Improving Adherence to Oral Oncolytics

The use of oral oncolytics has become increasingly prevalent in cancer care with their use accelerated by the COVID-19 pandemic.¹ Adherence to these medications, however, can be challenging for patients.²

In a session of the virtual American Society of Health-System Pharmacists (ASHP) Specialty Pharmacy Conference, presenter Eve Segal, PharmD, BCOP, lead clinical pharmacist, University of Washington Medical Center/Seattle Cancer Care Alliance, discussed advantages of oral oncolytics as well as a need for pharmacists to understand barriers to adherence faced by patients who are prescribed these medications. Segal also offered strategies for improving adherence for patients taking these medications.²

“Oral oncolytics really have solidified their place in cancer treatment. The oral route has many advantages in cancer management. In some cases, the oral route is actually preferred [to other forms of medication],” Segal said during the ASHP session.

According to Segal, oral oncolytics offer more convenience and improved quality of life for patients than other forms of therapy. She noted less interference with work and social activities, avoiding painful injections and prolonged time with infusions, as well as allowing patients to take more ownership of their therapy with self-administration. Additionally, in some cases, patients taking oral oncolytics may experience prolonged drug exposure and may have access to a more effective delivery option.^2,3

Although adherence to medication leads to better control of the disease, rates of adherence vary widely. A review of literature showed that adherence rates with oral antineoplastic therapies range between 46% and 100%, with differences in study results based on patient sample, medication type, measure of assessment, adherence calculation, and when follow-up occurred.⁴ Segal said barriers exist that prevent many patients from taking their oral oncolytics. She cited common barriers^2,4:

• Logistical: cost, regimen complexity, adverse events, poor access to medication
• Perceptual: poor understanding, lack of belief in efficacy, lack of understanding for therapy's purpose, inability to see benefits
• Physical: visual deficits, physical difficulties
• Mental: memory deficits, mental illness
• Social: poor communication with care team, language deficits, poor literacy, lack of support system, cultural or religious beliefs

Direct and indirect methods can help improve adherence. Although expensive and impractical, smart pill bottles and smart caps can assist many patients, for example. Self-reporting by patients, pill counts, and pharmacy claims data are examples of indirect support for adherence; however, these methods do not prove that a patient has taken a medication.⁵

“Each method has its own advantages and disadvantages,” Segal said. “Keep in mind that there is no gold standard to assessing and evaluating adherence.”

By working with an oncology care team, pharmacists have opportunities to help improve care for patients with cancer who are taking oral oncolytic agents.⁵ Segal suggested using a combination of patient education and behavioral intervention, and routinely following up with patients to combat nonadherence. These strategies may include informational handouts that use plain language; calendars or other visual reminders; reviewing the refill process and confirming that a patient understands it; ensuring a patient is scheduled for a follow-up visit to assess adherence and potential toxicities to treatments; discussing medication cost; use of pill boxes; and smartphone apps that remind patients to take their medications. Segal said a pharmacist’s approach should be customized to individual patients based on what works best for them.²

Overall, patient education is key, Segal said, noting that there is no clear, best way to educate patients, but the information provided should be consistent.²

“Patients should also know how to obtain their medication, the role of the specialty pharmacy, and [about] financial assistance,” she said.

REFERENCES

1. Castro C, Manoogian A. COVID-19 and the impact on oral oncolytics: a specialty pharmacy perspective. Directions in Oncology Pharmacy®. 2020;2(4):16-17. https://www.pharmacytimes.com/view/ covid-19-and-the-impact-on-oral-oncolytics-a-specialty-pharmacy-perspective
2. Segal E. Improving adherence to patients receiving oral oncolytics: a review of current strategies. Presented at: American Society of Health-System Pharmacists Specialty Pharmacy Conference; virtual. June 14-16, 2021.
3. Segal EM, Flood MR, Mancini RS, et al. Oral chemotherapy food and drug interactions: a comprehensive review of the literature. J Oncol Pract. 2014;10(4):e255-268. doi:10.1200/JOP.2013.001183
4. Greer JA, Amoyal N, Nisotel L, et al. A systematic review of adherence to oral antineoplastic therapies. Oncologist. 2016;21(3):354-376. doi:10.1634/ theoncologist.2015-0405
5. Mackler E, Segal EM, Muluneh B, Jeffers K, Carmichael J. 2018 Hematology/ Oncology Pharmacist Association best practices for the management of oral oncolytic therapy: pharmacy practice standard. J Oncol Pract. 2019;15(4):e346-e355. doi:10.1200/ JOP.18.00581