Oral Cancer Medications: New Paradigm Brings New Challenges

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The increase in the use of oral medications presents new challenges, such as patient adherence.
The increase in the use of oral medications presents new challenges, such as patient adherence.
The following article features coverage from the 2017 ONA Navigation Summit in Austin, Texas. Click here to read more of Oncology Nurse Advisor's conference coverage. 

Oral cancer therapies are creating a paradigm shift in how antineoplastic medications are administered. Navigators need to find the technology that suits the patient best to ensure adherence to the oral cancer therapy regimen, according to a presentation at the 2017 Oncology Nurse Advisor Navigation Summit.

An estimated 25% to 30% of all new antineoplastic agents in development are oral cancer therapies, and almost 50% of the 300 medication in phase 2 and 3 clinical trials are oral medications. This trend represents a paradigm shift in chemotherapy administration and changes in oncology practice, said Jan Tipton, MSN, RN, AOCN, of the University of Toledo Medical Center.

The shift to oral therapies means less parenteral intermittent IV infusions. Patients taking oral cancer therapies in the home setting have less supervision, fewer office visits, and less frequent interaction with the oncology care team. Processes for prescription receipt, patient education, and clinician monitoring for adverse effects and adherence are also changing.

Adherence is defined as the extent of conformity to the recommendations about day-to-day treatment by the provider with respect to timing, dosing, and frequency, explained Ms Tipton. The term adherence replaces the term compliance due to its negative connotation and passive role for the patient. The new term suggests shared decision-making between the health care provider and patient.

Reports in the literature estimate adherence to oral cancer therapies as less than 80%, with up to 10% of patients not refilling their prescriptions. Adherence rates may be inadequate for treating the cancer and may impact treatment outcomes.

Patient-related factors that negatively impact adherence are patient demographics (education, income level), psychosocial issues (less social support, depressed state), and patient perceptions (a lower perceived necessity of medication). Other factors are related to condition/disease (more comorbidities), utilization (more ED visits, hospitalizations), provider and system (less frequent communication, patient-clinician relationship factors, higher out-of-pocket costs).

Lastly, medication-related factors such as increased toxicity, polypharmacy, drug-drug interactions, and safe handling issues may negatively impact patient adherence to therapy regimens.

Five rights of medication administration shift from nurse to patient/caregivers: right medication, right dose, right time, right route, right patient.

However, no clinically defined critical threshold for medical adherence to oral antineoplastic therapies is established. “We are not sure how these medications are absorbed and not sure of the impact of missed doses or the frequency missed doses,” said Ms Tipton.

The National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), Oncology Nursing Society (ONS), and the Multinational Association of Supportive Care in Cancer (MASCC) have all come out with recommendations on best practices. However, universal standards for managing adherence to oral therapies are not established.

Evidence of the effectiveness of oral adherence interventions is lacking in patients with cancer. The interventions that involve direct patient communication, such as text messages, automated voice response (AVR), and treating depression appear likely to be effective. But feedback from the patient is important. There is no one simple answer that is going to work, explained Ms Tipton. 

Development of a standard procedure for educating patients, reviewing and documenting treatment plans, and routine monitoring of patient adherence to oral regimens are practice changes that could improve adherence. Integrating a validated assessment tool for medication adherence could improve monitoring. Use of affirmative questions are more likely to yield more reliable and accurate responses (“What percentage of the time did you take your medication as prescribed over the past week?” vs “How many doses did you miss in the last week?”).

Routine follow-up visits when new oral cancer therapies are started to assess for access, tolerability, and adherence is an effective way to monitor for adverse effects. Although evidence in the literature is unclear as to how often these follow-ups should occur, Ms Tipton suggested navigators plan these calls for approximately 2 weeks after the start of a new agent.

Assess the patient's learning needs and suggest tools and technology that will best match those needs and lifestyle, she suggested. “Don't get hooked on using a boilerplate plan.” Navigators need to find the technology that works best for the patient, whether it is phone calls, emails, text messages, video calls, patient portals, or drop-in visits.

Read more of Oncology Nurse Advisor's coverage of the 2017 ONA Navigation Summit by visiting the conference page.

Reference

Tipton J. Oral therapies: strategies to ensure adherence. Oral presentation at: 2017 Oncology Nurse Advisor Navigation Summit; June 15-17, 2017; Austin, TX.

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