Oral Antineoplastics: Improving Adherence by Managing Patients' Expectations

Oral antineoplastics have advantages, but patient adherence is a concern.

The word cancer still makes most patients cringe. Its association with painful death seems to overshadow noteworthy progress in combating the disease over the past 10 years. What progress? First, new targeted treatments have led to complete remission for many patients; cancer death rates have declined 20% since 1991. Second, even if patients are not cured, extended survival is common. Some cancers become chronic diseases. Cancer specialists now say, “Patients will die with the cancer, rather than from the cancer.”¹ Third, more agents (defined as drugs and biologics) are available in oral dosage forms, and more than 25% of the 400 antineoplastic agents in development are planned as oral agents.^2,3

Oral agents are less costly to administer than intravenous (IV) drugs, do not require a central line, and do reduce some treatment risks, especially infection. As a bonus, patients tend to prefer oral agents.^4-6 Due to their complexity, oral agents are more costly to develop than IV dosage forms, and that generally translates to higher costs at the pharmacy.^7,8 Table 1 describes oral agents’ challenging characteristics.

Oral antineoplastics create a new concern for clinicians: ensuring patients remain adherent. Patients may choose not to follow health professionals’ advice, especially if patients weigh the risks and benefits and find that the risks tip the scale. One might expect that cancer patients, because of the seriousness of their disease, would be model adherers.⁷ This is not necessarily true.^10-16 Additionally, cancer patients who are nonadherent to medication often fail to adhere to other treatment recommendations and tend to have worse outcomes than model adherers.^17-19

Medication nonadherence is difficult to measure. Most adherence studies have pertained to chronic conditions that threaten patients’ health and longevity, but with less immediacy than cancer. In chronic disease, adherence is estimated at about 50% within a year.^17-19 Only a few studies document nonadherence in cancer:

• Only 64% to 88% of breast cancer patients actually take prescribed adjuvant hormonal therapy; if they do start, 50% to 80% remain adherent by the fourth year of treatment.¹⁴
• A study that compared women taking oral capecitabine from bottles with electronic tracking devices with women receiving standard IV therapy found an adherence rate of 77% with oral capecitabine.¹⁵
• Chronic myelogenous leukemia patients who are nonadherent to imatinib therapy have poorer outcomes, higher health care costs, and more treatment resistance; the 5-year survival rate is significantly better for imatinib-adherent patients.¹⁶

Adherence Barriers, Adherence Promoters

Adherence barriers can be individual (eg, side effects, medication cost, unique health belief), cultural (eg, affected by ethnicity, peer group, age), or systemic (medication access).^18,19 People from racial minorities, elderly patients, and very young patients may be at higher risk for nonadherence.^18,19 Measures that can improve adherence include keeping regimens simple, finding patient assistance programs when cost is a problem, and suggesting ways to cope with side effects.

Because oral therapy often decreases the frequency of patient contact with the oncology team, patients look to pharmacists for support.9 As our roles evolve and the need to tailor information to diverse and specific recipients grows, pharmacists must know how to manage patient expectations.²⁰

Managing expectations means initiating a communication process so patients, caregivers, and other clinicians have an unambiguous understanding of what to expect. It is not a 1-time communication; ongoing dialogue is critical. It means delineating possibilities, probabilities, and definite outcomes incrementally and often. It also requires some vigilance to determine when a person’s understanding and anticipatory beliefs misalign with reality. It often requires you to gently redirect patients to realistic goals. This means that at each encounter, you ensure that patients understand, and remind them, what a medication or treatment (or pharmacist) can and cannot do.²¹ Table 2 describes steps for managing a patient’s expectations.

Improving Counseling

A few additional points can help you improve your counseling skills with cancer patients. Check product information and explain handling guidelines. Make sure that patients have supplies they need (ie, gloves or masks). Address the need to crush tablets or open capsules for the very young or very old. Remind patients that some oral antineoplastics cannot be crushed or opened. Make patients aware of reliable websites that cover their specific cancers.

The National Cancer Institute (www.nci.nih.gov) is a good source of patient information in English and Spanish. Disease-specific advocacy sites can also be helpful.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance clinical writer.

Refernces

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• Weingart S, Brown E, Bach PB, et al. NCCN Task Force Report: Oral chemotherapy. J Natl Compr Canc Netw. 2008:6(suppl 3):S1-S14.
• Correia RJ. Oral oncology therapies: specialty pharmacy's newest challenge. Pharm Times. May 18, 2011. www.pharmacytimes.com/publications/specialty-pt/2011/May2011/Oral-Oncology-Therapies-Specialty-Pharmacys-Newest-Challenge-. Accessed July 1, 2013.
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• Neugut AI, Hillyer GC, Kushi LH, et al. Non-initiation of adjuvant hormonal therapy in women with hormone receptor-positive breast cancer: The Breast Cancer Quality of Care Study (BQUAL). Breast Cancer Res Treat. 2012;134:419-428.
• Partridge AH, Archer L, Kornblith AB, et al. Adherence and persistence with oral adjuvant chemotherapy in older women with early-stage breast cancer in CALGB 49907: adherence companion study 60104. J Clin Oncol. 2010;28:2418-2422.
• Noens L, van Lierde MA, De Bock R, et al. Prevalence, determinants, and outcomes of nonadherence to imatinib therapy in patients with chronic myeloid leukemia: the ADAGIO study. Blood. 2009;113:5401-5411.
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• World Health Organization. Adherence to long-term therapies: evidence for action. www.who.int/chp/knowledge/publications/adherence_full_report.pdf. Accessed July 1, 2013.
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