Optimizing Adherence to Oral Anticancer Agents: No "One Size Fits All" Solution

Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Editor-in-Chief OncLive Nursing

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing Louisiana State Health Sciences Center in New Orleans, Louisiana

An oncologist who recently retired from practice told me that he retired because he couldn’t pronounce the names of the drugs anymore. We can all relate to his observation that the number of new anticancer agents is increasing. Many of the newer agents are oral agents that are self-administered and consequently raise questions and concerns about patients’ adherence.

In a meta-analysis of 22 studies measuring adherence and factors impacting adherence, having social support, lower out-of-pocket costs, and taking aromatase inhibitors had a positive effect on patients’ adherence. Taking several different medications, depression, and very young or very old age were associated with lower adherence to oral anticancer agents.

Other factors had no influence on adherence or a clear conclusion was not possible based on the limited available data, and these included gender, ethnicity, marital status, education, socioeconomic status, comorbidities, performance status, duration of disease, stage of disease, number of hospitalizations, type of treatment (with the exception of aromatase inhibitors, which were associated with higher adherence), duration of treatment, number of tablets/capsules, regimen complexity, and side effects.¹

It’s not surprising that lower out-of-pocket costs and having social support (defined as the perception of being supported by other people) would positively influence adherence to oral anticancer agents. When compared to other oral anticancer agents, aromatase inhibitors have relatively mild side effects and are taken daily (consistent dose and schedule of administration), so a positive impact on adherence is again not surprising. It’s understandable that taking multiple medications could negatively impact adherence. Depression can negatively impact a variety of things, adherence included. Very young children and very old adults have several things in common that can negatively impact adherence, including difficulties with swallowing, and often must rely on others for oral anticancer agent administration.

The literature is now abundant with studies of adherence; however, most of the studies have focused on a specific patient population, were conducted at one or few facilities, and generally examined short-term adherence rather than adherence over time. Some of the studies evaluated strategies thought to optimize adherence, such as use of patient diaries, text or phone reminders, follow-up phone calls or emails, and so on. However, nothing to date has been suggested to be a “one size fits all solution.” So the bottom line is how to best assess and educate the individual.

It’s critically important to determine how the patient views his or her role in adherence and to identify capabilities (eg, ability to read a label, swallowing ability) and barriers (eg, high copay, impaired eyesight, multiple medications, depression). After teaching the patient about the oral agents, we need to ask how much of the agent will be taken, when it will be taken, how it will be taken, and actions that need to be taken for a missed dose. The patient should be able to list side effects and self-care measures, and identify toxicities that need to be reported. The patient and family need to be engaged in the discussion of how to best ensure that the correct dose is taken in the correct amount at the correct time. What works for one patient may not work for another, and what works for a specific patient at one point in time may fail to work at a later date.

Through continuous assessment and education of our patients on oral agents, we can begin to identify what works for the individual patient and create a patient-specific plan of care and follow-up. In addition to helping ensure optimal treatment outcomes, adherence assessment and implementation of strategies to enhance adherence promotes quality care for all of our patients.

Reference

• Mathes T, Pieper D, Antoine S, et al. Adherence influencing factors in patients taking oral anticancer agents: a systematic review. Cancer Epidemiol. 2014;38(3):214-226.