Breaking Down Barriers to Oral Adherence in Patients with Breast Cancer

Debu Tripathy, MD

Debu Tripathy, MD

For patients with breast cancer, oral agents are becoming more prevalent as they have been shown to reduce the risk of recurrence and death. Additionally, longer courses of therapy are under study. Despite side effects such as hot flashes and joint pain experienced by some women, oral anticancer medications are “the wave of the future,” according to Ann O’Mara, PhD, RN, MPH. O’Mara is the head of palliative care in the Division of Cancer Prevention at the National Cancer Institute.

“Many patients can take their medication as a pill, in the comfort of their homes.” The challenge, however, is ensuring that patients do take their medication as prescribed so that they achieve the maximum benefit from their therapy.

Indeed, as Debu Tripathy, MD, told Oncology Nursing News recently, “compliance is an issue,” with these medications. In this interview, Tripathy, chief of Breast Medical Oncology at the University of Texas MD Anderson Cancer Center, discusses some of the reasons for nonadherence and how nurses can help.

Oncology Nursing News: What are some of the challenges regarding patient nonadherence in the breast cancer setting?

Debu Tripathy, MD: About one-third of people stop taking their medications after 5 years, and even more so, after 10. Oncologists need to discuss with their patients "What is the risk for you? Are there characteristics about your cancer? How are you tolerating your medications so far? What about bone health?" We know some of these medications can accelerate bone loss and osteoporosis and can even increase the fracture rate. So, bone density has to be looked at and managed as needed.

What are some of the side effects that may contribute to nonadherence?

The drugs palbociclib (Ibrance) and everolimus (Afinitor), can cause side effects that make some patients discontinue earlier than they might need to if we could manage these symptoms. It's very important to not only anticipate and monitor for the symptoms, but to educate patients about them.

For everolimus, mouth sores early on is something that is seen in about 20% to 30% of patients. They're usually mild, but it is one reason patients discontinue therapy. For some women, these sores can come on very quickly and be very intense, especially at the beginning of therapy, but it's not a problem later on. If patients can get through that first phase, they may actually stay on therapy.

That first phase can be made much easier by monitoring, and there are some interventions now that help. For example, research has shown that using a steroid mouthwash (a 1% steroid dexamethasone solution) reduced the number of patients with mouth sores, so this is something that patients can be educated about ahead of time. There are treatments that can help. Similarly, palbociclib, though not so much in the way of mouth ulcers, but fatigue, low white counts, the rare risk of infection. All of these need monitoring.

What can nurses do to combat and prevent nonadherence?

Counseling patients on compliance in general is important. Even with hormonal therapy, compliance is low. About a half of patients stop hormonal therapy. It is associated with those who have more symptoms, but that's not the only reason people stop. People just stop because they forget, because it's not important, or maybe they're in denial. So counseling of these patients, making sure that they understand the program, is very important.

There is a great deal that we can do for our patients, from the nursing realm and from an approach centered on the best team-based care, where clinicians coordinate patient care, communicating with each other, and make sure that the patient is well-covered.

Tips from Nurses

There are a number of ways nurses can assist with adherence. Nurses themselves have offered recommendations for this, including:

• Take a personalized approach to the treatment
• Monitor for drug—drug interactions.
• Look out for prescription stretching.
• Check in early and often—initiate contact rather than wait for the patient.
• Help patients with alerts, alarms, or text messages.
• Be aware of cost as a barrier.
• Provide full, upfront patient education.

To read more, visit 7 Oral Adherence Tips From Nurses and Pharmacists.