Nurses Leading the Way: Promoting Adherence to Oral Cancer Medications

Sandra Spoelstra, PhD, RN

Assistant Professor, Michigan State University College of Nursing.

Patients with cancer miss as much as one-third of the prescribed doses of oral anticancer agents required for treatment of their disease.^1-2 Even more disconcerting is that within the next three years, 25% of cancer treatment will be delivered in pill form.² This shift in the treatment paradigm will result in increased care in the home, placing greater responsibility on patients.

Barriers to oral agent adherence for patients include no or limited coverage for the medication, complex dosing regimens, difficulty obtaining the prescription, running out of the prescription, forgetting to take the pills, skipping or stopping because they believed the medication was not working or because it created symptoms from side effects, and not seeking help from others.^3-5 Often, the more adherent patients are to oral chemotherapy agents, the more likely they are to experience symptoms. Patients prescribed oral agents have indicated titrating doses as they were unable to tolerate symptoms occurring as a side effect of the cancer treatment.⁶

Thus, prompt and aggressive management of symptoms becomes vital to managing adherence at home. Furthermore, pharmacy literature suggests a narrow therapeutic index for cancer therapy,⁷ increasing the importance of oral agent adherence, as nonadherence may affect time to disease progression and mortality. The therapeutic outcome for patients taking oral agents depends heavily on the ability of patients to adhere to the prescribed regimen.

Healthcare research has not conclusively identified effective interventions to promote medication adherence.^8,9 Chemotherapy classes are a common part of care for patients receiving IV treatment. However, training for patients on oral agents is underdeveloped, and needs to include adherence, monitoring and reporting of symptoms from side effects and toxicities, coordination of changes in dosing if altered or stopped, and management of insurance coverage and drug delivery. Oncology nurses must take the lead in structuring care settings that promote patient behavior to attain optimal adherence.

Oncology nurses can help patients and their families understand what they are responsible for in many ways (Box). The number of cancer patients who receive oral agents in pill form is increasing, and oncology nurses can lead the way enabling patients to adhere to and complete their cancer treatment.

Adherence—The Nurse’s Key Role

Identify and inform on the cost of the medication. Clarify if cost prohibits adherence. Seek and carry out financial assistance if needed.

Identify when and where to obtain the medication and refills so that there are no lapses in treatment.

Explain adherence: taking medication at prescribed day/time (compliance) plus entire regimen (persistence).

Focus on adherence on a regular basis (eg, at once-a-month appointment, weekly phone call).

Ask patients to monitor adherence by using a calendar or journal, and to bring the document to each appointment.

Assist in selecting and obtaining an adherence reminder prompt (eg, pill box, alarm).

Evaluate previous medication adherence experience and how it may affect taking oral agents.

Clarify how to access and use evidence-based symptom management strategies.

Implement regular self-assessment of symptoms.

Clarify how and when to call the clinician regarding symptoms and toxicities.

Identify medication-taking behaviors (eg, with or without certain foods, timing with meals), storage, handling, and any safety issues.

Listen and identify concerns, issues, and desires of patients and their family members and address on each interaction.

Identify common side effects from the oral agent prescribed and provide written and verbal information.

References

1. Spoelstra S, Given BA, Given CW, et al. An intervention to improve adherence and management of symptoms for patients prescribed oral chemotherapy agents: an exploratory study. Cancer Nurs. 2013;36(1): 18-28.
2. Weingart SN, Bach PB, Johnson SA, et al. NCCN Task Force Report: Oral Chemotherapy. J Natl Compr Canc Netw. 2008;6(suppl 3):S1-S17.
3. Fox SW, Lyon D. Symptom clusters and quality of life in survivors of ovarian cancer. Cancer Nurs. 2007;30(5):354-361.
4. Anderson E, Winett R, Wojick J. Self-regulation, self-efficacy, outcome expectations, and social support: social cognitive theory and nutrition behavior. Ann Behav Med. 2007;34(3):304-312.
5. DiMatteo MR, Haskard KB, Williams SL. Health beliefs, disease severity, and patient adherence: a meta-analysis. Med Care. 2007;45(6):521-528.
6. Sharma S, Saltz L. Oral chemotheraputic agents for colorectal cancer. Oncologist. 2000;5(2):99-107.
7. DeMario MD, Ratain MJ. Oral chemotherapy: rationale and future directions. J Clin Oncol. 1998;16(7):2557-2567.
8. Ruppar TM, Conn VS, Russell CL. Medication adherence interventions for older adults: literature review. Res Theory Nurs Pract. 2008;22(2): 114-147.
9. Conn VS, Hafdahl AR, Cooper PS, Ruppar TM, Mehr DR, Russell CL. Interventions to improve medication adherence among older adults: metaanalysis of adherence outcomes among randomized controlled trials. Gerontologist. 2009;49(4):447-462.