When considering the importance of medication adherence, former US Surgeon General C. Everett Koop said it best: “Drugs don’t work in patients who don’t take them.” That was 35 years ago, and the issue remains a major area of concern for clinicians today.

Many prescriptions are never filled—and even when filled, they often are not taken as prescribed. Stay-at-home orders from the coronavirus disease 2019 (COVID-19) pandemic may be making things worse.

As the pandemic continues to spread, medication adherence has never been more critical, especially for elderly patients and those with chronic conditions who are the most susceptible to complications, including death, from COVID-19, according to the Centers for Disease Control and Prevention. To protect the most vulnerable patients, physicians and pharmacists must work together to identify the reasons patients aren’t taking their medications as prescribed and provide solutions that improve adherence.

There are 3 primary reasons patients don’t fill prescriptions or take their medications as directed: high cost, lack of symptoms, and forgetfulness.

A major contributor to medication nonadherence is high out-of-pocket costs for prescription drugs. Results of a study published in Annals of Internal Medicine also found a direct correlation between the amount of a patient’s copay and the likelihood of prescription abandonment. Patients with $50 copays were nearly 4 times more likely to abandon a prescription at a pharmacy than patients paying $10.

Today, millions of Americans have lost their jobs, their health insurance, and the incomes they used to pay for out-of-pocket health care costs. One in 7 report they would avoid seeking care for potential COVID-19 symptoms because of cost concerns, according to a recent Gallup-West Health poll. Unless patients find some financial relief, medication nonadherence rates surely will rise.

Lack of symptoms and misunderstanding of disease

Patients often do not understand why they need certain medications. It’s not uncommon for a person to say they don’t feel their blood pressure is high or that they don’t have any symptoms from high cholesterol. If they don’t feel sick, people may stop taking their medications, which can have serious consequences over time. This situation often leads to unnecessary visits to the emergency department and, occasionally, hospital admissions that could have been avoided. During the current health crisis, we have all been encouraged to stay at home, limit trips to the grocery store and pharmacy, and postpone nonessential medical care. This means patients may have less interaction with physicians and pharmacists who can educate them about prescribed therapies. Now is the time for care team members to adopt proactive measures to make sure patients understand what their medications are for, how to take them, and why doing so as prescribed is important.

Delaying or forgetting to pick up prescriptions

Even in life before the pandemic, it was easy to put off a trip to the pharmacy for a prescription. Now, as many of us remain sheltered at home, it’s a challenge to recall what day it is, much less remember to pick up a prescription.

Using reminder tools that notify patients when medications are prescribed and when they are ready to be picked up, pharmacists and physicians can help reduce prescription abandonment. Many independent pharmacies and national chains are offering free delivery services for prescriptions, which is particularly beneficial for patients who feel leaving home could compromise their health. Additionally, health plans have eased restrictions on filling prescriptions in larger quantities, reducing trips to the pharmacy.

Improving medication adherence with technology

Care team members can improve medication adherence and health outcomes by leveraging technologies that provide price transparency, offer access to educational materials, and send reminders directly to patients’ mobile devices. Technology also can facilitate secure communication between prescribers and pharmacists.

For example, when prescribers see patient-specific drug pricing details at the point of encounter within prescribing workflows, it empowers them to discuss formulary options and out-of-pocket costs with patients and potentially review financial assistance options if cost is a barrier. Real-time price transparency tools let patients know exactly how much their medication will cost before going to the pharmacy. These tools eliminate the “sticker shock” experienced when the pharmacist accesses the patient’s health plan benefits to discover the medication is unaffordable for the patient.

Care providers also can reduce financial barriers with new technology that gives patients direct access to copay assistance options. Emerging solutions may link patients to educational content about prescribed medications, giving them a better understanding of the prescribed therapy.

Thomas E. Sullivan, MD, is chief strategy officer and chief privacy officer for DrFirst. He is a board-certified cardiologist and internal medicine specialist with more than 40 years of clinical practice, and he is a past president of the Massachusetts Medical Society.

Improve Medication Adherence With Technology

Thomas E. Sullivan, M.D.

Regulatory demands, scarcity of trained oncology pharmacists, and the increasingly high cost of drugs are some barriers to optimal pharmaceutical support of patients, says Howard Cohen, RPh, MS, FASHP. Cohen is director of oncology pharmacy services, Smilow Cancer Center, Yale New Haven Health. In this video, captured during the 2018 National Community Oncology Dispensing Association (NCODA) Fall Summit, he discusses the challenges of cancer treatment from a pharmacy perspective.

Howard Cohen, RPh, MS, FASHP, director of oncology pharmacy services, Smilow Cancer Center, Yale New Haven Health, discusses the challenges of cancer treatment from a pharmacy perspective.

Challenges in Oncology Pharmacy

	Howard Cohen RPh, MS, FASHP, is Interim Associate Director, Oncology Pharmacy at the Smilow Cancer Hospital at Yale-New Haven.

The Smilow Cancer Hospital at Yale-New Haven is an NCCN- and NCI-designated cancer center. Over the past several years, process improvements in the care of our oncology patients have been implemented that focus on the provision of safe and high quality clinical care and employee safety. These process improvements included implementation of Epic EMR, development of standardized oncology treatment protocols, and a standardized multidisciplinary approach to patient care. 

While tremendous work has been accomplished within our clinics, care centers and inpatient units, little has been done with regard to the oral chemotherapy drugs that are prescribed for home administration by our ambulatory patients. It is widely recognized that these oral drugs are considered hazardous medications that carry with them potential safety and quality of care issues. Patients prescribed oral chemotherapy and targeted therapies should be supported, educated, and monitored with the same vigilance as those receiving chemotherapy in our clinics and inpatient units.

We need to ensure patients have access to the oral chemotherapy drugs and adhere to the oral chemotherapy regimens. We need to educate our patients about potential toxicities and serious side effects. We need to understand that when we prescribe an oral chemotherapy agent, we shift much of the responsibilities of managing the treatment regimen including the monitoring and potential toxicities from the oncology care team to the patient. In 2013, our ASCO QOPI (Quality Oncology Practice Initiative) certification visit identified oral chemotherapy as an area that needed attention. A standardized program for oral chemotherapy was needed to effectively monitor and improve patient outcomes.

In an effort to address the management of oral chemotherapy medications, we first conducted a survey of all clinical staff to determine satisfaction with the current processes, and to identify gaps within our system. Many issues were identified and included the following:

		Lack of feedback from specialty pharmacies

		Variable documentation and inconsistent oral chemotherapy tracking

		Delays with patients obtaining their medications

		An overall lack of a coordinated patient communication and education plan

A chartered multidisciplinary task force met over the course of 4 months to reach the goal of developing a specific program for patients prescribed oral chemotherapy that would: (1) help to identify all patients prescribed oral chemotherapy; (2) standardize the process of the oral chemotherapy prescription, including patient consent; (3) ensure patient access to oral chemotherapy drugs; (4) ensure clinical support, including patient education and counseling and ongoing monitoring.

	The Epic oral chemotherapy treatment plan development included a clinical review by oncology trained pharmacists and nurses.	

			All patients prescribed oral chemotherapy receive pretreatment evaluation and patient consent.

			A plan for staff and patient caregiver education

			A work plan that would decrease delays in patient access to oral chemotherapy medications, including the development of a specialty pharmacy that would serve as a hub for all discharged oral chemotherapy prescriptions

			Only one cycle of treatment would be dispensed at first cycle of treatment, and all prescriptions would be dispensed in blister packaging to avoid contact with the hazardous medications.

			All prior authorizations will be completed, and patients would be given a choice to have their prescriptions filled by our specialty pharmacy or at a specialty pharmacy of their choice. Additionally, we included our Medication Assistance Program (MAP) to assist indigent patients with access and reimbursement issues regarding oral chemotherapy.

			A plan to provide ongoing patient education and counseling

			An ongoing process for the monitoring of the patient for regimen specific adherence and compliance with flow sheet documentation and follow up

			A process to ensure ongoing toxicity assessment and early identification of side effects

			An ongoing evaluation process, including quality assurance, and patient and staff satisfaction

We also wanted to ensure patient safety and compliance by establishing an ongoing and regimen-specific adherence and toxicity assessment program that would include early identification of side effects.

Recognizing high patient copayments, limited access to medications, and several other patient barriers, we decided to include the development and implementation of a specialty pharmacy in our improvement plan. The specialty pharmacy would serve as the hub to identify all patients prescribed oral chemotherapy and triage all prescriptions.

Given the oral chemotherapy team acknowledged that oral chemotherapy medications are classified as hazardous medications that bring about concern for patient safety, we first created a current state process map, identified potential risk points through a gap analysis process using a cause-and-effect diagram, and then mapped our ideal approach to ensure both safety and quality.

A final oral chemotherapy process map was developed that detailed our care model to support patients receiving oral chemotherapy (

Implementation of the new oral chemotherapy care model will include a pilot in several adult ambulatory Cancer Care Centers and one oncology disease team. The success of the pilot would allow for hospital-wide expansion.We believe that the care model that has been developed will improve care for our patients who are prescribed oral chemotherapy. We recommend the ongoing review and adjustment of our workflow and the development of programs that address approaches for safe administration of oral chemotherapy.

Over the past several years, process improvements in the care of our oncology patients have been implemented that focus on the provision of safe and high quality clinical care and employee safety. 

Improving Safety and Quality with Oral Chemotherapy

Howard Cohen RPh, MS, FASHP

Or in the case of my son Andy, your grandfathers’ cancer.  As members of Tom Brokaw’s “greatest generation,” Andy’s grandfathers took up smoking at an early age, but subsequently they heeded the Surgeon General’s warning and quit. Cessation didn’t spare either man a later diagnosis—in one case 25 years later&mdash;of terminal lung cancer.

Twenty months ago Andy learned the hard way that lung cancer isn’t just for smokers. Despite a history of never smoking, Andy was diagnosed at Stage IV and now faces not only his disease but a persistent stigma surrounding lung cancer victims that their disease has been self-inflicted by smoking. A lack of sympathy among the general public has led to lung cancer research being severely underfunded in comparison to other cancers.

While I can accept that my son has been dealt a bad hand, I will not accept the second class citizenship he endures due to a stereotype that assumes he is twice his age and a smoker. Tragically, Andy is far from alone. In fact, as a stand-alone disease, lung cancer in never smokers is the 6th leading cancer killer in the United States and the world’s number one cancer killer annually. And it strikes young adults like Andy, who is 34, at an alarming rate. A beautiful and supportive wife, 3 cute kids, and an army of family, friends, and strangers help Andy keep his hope alive.

Fortunately for us, Bonnie J. Addario doesn’t accept lung cancer’s stigma either! The foundation bearing her name is funding a research study looking specifically at the incidence and cause of lung cancer in people under 40. Since genomic alterations frequently lead to lung cancer, especially in never smokers, a key part of the Genomics of Young Lung Cancer study will be extensive genetic testing by Foundation Medicine, a company that tests patients to ensure an understanding of the molecular changes that contribute to their disease. I’m happy to say that Andy is participating.

In closing let me say that I’m doing my best not to be angry or resentful about the short straw drawn by lung cancer research. That far more has not been accomplished in fighting this disease I will chalk up to an innocent misperception, but with Bonnie J. Addario and Foundation Medicine as my partners, I’m starting the accountability clock right now.

As members of Tom Brokaw's "greatest generation," Andy's grandfathers took up smoking at an early age, but subsequently they heeded the Surgeon General's warning and quit. Cessation didn't spare either man a later diagnosis-in one case 25 years later-of terminal lung cancer.

Not Your Father's Cancer...

Phil Trahan

Some patients with breast cancer might be apprehensive to undergo genetic testing, but it is crucial both for them and their family members. Lauren Carcas, MD, medical oncologist at the Miami Cancer Institute, discusses some main points nurses can make to these patients to encourage them to get tested.

I always argue that knowing family history is arguably one of the most important things to know about what your risk is for breast cancer. And just like I said, I think that genetic testing is a situation where knowledge is power. If you know your risk, you can potentially take action to reduce that risk, and potentially nearly eliminate that risk. But if you already have a diagnosis of breast cancer, it's really important because that might impact your treatment decision.

Really you have to be your own advocate, and part of advocating for yourself is knowing the total history and knowing the total diagnosis. Knowing that you have a gene mutation that is the underlying cause of your diagnosis is really important.

Genetic Testing: Knowledge Is Power

Lauren Carcas, MD

Amanda Kong, MD, MS, associate professor of surgery at Medical College of Wisconsin, discusses patterns of care in high- and low-volume hospitals.

Published studies have found that patients with cancer who go to hospitals treating more patients do better than those who go to hospitals treating fewer patients with that type of cancer.

Kong and other researchers looked at high- and low-volume hospitals and found that high-volume hospitals treat aggressive cancer more aggressively. Low-volume hospitals were either doing too much aggressive surgery or not enough surgery.

Variables that affect patient outcome, such as economic status, were included in the analysis, but researchers still concluded that patterns of care were a strong differentiating factor between high- and low-volume hospitals.

Amanda Kong, MD, MS, associate professor of surgery at Medical College of Wisconsin, discusses patterns of care in high- and low-volume hospitals. 

Amanda Kong on Patterns of Care in High and Low Level Hospitals

Amanda Kong, MD, MS

Caring for a patient with advanced cancer can have a significant impact on the caregiver’s physical and mental health.

 We also know from previous research that patient and caregiver mood states are interdependent.

 Thus, it is impossible to address adverse psychological outcomes in patients without also examining the caregivers’ needs. The demographics of these caregivers are changing: Men now account for 40% of the caregiver population.

Even with the rise in male caregivers for patients with cancer, little research has been done to ensure there is effective support for both male and female caregivers. Several researchers have reported that men experience fewer negative aspects of caregiving (such as depression) compared with female caregivers.

 However, this does not hold up when researching other psychological domains. A study by Kim and colleagues

 found higher distress in male spousal caregivers compared with their female counterparts when patients had worse psychosocial functioning. Additionally, male caregivers of patients with breast and gynecologic cancers reported difficulty expressing emotions to others, particularly their male friends.

 The purpose of this study was to examine the gender differences in mood states in caregivers of patients with advanced cancer.

Data were collected from a sub-sample of an Institutional Review Board—approved, nonrandomized palliative care clinical trial. The parent study recruited patients with advanced lung, gastrointestinal, or gynecologic cancer and their caregivers. Caregivers were interviewed by a research assistant who administered the Profile of Mood States (POMS)-short form. The POMS, a psychological rating scale used to assess transient, distinct mood states,11 measures 6 dimensions of mood and uses a 5-point Likert scale.

Scores are summed for each subscale. Higher scores for these subscales are representative of greater mood disturbance.

Of the 222 caregivers enrolled in the study, 152 (68.5%) were female and 70 (31.5%) were male. The majority were Caucasian, with the most common relationship to the patient being spouse/partner. We found that the male caregivers were slightly older (mean age, 60 years), more likely to be a spouse of the patient (90%), and more likely to be employed than their female counterparts. Female caregivers had a mean age of 55 years, were a spouse of the patient in 58% of the cases, and were employed in 55% of the cases.

In addition to describing the demographic similarities and differences between male and female caregivers, we examined psychological outcomes of caregiving by gender. In previous similar studies, most of the male caregivers were spouses of female patients with breast or gynecologic cancer.10 In our sample, however, 42.9% of the male caregivers were caregivers of female patients with gynecologic cancer. Our sample of male caregivers comprised caregivers of patients with lung (21.4%) or gastrointestinal (35.7%) cancer.

We found that male caregivers of patients with cancer had lower tension/anxiety scores (P = .04), lower depression scores (P = .009), and less fatigue (P = .04) than female caregivers of patients with cancer (Figure).

Female caregivers reported higher levels of tension/anxiety, depression, and fatigue. The findings regarding depression differences are similar to those reported in the general caregiver population as well as the general population. However, few studies have looked at other psychological or physical outcomes such as tension, anxiety, and fatigue.

This information is essential for clinical nurses in the oncology setting. It is important to assess all caregivers for distress, anxiety, depression, and fatigue early in the cancer care process. Although male caregivers had lower scores on these dimensions compared with female caregivers, they still reported scores higher than the general population in these domains—particularly in the area of fatigue. Clinical nurses often have the best understanding of how caregivers are faring and are often the member of the healthcare team who spends the most time with both the patient and the caregiver. As cancer care continues to rely on the efforts of caregivers, it is important for oncology nurses to assess both patients and their caregivers for indicators of stress, anxiety, and fatigue.

Our data support the work of others in showing that female caregivers are more likely to be depressed and anxious; however, it is important to note that both genders experience these negative psychological outcomes. Oncology nurses are in the best position to assess, support, and refer caregivers of patients with cancer—both male and female&mdash;to sources of support. Whether caregivers receive informal support from family, friends, or support groups or receive more formal support from a primary care provider, oncology nurses are best equipped to see that these caregivers receive the support that they need.

1. Corà A, Partinico M, Munafò M, Palomba D, Health risk factors in caregivers of terminal cancer patients: a pilot study. 

. 2012;35(1):38-47. doi: 10.1097/NCC.0b013e31820d0c23.

2. Frambes D, Given B, Lehto R, Sikorskii A, Wyatt G. Informal Caregivers of cancer patients: review of interventions, care activities, and outcomes. 

. 2017;40(7):1069-1097. doi: 10.1177/0193945917699364.

3. Jacobs J, Shaffer K, Nipp R et al. Distress is Interdependent in Patients and Caregivers with Newly Diagnosed Incurable Cancers. 

. 2017;51(4):519-531. doi: 10.1007/s12160-017-9875-3.

4. Bambauer KZ, Zhang B, Maciejewski PK, et al. Mutuality and specificity of mental disorders in advanced cancer patients and caregivers. 

5. Sharma N, Chakrabarti S, Grover S. Gender differences in caregiving among family - caregivers of people with mental illnesses. 

. 2016;6(1):7-17. doi: 10.5498/wjp.v6.i1.7.

6. Nijboer C, Triemstra M, Tempelaar R, Mulder M, Sanderman R, van den Bos G. Patterns of Caregiver experiences among partners of cancer patients. 

7. 5. Li Q, Mak Y, Loke A. Spouses' experience of caregiving for cancer patients: a literature review

. 2012;60(2):178-187. doi: 10.1111/inr.12000.

8. Pinquart M, Sorensen S. Gender Differences in caregiver stressors, social resources, and health: an updated meta-analysis. 

. 2006;61(1):P33-P45. doi: 10.1093/geronb/61.1.P33.

9. 7. Kim Y, Loscalzo M, Wellisch D, Spillers R. Gender differences in caregiving stress among caregivers of cancer survivors. 

. 2006;15(12):1086-1092. doi: 10.1002/pon.1049.

10. Lopez V, Copp G, Molassiotis A. Male Caregivers of patients with breast and gynecologic cancer. 

. 2012;35(6):402-410. doi: 10.1097/ncc.0b013e318231daf0.

11. McNair D, Lorr M, Droppleman L. Profile of Mood States. 1971. 

Educational and Industrial Testing Service

Caregivers' Mental Health Varies by Gender

Amy R. Lipson, PhD, is a senior research associate, and Sara L. Douglas, PhD, RN is the Arline H. & Curtis F. Garvin Professor in Nursing Excellence and assistant dean for research at the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.

Gathering data on goals of care for patients with advanced cancer throughout the illness trajectory, including end-of-life (EOL) goals, can help guide treatment decisions.

 Communication between the health&shy;care team and oncology patients can increase the likelihood that patients receive treatment aligned with their own 

 Accurate assessment is an important aspect of ensuring goals of care align with treatment.

 a team of researchers at Frances Payne Bolton School of Nursing, Case Western Reserve University, sought to exam&shy;ine whether there were differences in resource use at EOL between patients with advanced cancer who identified goals of care focused heavily upon survival versus those who identified goals of care heavily focused on quality of life (QOL). The larger study used a longitudinal descriptive study design and collected data on patients with a diagno&shy;sis of stage 4 gastrointestinal or lung cancers. Data were collected at University Hospitals Seidman Cancer Center in Cleveland, Ohio, every 3 months until the end of the 15-month study period or patient death. Subjects were asked at each time point, “Regarding your care, what is most important to you right now?” (

). Anchors on the 100-point visual analog scale were QOL and survival, with a value of 50 indicating a goal with equal weight given to both domains. Values greater than 50 indicated a goal of care that focused more on survival than QOL. The goals of care data reported here were obtained closest to the sub&shy;ject’s death date.

In this sample of 168 patients with advanced cancer who died during the 15-month study period, the majority of the sample were Caucasian (69.0%) and female (51.8%) and had a diagnosis of gastrointestinal cancer (66.1%), an ECOG performance score of 1 (64.9%), and a mean age of 63.9 (SD = 10.4). Prior to death, 62.9% had an advance directive, 54.2% had received palliative care, and 47.6% had received hospice services. Within 30 days prior to death, 45.5% of the sample had at least 1 visit to the emergency department and 58.1% had at least 1 hospital&shy;ization (with 19% of those being admitted to an intensive care unit).

To further examine how the patients’ goals of care were associated with resource use at EOL, we focused on data in the tails of the goals-of-care scale. We compared resource use between those falling in the group more focused on survival with those more focused on QOL. Those focused more on QOL were more likely to enroll in hospice. All other resource use comparisons (emergency department visits, hospitaliza&shy;tions, intensive care, and palliative care) were not statisti&shy;cally significant. We found that by asking patients a sim&shy;ple question regarding their goals of care, we could assess whether they wanted care that was focused more on survival or QOL. In addition, we found that those who favored goals of care emphasizing QOL had EOL care that was consistent with this goal.

Oncology nurses are in a unique position to talk with patients regarding their goals of care.

 Since the establish&shy;ment of the End-of-Life Nursing Education Consortium in 2000, a collaboration between the American Association of Colleges of Nursing and City of Hope, Duarte, California, to improve palliative care nationwide, momentum has been building to create programs that train nurses to initiate these kinds of discussions with patients. This type of open com&shy;munication can ensure that patient information regarding goals of care is communicated to the healthcare team and, as a result, enhance the likelihood that the patient receives EOL care consistent with their own goals.

You JJ, Fowler RA, Heyland DK; Canadian Researchers at the End of Life Network (CARENET). Just ask: Discussing goals of care with patients in hospital with serious illness. 

. 2014;186(6):425-432. doi:10.1503/ cmaj.121274.

Balogh EP, Ganz PA, Murphy SB, Nass SJ, Ferrell BR, Stovall E. Patient-centered cancer treatment planning: Improving the quality of oncology care. Summary of an Institute of Medicine Workshop. 

2011;16(12):1800-1805. doi:10.1634/theoncologist.2011-0252.

Wittenberg E, Ferrell B, Goldsmith J, Buller H, Neiman T. Nurse communication about goals of care. 

Lipson AR, Douglas SL. Factors influencing care decisions for patients with advanced cancer. 

Researchers exam&shy;ined whether there were differences in resource use at end of life between patients with advanced cancer who identified goals of care focused heavily upon survival versus those who identified goals of care heavily focused on quality of life.

Impact of Goals of Care on Resource Use at End of Life

Amy R. Lipson, PhD

Seth Eisenberg, RN, ADN, OCN, professional practice coordinator, infusion services, Seattle Cancer Care Alliance, discusses using a multilayered approach to chemotherapy safety.

Eisenberg says that while closed system transfer devices add another layer of safety, it is only one part of preventing contamination. Wipe tests have shown that there can be chemotherapy contamination on the outside of chemotherapy vials before it even reaches the hospitals.

Researchers need to look at the big picture and reevaluate how chemotherapy is delivered to hospitals, Eisenberg says. However, it is going to cost a tremendous amount of money and time to reinvest a vial that made delivery more safe.

Seth Eisenberg Discusses a Multilayered Approach to Chemotherapy Safety

Seth Eisenberg, RN, ADN, OCN, professional practice coordinator, infusion services, Seattle Cancer Care Alliance, discusses the importance of practicing total chemotherapy safety when nurses handle chemotherapy.

Eisenberg explains that since there are a number of areas in which a contamination can occur, nurses have to look at chemotherapy handling safety in layers. Nurses should not rely solely on any one particular system because nothing is going to function with complete accuracy, Eisenberg says.

Seth Eisenberg Discusses the Importance of Total Chemotherapy Safety

Seth Eisenberg, RN, ADN, OCN

Susan Larsen Beck, PhD, APRN, FAAN, AOCN, professor, College Of Nursing, University of Utah, Member, Cancer Control and Population Sciences Program, Huntsman Cancer Institute, discusses pain management in oncology.

Beck says she feels researchers have taken a step backwards, not forwards, when it comes to pain management. While many patients, including oncology patients, struggle with pain and chronic pain, there are also people that become addicted to pain medications and die.

Beck says these two different groups are not coming together to find a solution to effectively manage pain while reducing the mortality associated with prescription drug abuse. There have been regulatory moves that have changed the environment to increase the reluctance of providers to provide effective pain management. Beck feels that some patients are also reluctant to take pain medication, because they fear that they will become addicted to it.

A national study found that the average pain for hospitalized patients around the country was 6.2 on a 0-10 scale with 30% of patients being in severe pain most of the time. In oncology, the average pain reported was about 5.7, Beck says. Previous research conducted by Beck found that the mean of the worst pain was in that range, where here it was reported to be the mean of the average pain.

Susan Larsen Beck PhD, APRN, FAAN, AOCN, professor, College Of Nursing, University of Utah, Member, Cancer Control and Population Sciences Program, Huntsman Cancer Institute, discusses pain management in oncology.

Susan Beck Discusses Pain Management

Susan Larsen Beck PhD, APRN, FAAN, AOCN, professor, College Of Nursing, University of Utah, Member, Cancer Control and Population Sciences Program, Huntsman Cancer Institute, discusses two trials evaluating the efficacy of having an IT-integrated, computer-based telephone system for monitoring patient-reported symptoms.

Beck says she and her team are trying to develop a system to better monitor patient symptoms once they were home after receiving chemotherapy. Usually, patients are reluctant to call once they are home and just normalize themselves with their symptoms.

In order to capture the period from when a patient goes home after receiving chemotherapy and their next doctor’s appointment, Beck and her team developed an automated system where patients could call in on a daily basis to be screened for a variety of symptoms that are common during chemotherapy. If they developed the symptoms at a threshold level, an alert was sent to their oncology physician and nurse, Beck says.

The results showed that the system worked great: the patients liked it and called in regularly but the physicians and nurses either didn’t follow-up with the patients or they normalize it. Therefore, the patient’s outcomes didn’t improve.

In a second study, advanced practice nurses were assigned to case-manage the symptoms of the patients. This case-management system was comprised of all the information recorded from the patient and accessible by the nurse practitioners.

Beck says an evidence-based approach was developed for the nurse practitioner to respond to the symptoms. This study worked very well and showed that patients had more symptom-free days when they received the follow-up care.

Beck and her team are currently looking into how to expand the system so it can be used in practice, Beck says. 

Susan Beck Discusses Technology-Enhanced Interventions to Improve Patient Outcomes

Susan Larsen Beck PhD, APRN, FAAN, AOCN

Mabel Ryder, MD, endocrinologist and medical oncologist, Mayo Clinic, discusses targeting the tumor microenvironment in thyroid cancer.Â 

Previously, most research thyroid cancer progression has been done on the cancer cell itself, Ryder says. In her research, Ryder looked at how cells in the microenvironment would affect thyroid cancer cells and promote progression.

Using mouse models, Ryder identified tumor-associated macrophages and found evidence that the cells promote thyroid cancer progression.Â 

Ryder says that tumor-associated macrophages represent a potential therapeutic target for advanced thyroid cancer, particularly in patients whose disease has been resistant to most molecular targeted therapies. Â 

Mabel Ryder on Tumor-Associated Macrophages in Thyroid Cancer

Mabel Ryder, MD

Treatment for patients with breast cancer is changing, and as this shift to more targeted therapies occurs, oncology nurses need to think about treating their patients differently. At the 3

 had the chance to discuss with Madelaine Kuiper, MSN, RN, nurse practitioner at UCLA Santa Monica Hematology/Oncology Breast Program, what nurses need to know about how to treat breast cancer now.

I think a focus that I'm really trying to teach nurses that are looking after breast cancer patients or coming in contact with is not to think of breast cancer as traditionally being treated with chemotherapy, but what are the biomarkers. How do these diseases work, how can we target those, and best use those treatment options? But again, talking about the essentials of oncology, or particularly in breast oncology … where we're heading with a lot of our drugs requires a lot of bringing it through more oral drugs, so how do we improve compliance with oral drugs?

If we're expecting our patients to take them, how do we know that they're taking them safely and adequately so that they get the full potential from the therapeutic benefits from these drugs? How can we facilitate that to [not only] improve compliance, but [also] to improve their responses to therapy, and really to maximize that length of therapy that we can get. Unfortunately, in the metastatic setting, it's not a curable disease but [patients] can live well with a good quality of life for a long period of time, but we need to utilize these drugs carefully. 

At the 3rd Annual School of Nursing Oncology, Oncology Nursing News had the chance to sit down with Madelaine Kuiper, MSN, RN, and talk about what nurses need to understand about the evolving landscape of breast cancer treatment.  

Authors