Feasibility and Perceived Benefit of an Oral Chemotherapy Pharmacy Monitoring Program to Assess Symptom Burden and Medication Adherence in Patients with Cancer

Presenter: Stefan Allen, PharmD, PhD Candidate, UT Austin College of Pharmacy/UT Health San Antonio (PERC)

Co-Authors: Laura Tenner, MD, GI Medical Oncologist, Associate Professor, Director of Pharmacy and Therapeutics Program, Co-Director of Cancer Survivorship Program, UT Health San Antonio/Mays Cancer Center; Sherri Cervantez, MD, Assistant Professor of Medicine, Director of Palliative Oncology, UT Health San Antonio/Mays Cancer Center; Ivan Reveles, PharmD, MS, BCOP, University of Texas at Austin; Bradi Frei, PharmD, MS, BCOP, Professor, Pharmacy Practice, University of Incarnate Word, Feik School of Pharmacy/Mays Cancer Center; Jim Koeller, MS, Professor, Pharmacy Practice, UT Austin College of Pharmacy/UT Health San Antonio (PERC)

Background: Oncologists are increasingly prescribing oral antineoplastic agents (OAAs), which reduce office visits and avoid infusion-related complications.¹ However, many OAAs have challenging administration schedules and significant adverse reactions. The burden of medication administration and monitoring shifts to the patient or caregiver, which can affect adherence, safety, and outcomes.² Practice guidelines recommend prescribers monitor patients for symptoms and adherence, but do not provide specific monitoring recommendations or survey tools.^3,4 Studies support that pharmacists play an integral role in monitoring medication safety and adherence (including access) and improve side-effect management and patient satisfaction.^5,6

Objectives: To evaluate the (1) feasibility and (2) physician- and patient-perceived benefit of a pharmacist-delivered adherence and symptom monitoring program for patients taking OAAs.

Methods: Feasibility was evaluated through patient participation in a pilot program. Perceived benefit was evaluated with satisfaction surveys. Over 6 months we enrolled patients at a University of Texas outpatient cancer clinic who received any of the following 6 OAAs: capecitabine, sorafenib, regorafenib, osimertinib, afatinib, or erlotinib. A pharmacist was scheduled to contact patients twice each cycle or month, between clinic visits, for symptom or adherence monitoring over a 3-month follow-up. Pharmacy monitored the symptoms using the Edmonton Symptom Assessment Scale (ESAS-FS) and adherence.⁶ A pharmacist managed or triaged symptoms (ie, diarrhea, mucositis, rash, nausea, and vomiting) per protocol in collaboration with the physicians. Patient contact was recorded directly in the institution’s electronic health record. Physicians, physician assistants, and patients completed satisfaction surveys.

Results: Of the 51 patients screened for eligibility, 48 (94%) participated in the study. The patients’ median (interquartile) age was 59 years (range, 51-68 years), and the patients were predominantly female (65%) and Hispanic (65%). CareLink, a safety-net program, accounted for 33% of insurance coverage, with 48% of individuals having Medicare or Medicaid. Of 361 expected encounters with patients, 252 (88.5%) were performed. The ESAS-FS was administered by pharmacy 102 times, with the median total score severity decreasing over time. A total of 48 symptom management recommendations were made to patients and to physicians, with an acceptance rate of 98%. Patients and physicians agreed with the majority of the statements (96% and 90%, respectively), indicating that the program was helpful. Although 97% of patients would recommend the program to others, only 45% agreed that it improved communication with their physicians.

Conclusion: The findings of this quality improvement study suggest that a pharmacist monitoring program for patients taking OAAs is feasible and shows perceived benefit by patients and by physicians. Further research is needed to evaluate whether this program improves safety, adherence, and outcomes in patients using OAAs.

1. Weingart SN, Brown E, Bach PB, et al. NCCN task force report: oral chemotherapy. J Natl Compr Canc Netw. 2008;6(suppl 3):S1-S14.
2. Greer JA, Amoyal N, Nisotel L, et al. A systematic review of adherence to oral antineoplastic therapies. Oncologist. 2016;21:354-376.
3. Neuss MN, Gilmore TR, Belderson KM, et al. 2016 updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, including standards for pediatric oncology. J Oncol Pract. 2016;12:1262-1271. Erratum in: J Oncol Pract. 2017;13:144.
4. Neuss MN, Polovich M, McNiff K, et al. 2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy. J Oncol Pract. 2013;9(2 suppl):5s-13s. Erratum in: J Oncol Pract. 2013;9:265.
5. Wong A, Rodriguez-Nunez A, Tayjasanant S, et al. Edmonton Symptom Assessment Scale (ESAS): time duration of self-completion versus assisted-completion in palliative care patients—a randomized controlled trial. J Clin Oncol. 2016;34(26_suppl):Abstract 67.
6. Hui D, Bruera E. The Edmonton Symptom Assessment System 25 years later: past, present, and future developments. J Pain Symptom Manage. 2017;53:630-643.