Figure 1 - uploaded by Thivaher Paramsothy
Content may be subject to copyright.
Source publication
Purpose:
Oral anticancer medications (OACMs) have created new treatment opportunities, but also challenges for patients and practitioners. We aimed to compare health care provider (HCP) and patient perceptions on OACM adherence, toxicity reporting, and patient educational needs.
Methods:
An online survey for HCPs and paper survey for patients we...
Context in source publication
Citations
... Interactions with other drugs have been identified as significant barriers to adherence to oral anticancer medications by healthcare providers and patients. 26 Drug-drug interactions (DDIs), including those with serious clinical consequences, can also occur when prescription medications are co-administered with over-the-counter and herbal medicines, 27,28 which are used by 20% of oncology patients. 29 As these non-prescription medications are likely to be selfobtained, clinicians may not be aware that patients are taking them, thus increasing the risk of DDIs that could lead to a lack of efficacy or AEs. ...
Purpose:
In this review, we address adherence rates in clinical settings, barriers to compliance with dosing schedules, and potential strategies to overcome challenges in maintaining high levels of adherence.
Materials and methods:
Four studies reporting real-world adherence to prostate cancer medications, 52 studies describing barriers to adherence, and 16 studies on methods to minimize poor adherence were reviewed.
Results:
Mean nonadherence rates of 25 to 51% have been identified in prostate cancer patients prescribed oral therapies, with higher rates in older patients. An extensive review of prostate cancer patients receiving gonadotropin hormone-releasing hormone agonist injections found an overall nonadherence rate of over 27%. Patients may encounter barriers to complying with dosing instructions related to the medication (eg, complex dosing schedules, the total burden of medication management, fasting or dietary requirements, high medication costs, adverse effects, and drug-drug interactions). Barriers may also be related to patient-specific factors (eg, suboptimal education regarding the importance of adherence, physical limitations and cognitive decline associated with advancing age, living alone without a care partner, high symptom burden, needle phobia, and comorbid mental disorders). Interventions to improve dosing adherence may include automated reminders, treatment diaries, educational materials, and the involvement of patients, family members, care partners, and healthcare teams.
Conclusions:
Many oral anticancer medications improve survival in men with prostate cancer and therefore it is vital to establish good adherence by understanding the pitfalls that patients may encounter. In situations where both oral and injectable drugs are interchangeable, injections of long-acting drugs lead to fewer opportunities for dosing nonadherence than oral therapies. In contrast, oral medicines do not require scheduling for injections and travel for injection appointments. Therefore, maximizing adherence to all treatment regimens will reduce the chance of efficacy failures and likely lead to improved clinical outcomes.
... Side effects during treatment of cancer can be numerous and may lead to decreased quality of life (QOL) and discontinuation of treatment [1]. Providers are often unaware of their patient's experiences of side effects and patients are often hesitant to discuss them with providers [2][3][4]. Proactive side effect monitoring with patient-reported outcome (PRO) systems can improve detection of symptoms [5][6][7]. PRO systems involve asking patients about specific side effects using known standard measures such as European Organization for Research and Treatment quality of life assessments (EORTC) and Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE), via email, application (app) or automated telephone call [8,9]. ...
Purpose:
The purpose of this study was to evaluate patient, oncologist and nurse perspectives on side effects and patient reported outcomes (PROs) with the question of how to optimize side effect management and PRO tools in this unique population.
Methods:
This pilot study utilized a mixed method explanatory design. Patients receiving intravenous (IV) chemotherapy from June to August 2020 were surveyed about side effect burden and PRO system preferences. Providers and nurses (PN) completed complementary surveys. Semi-structured phone interviews were conducted among a subset of each group.
Results:
Of 90 patient surveys collected; 51.1% minority, 35.6% rural, and 40.0% income < $30,000, 48% felt side effect management was a significant issue. All patients reported access to a communication device but 12.2% did not own a cell phone; 68% smart phone, 20% cell phone, 22% landline, 53% computer, and 39% tablet. Patients preferred a response to reported side effects within 0-3 h (73%) while only 29% of the 55 PN surveyed did (p < 0.0001). Interviews reinforced that side effect burden was a significant issue, the varied communication devices, and a PRO system could improve side effect management.
Conclusion:
In a non-White, rural and low-income patient population, 87.8% of patients reported owning a cell phone. Although all agreed side effect management was a prominent issue, expectations between patients and PN differed substantially. Qualitative data echoed the above and providing concrete suggestions to inform development of a PRO program and side effect mitigation strategies among a diverse patient population.
... To date, no standard practice across clinics and organizations is available for patients to follow and to report ADEs. One online survey for both HCPs and patients indicates that at least 30% of patients taken OAAs do not report their ADEs, and more than one-third oncologists believe that patients' avoidance of reporting is a barrier to effective management of cancer treatments [7]. With longer survival, many cancer patients now live with multiple chronic comorbidities and often take multiple medications at the same time as taking OAAs. ...
Medication errors have been a major threat to patient safety. Current research on medication errors is largely dependent on in-hospital reports. With the rapid shift of health care to chronic condition management, there is an urgent need to investigate medication errors in the community. In this paper, we discuss that the model of medication self-management developed for outpatient settings may be used to guide the development of prevention strategies for medication errors beyond hospitals. Further, timely reporting medication errors from patients in the communities may be helpful in mitigating the severity of side effects and reducing preventable safety events.
... Most providers, but few patients, reported comprehension (92% vs. 1%), cost (91% vs. 25%), regimen complexity (88% vs. 4%), and interactions with other medications (76% vs. 21%) as barriers. Interestingly, almost all providers believed that patients reported adverse effects some or most of the time but 30% of patients indicated they never or rarely reported adverse effects [29,42,46]. ...
The purpose of this pilot study was to assess Chronic Myeloid Leukemia (CML) patients’ adherence to, beliefs about, and barriers to oral anticancer agents (OAC) using brief self-report measures in community-based cancer clinics. Patients completed a structured interview including a health literacy assessment, a Brief Medication Questionnaire, two single-item self-report adherence questions, and the Medications Adherence Reasons Scale. Of the 86 participants, 88.4% were white; 55.8% male; mean age, 58.7 years; and 22.1% had limited health literacy. Nonadherence (missing at least one dose in the last week) was reported by 18.6% of participants and associated (p < 0.003) with less-than-excellent perceived ability to take CML medications (16.3%). Black participants reported more difficulty taking CML medications than white participants (28.6% vs. 8.3%, p = 0.053). Among all participants, 43.0% reported their CML medicine was ineffective and 24.4% that taking CML pills was somewhat to very hard. The most common reasons for missing a dose were simply missed it (24.4%) and side effects (18.6%). Most patients perceived their ability to take CML medication was good to excellent, yet nearly one in five reported missing at least one dose in the last week. Brief, no-cost self-report assessments to screen CML patients’ OAC adherence, barriers, and beliefs could facilitate counseling in busy community cancer clinics.
... Gandhi et al reported results from a prospective, multicenter, surveybased study and found that patients who filled prescriptions at the pharmacy associated with the cancer center seemed to report toxicities more often than those not affiliated with a cancer center. 19 They did, however, note that those filling prescriptions at a pharmacy outside of the cancer center tended to report toxicities to their family physicians or community pharmacists, rather than to a provider at the cancer center, suggesting that a lack of integration may contribute to poorer adherence. 19 LIMITATIONS Inherent limitations of this study include the retrospective nature of the study, which may affect the ability to limit confounding and to access complete datasets. ...
... 19 They did, however, note that those filling prescriptions at a pharmacy outside of the cancer center tended to report toxicities to their family physicians or community pharmacists, rather than to a provider at the cancer center, suggesting that a lack of integration may contribute to poorer adherence. 19 LIMITATIONS Inherent limitations of this study include the retrospective nature of the study, which may affect the ability to limit confounding and to access complete datasets. As a single-center study, applicability to other institutions may be limited. ...
BACKGROUND: Oral oncolytics are becoming increasingly common in the treatment of solid and hematological malignancies. Medication adherence is especially important to ensure adequate drug levels to treat active malignancies, notably in curative-intent therapy. Further data are needed to quantify and confirm the effects of internal health-system specialty pharmacies (HSSPs) on medication adherence. OBJECTIVE: To confirm the effect of an internal HSSP compared with external specialty pharmacies on oncolytic adherence as measured by proportion of days covered (PDC), medication possession ratio (MPR), and time to treatment (TTT). METHODS: This single-center retrospective cohort study included patients receiving oral oncolytics through an internal HSSP or external specialty pharmacies between January 2019 and June 2020. Fill data were extracted from pharmacy claims databases and electronic medical records. The primary adherence outcome was patient-level PDC. Secondary adherence outcomes included patient-level MPR and TTT. For PDC and MPR analyses, patients with at least 3 fills per oncolytic were included. All patients were included for the TTT analysis. Chi-square or Fisher's exact tests were used to analyze categorical differences between pharmacy groups. Differences in continuous variables across pharmacy groups were evaluated using Wilcoxon rank-sum tests. RESULTS: 871 prescriptions met inclusion criteria: 549 patients were included in the PDC/MPR analysis, and 758 patients were included in the TTT analysis (patients might have multiple prescriptions). Patients who filled at an internal HSSP had a higher median PDC compared with those who filled at external specialty pharmacies (0.99 [IQR = 0.89-1.00] vs 0.91 [IQR = 0.76-0.98]; P < 0.01). The adherence rate as measured by MPR was higher for patients who used an internal HSSP compared with those who used external specialty pharmacies (MPR = 1.00 [IQR = 0.90-1.00] vs 0.93 [IQR = 0.76-1.00]; P < 0.01). Median TTT was lower for patients using the internal HSSP vs an external specialty pharmacy (5 days [IQR = 2-13] vs 27 days [IQR = 2-82], respectively; P < 0.01). CONCLUSIONS: Internal HSSP services improved adherence as measured by PDC and MPR. Significantly lower TTT was seen with the internal HSSP compared with external pharmacies. These data confirm and support use of internal HSSPs to dispense oral oncolytics for treatment of solid and hematological malignancies. DISCLOSURES: This study received no financial support. The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
... Patients with cancer often do not report adverse effects of medication because they believe toxicity is expected or they are tolerating them; the focus is on managing these side effects. 73 In clinical management of HF, the focus is on complete avoidance of side effects. Concern about side effects is a leading reason why patients discontinue HF medications. ...
Globally, there has been little change in mortality rates from cardiovascular (CV) diseases or cancers over the past two decades (1997–2018). This is especially true for heart failure (HF) where 5-year mortality rates remain as high as 45–55%. In the same timeframe, the proportion of drug revenue, and regulatory drug approvals for cancer drugs, far out paces those for CV drugs. In 2018, while cancer drugs made 27% of Food and Drug Administration drug approvals, only 1% of drug approvals was for a CV drug, and over this entire 20 year span, only four drugs were approved for HF in the USA. Cardiovascular trialists need to reassess the design, execution, and purpose of CV clinical trials. In the area of oncology research, trials are much smaller, follow-up is shorter, and targeted therapies are common. Cardiovascular diseases and cancer are the two most common causes of death globally, and although they differ substantially, this review evaluates whether some elements of oncology research may be applicable in the CV arena. As one of the most underserved CV diseases, the review focuses on aspects of cancer research that may be applicable to HF research with the aim of streamlining the clinical trial process and decreasing the time and cost required to bring safe, effective, treatments to patients who need them. The paper is based on discussions among clinical trialists, industry representatives, regulatory authorities, and patients, which took place at the Cardiovascular Clinical Trialists Workshop in Washington, DC, on 8 December 2019 (https://www.globalcvctforum.com/2019 (14 September 2020)).
... As rucaparib is an oral medication taken in an outpatient setting, it is important to maintain regular clinical followup with patients, such as monthly follow-up during the first 3 months, with less frequent (e.g., every 3 months) follow-up thereafter for patients with good tolerability. Follow-up may be achieved through direct interactions with treating clinicians, interactions with other members of a multidisciplinary team (e.g., nurses and pharmacists), or through web-based applications [22][23][24][25]. Notably, recent surveys indicate that patients taking oral anticancer medications are interested in technologies to help them manage their treatment, such as pill reminders and apps that allow reporting of symptoms to physicians [24,26]. ...
... Follow-up may be achieved through direct interactions with treating clinicians, interactions with other members of a multidisciplinary team (e.g., nurses and pharmacists), or through web-based applications [22][23][24][25]. Notably, recent surveys indicate that patients taking oral anticancer medications are interested in technologies to help them manage their treatment, such as pill reminders and apps that allow reporting of symptoms to physicians [24,26]. Electronic medication reminders have been shown to encourage adherence [27,28], and the ability to report symptoms to clinicians or other healthcare team members via the internet has been associated with improvements in patient quality of life, better management of AEs, decreased hospitalizations, and longer overall survival [27,[29][30][31][32]. ...
... Although generally low grade, diarrhea often occurs when patients initiate rucaparib (median time to onset [95% CI], 29 [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] days) [21]. Clinicians should exclude other causes (e.g. ...
The poly(ADP-ribose) polymerase inhibitor rucaparib is approved as monotherapy in the treatment and maintenance settings for women with relapsed ovarian cancer in the European Union and the United States. We review the safety profile of rucaparib in both settings and provide recommendations for the clinical management of the main adverse events (AEs) that may occur during rucaparib treatment. We searched PubMed and congress proceedings for safety data on oral rucaparib monotherapy (600 mg twice daily) from clinical trials involving patients with relapsed ovarian cancer. AE management guidance was developed from clinical trial protocols, rucaparib prescribing information, oncology association guidelines, and author experience. The most frequent any-grade treatment-emergent AEs (TEAEs) included gastrointestinal symptoms, asthenia/fatigue, dysgeusia, anemia/decreased hemoglobin, and increased alanine/aspartate aminotransferase. Across clinical trials, 61.8% of patients had one or more grade 3 or higher TEAEs. Clinicians should employ close follow-up for TEAEs, particularly early in treatment, and educate patients about expected TEAEs and methods for their monitoring and management (e.g., antiemetics for nausea/vomiting, transfusions for hematologic TEAEs, or dose interruptions/reductions for moderate/severe TEAEs). Overall, 16.2% of patients discontinued rucaparib due to TEAEs. Management of AEs that may occur during rucaparib treatment is crucial for patients to obtain optimal clinical benefit by remaining on therapy and to avoid their detrimental impact on quality of life.
... 3,4 Oral oncolytics have serious adverse effects, and patient education has the potential to reduce adverse events, because patients are often unaware of or hesitant to report serious side effects and are unclear as to how to take these medications. [5][6][7][8][9] There is wide variability across cancer centers regarding education for oral oncolytics. 10 Pharmacist-driven interventions have been shown to improve adherence and education. ...
PURPOSE
The numbers and types of oral oncolytics in oncology are expanding rapidly. Oral oncolytics have serious adverse effects, and pharmacist-driven patient education has the potential to reduce adverse events. The University of New Mexico Comprehensive Cancer Center (UNM CCC) initiated a patient education and consent process for oral oncolytics in our minority, rural, and economically disadvantaged population.
PATIENTS AND METHODS
The UNM CCC initiated a pharmacist-driven education and consent process from August 2016 to October 2018. The process metric measured via statistical process control charts was the percentage of patients receiving oral oncolytic therapy who were educated and consented. The balancing metric was time for benefit investigation. The intervention was pharmacy team members providing standardized education for and obtaining consent from each patient, supported by electronic medical record orders, physician education, pharmacy notifications, and hospital discharge planning.
RESULTS
The initial monthly education and consent rate was 17.9%, followed by 45.5% the subsequent month. This quickly grew to an average of 87.0% (95% CI, 81.5% to 92.4%) for the subsequent 15 months in which control was achieved. Additional changes increased the education rate to 95.7% (95% CI, 93.4% to 98.1%). These 2 periods were statistically different ( P = .0025). There was no change in time for benefit investigation (5.60 v 5.52 days; P = .75).
CONCLUSION
A pharmacist-driven program for education and consent upon initiation of oral oncolytics is possible and can successfully educate a majority of patients. Future directions will include ensuring patient adherence and educating patients who fill oral oncolytic prescriptions outside UNM CCC.
... Complex factors including patients' socioeconomic status and health belief; factors related to the disease condition and health system-specific determinants influence OAM adherence [9][10][11][12]. These factors should be considered in the design and implementation of OAM adherence interventions [6,13]. ...
Smartphone apps can potentially help in enhancing oral anticancer medication (OAM) adherence. Patient adoption and efficacy of such apps depends on inclusion of user-centred and evidence-based features. The objective of this study was to identify important design considerations from the perspectives of patients taking OAMs, caregivers and oncology pharmacists. The study employed a qualitative study design. Data were collected using in-depth interviews with patients (n = 15), caregivers (n = 3) and pharmacists (n = 16). Interviews were audio-recorded, transcribed verbatim and inductive thematic analysis approach was used in data analysis. Monitoring medication-related problems, medication information, replacement of or integration with current systems and accessibility of app content on devices other than smartphones were the key themes identified in the analysis. Flexible input methods for monitored data, glanceability of monitored reports/information, near real-time adherence enhancing and symptom management interventions and customisable reminder options were design considerations identified under the monitoring medication-related problems theme. Participants suggested the provision of focused and easily understandable medication information with a potential for personalisation. Integration of app-based adherence systems with patients’ electronic medical records with added mechanisms for alerts in the dispensing system was also suggested as a key design requirement to improve quality of patient care and facilitate adoption by clinicians. Finally, smartphones were the most favoured platform with optional accessibility of app content on other devices. In conclusion, important design considerations were identified through a user-centred design approach. The findings will help developers and clinicians in the design of new app-based systems and evaluation of existing ones.
... For example, patients might direct questions to an extended network of practitioners providing base support in other ways (e.g., spiritual advisors, social workers, friends and family) or seek social support from a wider community network such as patient advocates, friends, or medical information staff in the pharmaceutical industry [40,98,99]. Patients who receive care external to an oncology center may be more likely to report adverse events to their primary care physicians or community pharmacists [100]. Many professionals outside of an oncology practice may have limited or no experience with OAMs [101]. ...
Interprofessional care is exhibited in outpatient oncology practices where practitioners from a myriad of specialties (e.g., oncology, nursing, pharmacy, health informatics and others) work collectively with patients to enhance therapeutic outcomes and minimize adverse effects. Historically, most ambulatory-based anticancer medication therapies have been administrated in infusion clinics or physician offices. Oral anticancer medications (OAMs) have become increasingly prevalent and preferred by patients for use in residential or other non-clinic settings. Self-administration of OAMs represents a significant shift in the management of cancer care and role responsibilities for patients and clinicians. While patients have a greater sense of empowerment and convenience when taking OAMs, adherence is a greater challenge than with intravenous therapies. This paper proposes use of a qualitative systems evaluation, based on theoretical frameworks for interdisciplinary team collaboration and systems science, to examine the social interactionism involved with the use of intravenous anticancer treatments and OAMs (as treatment technologies) by describing patient, organizational, and social systems considerations in communication, care, control, and context (i.e., Kaplan’s 4Cs). This conceptualization can help the healthcare system prepare for substantial workforce changes in cancer management, including increased utilization of oncology pharmacists.
