Tackling Adherence as More Oral Therapies Come to Market
As many as 25%–30% of all new antineoplastic agents in development are estimated to be oral, and almost half of the 300 medications in phase II and III clinical trials are oral medications. A paradigm shift is taking place in chemotherapy delivery. During a session at the Oncology Nurse Advisor Navigation Summit (http://media.oncologynurseadvisor.com/documents/303/ona_navsum_2017_tipton-webvers_75666.pdf), ONS member Jan Tipton, MSN, RN, AOCN®, at the University of Toledo Medical Center in Ohio, discussed how cancer is making a shift to oral medications.
Oral therapies require less supervision because of administration in the home setting, fewer office visits and interaction with the healthcare team, and a change in process for prescription receipt, education, and monitoring for side effects.
However, adherence to oral agents is reportedly less than 80%, with up to 10% of patients not refilling their prescriptions for oral agents. These adherence rates may be inadequate for treating cancer and could impact outcomes, Tipton said.
Factors related to nonadherence include demographics (less education and income), psychosocial (less social support, depression), and perception (lower perceived necessity of medication). Nonadherence is also associated with more comorbidities, toxicity and polypharmacy, more hospitalizations, less frequent communication, and greater out-of-pocket costs.
To date, no clinically defined threshold exists for medication adherence to oral antineoplastic therapies, Tipton said, noting that further research is needed. She said some evidence-based interventions that are likely to be effective are patient monitoring through text messages and automated voice response, as well as treating any underlying depression. Evidence-based interventions that do not have established effectiveness include education, cognitive-behavioral therapy, motivational interviewing, packaging, less frequent dosing, reminders, automated dispensers, provider monitoring and feedback, decision and calendar aids, mail and online refills, institutional level interventions, supportive interventions, workplace care delivery, intervention to improve provider communication, and cost and copay reduction.
Tipton concluded by discussing some practice changes to navigate patient adherence. She said to integrate validated assessments of adherence at every clinic visit, asking questions like, “How well have you been taking your medications prescribed during the past week?” (very poor to excellent) and “What percentage of the time did you take your medication as prescribed over the past week?” (0%–100%). Affirmative questions are more likely to yield reliable and accurate results she said, offering the example question, “How many doses did you miss in the last week?”
She also pointed to a multidisciplinary team, including oncology nurses, pharmacists, providers, and administrators, who are necessary to examine oral chemotherapy delivery, safety, and associated care. Providers should also assess patient and caregiver learning needs and tailor educational materials, tools, and technology to best fit each patient’s needs and lifestyle.
Patient navigators have a critical role in follow up, she said: Trust and consistency. Follow up with phone calls, emails, text messages, video conferencing, patient portals, drop-in visits, or whatever is needed to best suit each specific patient and caregiver.