BOSTON—The growing use of oral oncolytics corresponds to a growing challenge with poor adherence to therapy. With more than 40 oral oncolytics available and dozens in the pipeline, Susan Moore, RN, MSN, ANP-BC, AOCN, oncology nurse practitioner and consultant with MCG Oncology in Chicago, Illinois, warned nurses at the Oncology Nursing Society (ONS) annual meeting that “the issue is not going to fade away.”
Moore, who spends much of her time studying the problem of medication adherence, defined adherence as “the degree or extent of conformity to provider recommendations about day-to-day treatment with respect to timing, dosage, and frequency.” Poor adherence can also mean taking more than what is prescribed. The few studies in the literature on adherence are all over the map regarding the percentage of patients who fail to take their oral drugs as prescribed, but Moore said everyone nonetheless recognizes it as a serious problem.
“Patients have a variety of reasons for becoming nonadherent,” said Moore, but the most common is adverse effects. Other causes are psychologic issues, cognitive or physical impairment, skepticism about treatment benefits, and poor understanding of the disease process. She mentioned a mastectomy patient who skipped hormonal therapy in the mistaken belief that without breasts, she could not get breast cancer again. Other patients, particularly those with chronic myeloid leukemia (CML), feel better and stop taking their pills.
With oral drugs, patients are ultimately in charge. “We don’t know what’s going on at home,” said Moore. Educating patients taking oral therapies on the importance of adherence is essential. A 2010 study by Simchowitz and colleagues showed most patients want more education on how to take their drugs and what to expect.
But whose job is it to provide that education wondered Debra Winkeljohn RN, MSN, AOCN, CNS, Hematology Oncology Associates of New Mexico, Albuquerque. “Is it the physician, the oncology nurse, or the pharmacist?” She said oncology nurses must become more involved in dealing with oral oncolytics.
A 2008 survey of 1116 oncology nurses in 15 countries by Sultan and associates found that 47% had no formal education on oral therapies. Winkeljohn said her clinic‘s nurses “do great with IV therapy but when asked to do some of the teaching, they said we don’t really know much about these oral therapies.” She described it as a big hole in oncology nursing.
Never attempt to educate patients on their treatment plan at diagnosis. “Bring them back for a second visit,” said Winkeljohn. Teaching sessions should always be individualized, not rehearsed, and a family member or friend should accompany the patient, advised Winkeljohn. That person or another caregiver can be enlisted to help the patient stay adherent.
Motivating patients to remain adherent is difficult, and several techniques have been investigated with marginal success. Diaries and pill counts work for some, said Moore, but others hide poor adherence out of embarrassment. Contracts sometimes work but are obviously not enforceable. A 2003 study found mail reminders somewhat effective, but these would not work for patients on daily oral therapy. She proposed researching the effectiveness of daily cell phone reminders.
One study used an automatic voice response system to call patients each day. Patients left a message confirming whether they had taken their drug or indicating any problems. Nurses followed up with those who were not adherent, and rates of adherence improved. With multidrug regimens, which are especially problematic, one trial found using a 31-day blister pack with each day’s drugs contained in a blister raised adherence from 61% to 98% at a cost of only 14 cents per card.
Another approach under investigation is measuring metabolite in the patient’s blood levels or molecular response. Abstract 1053269 at the ONS Congress by Romvari and associates analyzed claims for CML patients and concluded that BCR-ABL counts were an effective tool for assessing adherence.
Nonadherence has serious consequences. For CML patients, decreasing levels of adherence correspond with lower rates of major molecular response. Poor adherence might lead to multidrug resistance or symptoms of recurrence mistaken as adverse effects.
Moore begged oncology nurses to do more research on this issue, such as looking at the effect of language barriers, health literacy, and economic status on adherence. She also proposed future studies incorporate adherence as an end point.