With an increasing number of cancer therapies being delivered orally, the importance of adherence continues to grow, and efforts to adapt adherence programs from other conditions like HIV could lead to better outcomes.
When treating HIV, adherence to prescribed medication schedules is strongly related to the degree and durability of viral suppression and is associated with decreased rates of progression, hospitalization, and mortality. HIV therapies are similar to oral cancer therapies in many respects. The regimens are complex, with multiple side effects, a high degree of toxicity, and a high pill burden.
Adherence programs that emphasized individual interventions, as well interventions of longer duration and those targeting practical medication management skills, met with greater success than initiatives that focused on behavioral or motivational approaches, according to Pamela Ginex, EdD, RN, OCN, a nurse researcher at Memorial Sloan Kettering Cancer Center in New York, in a podium session May 1 at the 39th Annual Oncology Nursing Society Congress in Anaheim, California.
Oral oncolytics offer the advantage of greater patient convenience, no need for IV access, the ability to achieve sustained drug levels, and minimal disruption to the patient’s daily life. However, disadvantages include increasing the distance from provider to patient, with fewer safeguards for administration, and patients bearing more responsibility for their own care.
In their key position as caregivers, nurses are seen as crucial to maintaining adherence. Nurses should be involved in the early process of establishing adherence, as nurses are more likely to consider factors involving the family and living situation than other healthcare professionals—factors that may have a significant impact on whether a high degree of adherence occurs, said the researchers.
“Nurses, in collaboration with other healthcare professionals, play a pivotal role in developing and implementing those studies,” said co-presenter Laura Fennimore, RN, DNP, director of Clinical Programs at the University of Pittsburgh Medical Center (UPMC) Health Plan. “Nurses continue to be the best advocates for our patients on oral treatment.”
Fennimore classified the various factors influencing adherence into categories of patient condition, type of therapy administered, and factors related to clinicians. Patient condition–related factors include cognitive impairment, comorbidities (particularly depression), anxiety, beliefs about treatment and outcome, health literacy, and substance abuse. Family stability and social support are crucial to adherence success as well.
Therapyâ€related factors include the types of side effects that might occur, the length and complexity of treatment, pattern of dosing, and interactions with other prescribed medications. Simple dosing presents the fewest challenges, but 10% to 40% of patients on even a simple regimen still had imperfect dosing. Adherence is also seen as inversely proportional to frequency, with average adherence rates of just 50% for four times–daily dosing. Clinicianâ€related factors were said to include quality of aftercare management, communication skills, belief in treatment, and quality of provider–patient relationship.
Based on studies in oral chemotherapy for cancer and in the field of HIV treatment, both educational and technologically-based interventions show considerable promise to increase adherence, said the researchers. However, more research on what constitutes effective strategies for boosting adherence is needed.
“Oral therapy for cancer treatment is here to stay and only going to increase as additional agents are developed,” the presenters concluded, and “nurses should have a significant presence in planning for patients care, research, and guidelines related to oral cancer treatment.”
Among the resources available to help nurses optimize patient adherence to oral medications is the ONS Oral Adherence Toolkit, available at https://www.ons.org/sites/default/files/oral%20adherence%20toolkit.pdf
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