As more cancer therapies move out of the infusion room and into the patient's home, ensuring that patients take these medications as prescribed poses an ongoing, multifaceted challenge for today's oncology practitioner.
Carol Blecher, RN, MS, AOCN, APNC, CBPN-C, CBCN
As more cancer therapies move out of the infusion room and into the patient’s home, ensuring that patients take these medications as prescribed poses an ongoing, multifaceted challenge for today’s oncology practitioner.
“Oral chemotherapy is not a solo act,” said Carol Blecher, RN, MS, AOCN, APNC, CBPN-C, CBCN, an advanced practice nurse and clinical educator at the Trinitas Regional Medical Center/Trinitas Comprehensive Cancer Center in Elizabeth, New Jersey. She said that using a team approach to delivery and administration, providing support and encouragement, and addressing any financial concerns are key factors in encouraging adherence. Blecher was among the speakers at the recent Oral Oncolytics conference held in Philadelphia, where stakeholders discussed how to improve patient access and adherence to oral cancer medications which, due to their prevalence and complexity, have become a prime focus of education and training, both from the provider and patient perspective.
“About 25% of all agents in the drug pipeline are going to be oral, which means that we’re going to have to work harder and smarter to help our patients get to where they need to be,” said Blecher.
Successful adherence depends on a number of factors. The physician writes the prescription, hands it to the patient, the patient fills it at a pharmacy, and the patient starts taking the medication as directed. Within those four steps, however, are a myriad of smaller steps that need to be fully completed to ensure success. These steps all revolve around the interaction between the patient (including the patient’s family and other caregivers), the provider team (physician, nurse, pharmacist, social worker, and ancillary healthcare providers), and the payer.
Oral chemotherapy agents are powerful and toxic. Handling them requires a certain level of respect, Blecher explained. “Now we are sending these agents home with patients who live in a family environment,” she continued. There may be children, grandchildren, or other extended family members around. When educating patients about oral oncolytics, the oncology nurse has to consider everyone who might come into contact with the patient and the medication and decide who else to include in the training session when it’s time to educate the patient.
“Knowing patient education as I do,” said Blecher, “the patient hears 50% of what we’re trying to teach.” She added that education becomes even more difficult when language is a barrier. The clinician needs to verify that the patient understands what was presented during the education session and make sure that essential issues have been covered (Box).
Each point where the patient engages the healthcare system is an opportunity to improve adherence, including making sure that the prescription has been filled.
To determine how well the patient is adhering to the medication regimen, Blecher has set up direct and indirect monitoring steps. The patient has monthly physician visits, but Blecher will arrange for evaluations between those office visits to track side effects. One benefit of administering chemotherapy in the hospital or in the infusion center is that the healthcare team knows that the medication was administered. With oral chemotherapy, Blecher doesn’t have that luxury, so she relies on questionnaires and self-reports.
She also often makes use of calendars. “I formulate calendars for most of my patients, indicating how many tablets they need to take in the morning and evening. It’s something you have to work out with your patients.”
Oncology nurses also should stress with patients the importance of reporting any adverse events they may experience with oral medications, said Blecher, adding that some patients may minimize or hide such symptoms so they can continue taking their medication.
When Blecher sees that a patient cancels an appointment but continues to request a medication refill, she will often call the patient back to emphasize the importance of coming into the office for an evaluation. “That behavior doesn’t fly,” she said. “I need to see them.”
Why do some patients with cancer stop taking their oral medications as prescribed?
According to a recent study, failure to understand the therapy regimen, adverse events, forgetting to take their medications, and system barriers—such as lack of coordination among providers and late pharmacy deliveries—all can play a role.
The research was conducted by Susan Schneider, PhD, RN, AOCN, FAAN, associate professor at Duke University School of Nursing, and presented at the Oncology Nursing Society’s 2013 Connections conference.
Schneider analyzed data from a prior study examining the effectiveness of a tailored protocol to promote oral chemotherapy adherence among 48 adults, among whom adherence rates were 65% to 95% over a 6-month period.
The three most common reasons cited for discontinuation were:
Schneider found that the reasons for nonadherence in this sample align with those found in the research literature, but that system barriers were higher than forecast and had not been identified frequently in the literature.
The research points to an important role for nurses working with healthcare teams to facilitate smooth care transitions and identify creative ways to support patients not seen regularly in the clinic.
The findings also underscore the need to monitor and manage symptoms to promote better adherence.
Usually what’s required is a dose adjustment, but, said Blecher. “Patients don’t want us to dosereduce. They want to continue on the dose that is their starting dose,” and thus may try to hide symptoms. She also urged practitioners not to discount the importance of face-to-face interactions with the patient and instructs her students on the effective use of interviewing techniques: “Listen more than you talk, because that’s where you’re going to get your information.”
Sometimes adherence hinges on a patient’s worry over financial obstacles. For many patients, how much a cancer medication will cost them in terms of a copayment determines if the prescription is picked up from the pharmacy.
Here again, nurses have an important role. Blecher explained that she may have to call the pharmacy to help straighten out how the prescription is adjudicated. “The pharmacy thinks the medication should be filed under Medicare Part D, but I need to clarify why the drug should be filed under Medicare Part B.”
Many pharmaceutical companies also offer patient assistance programs for their oral oncolytics. “It’s a process, and it’s time consuming,” Blecher acknowledged, “but it’s another avenue to explore on behalf of your patient.”
The American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) updated their joint safety standards on the safe use of parenteral chemotherapy in both inpatient and outpatient settings to include orally administered antineoplastics.1 The 2013 ASCO/ONS chemotherapy administration safety standards address such issues as the need to verify prescription refills, to educate both the patient and caregiver on developing drug administration schedules and the safe disposal of unused oral medications, and to facilitate communication among practitioners providing care to patients across multiple settings.
To apply these standards to the healthcare team, Blecher said, “We need to do a lot of training. We have to have policies and procedures. We have to make sure that the people are as well qualified and extensively trained for oral oncolytics as they are to administer intravenous chemotherapy.”
A diagnosis of cancer is difficult news for patients to absorb—it’s a long treatment process that can have severe side effects. Anything to help the patient increase adherence by changing a behavior will be beneficial.
“With cancer patients there is not a whole lot of time for ‘precontemplation,’” Blecher explained. “The patient may need to move forward with treatment right away. Patients may have completed a round of chemotherapy and are now moving on to oral treatments.“
“We really don’t have a lot of time to consider stages of change, but we need to work with them.”