supportive Care in Cancer (MASCC) recognized this need and developed the Oral Agent Teaching Tool. It provides a framework for educating patients being initiated on an oral chemotherapy agent and is freely available for clinician use. The MASCC tool was used in a cohort of lung cancer patients, and the authors found it could be adapted to drug-specific information and tailored to the individual patient's needs (Oncol Nurs Forum 2015;42(4):383-389). When developing materials for patient education, it is important to keep in mind the varying degree of health literacy among patients. Therefore, educational materials should be written in plain language, and clinicians should utilize teach-back methods to ensure patient comprehension.
Patient drug procurement should be a top priority of focus when identifying ways to promote adherence. Insurers and drug manufacturers often require dispensing oral oncology agents through a specialty mail-order pharmacy, and many patients do not have experience navigating these pharmacy entities. In addition, oral oncology medications have high monthly copays, and high out-of-pocket cost for the patient has been associated with decreasing adherence (J Manag Care Spec Pharm 2017;23(6):643-652). Health care providers should be discussing with patients whether they can afford their medications. Medication access specialists with knowledge of insurance prior to authorizations and medication assistance programs can be very helpful in navigating the patient through the process and reducing the lag time between medication prescribing and procurement.
A patient forgetting to take their medications is often cited as a top reason for non-adherence, so medication reminders are commonly utilized (J Oncol Pharm Pract 2017; doi:10.1177/1078155217704989). Patients should be encouraged to take their medication at the same time each day as a way to promote adherence. Also, associating their medication administration time with other daily tasks can assist in remembering to take the medicine. Organized pill boxes or medication diaries have the visual component of alerting patients to whether they've taken their dose for the day. In the era of technology, patients can download medication reminder applications on their phone as a measure to promote adherence. It doesn't matter which reminder tool is selected as long as the patient knows how to use it and will utilize it regularly.
Adherence is an important factor when considering various treatment options for patients with cancer. As more oral medications come to the market, ensuring patients take their medications appropriately will fall upon all members of the health care team. Physicians, pharmacists, and nurses should be appropriately educating patients about their oral medications and emphasizing the importance of adherence. The above strategies can be tailored to help improve adherence in each individual patient.
JEFF A. ENGLE, PHARMD, MS, and LISA LOHR, PHARMD, are both at the University of Minnesota Medical Center, Fairview Pharmacy Services, Minneapolis.
Pharmacy Forum
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