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A strategy for improving adherence among patients taking oral oncology medications.

As C. Everett Koop once cogently pointed out: “Drugs don’t work in patients who don’t take them.” Indeed, across all therapeutic categories, medication adherence is an ongoing challenge. An estimated 20 percent to 30 percent of prescriptions are never filled, and medication is not continued as prescribed in about 50 percent of cases. This is a troubling trend especially for oral oncology medications, which are rapidly replacing intravenous (IV) chemotherapy for a number of cancers.

Increasingly, these new oral agents target specific biologic processes in cancer cells and may be safer and more effective than traditional chemotherapies, which can indiscriminately attack both cancer and healthy cells. And not surprisingly, preference for oral oncology therapy is also high among patients because it is more convenient – it requires no hospital visit or IV, and is less disruptive to their daily lives. This is all good news for oncologists and their patients, but it creates a new challenge: adherence. By moving treatments from the healthcare facility to the home, responsibility for managing drug regimens and monitoring dosing and toxicity shifts from the oncology team to the patients and their caregivers.

For some patients, having this level of direct involvement in their disease management and treatment is empowering. But for others it can be overwhelming, especially if they don’t have the support in place to understand and manage their care. In many cases oral oncology medications involve complex regimens, risk of side effects, the need for safe handling and disposal of medication, and access barriers if the medication is not carried by their local pharmacies. All of these challenges create adherence risks as patients become unable or unwilling to manage the complexity of their medication.

Providers can further help their patients by following this SIMPLE plan for adherence.

S — Simplify the regimen by adapting it to the patient’s lifestyle. That may include adjusting the medication timing, frequency, amount, and dosage to minimize complexity and reduce the impact on their day-to-day lives.

I — Impart knowledge. Providers should engage patients and their caregivers in decision-making around their treatment, and patients should keep everyone on the medical team informed about those decisions, including their physicians, nurses, and pharmacists. They should also offer advice and access to tools that will help them manage costs; provide written and verbal prescription instructions that are easy to understand; and point them to additional research on the medication and the disease if they are interested. 

M — Modify patient beliefs and behavior. Before beginning an at-home treatment regimen, patients need to be confident that they can handle it. Providers can encourage this confidence by making sure they understand the health benefits of following the treatment regimen, and the risks if they don’t take their medications as prescribed. They should also address any fears or concerns the patients have from the beginning, follow-up to make sure they are staying on track, and reward them with positive feedback for adherence.

P — Provide communication and trust. Patients need to feel like they can rely on their providers to answer their questions and allay their fears. Providers can meet that need by honing their interview skills, practicing active listening, providing them with emotional support, and using plain language that is meaningful and motivating to them.

L — Leave the bias. The health literacy of a patient directly affects their healthcare experience and their treatment outcomes. When providers take the time to examine their own self-efficacy regarding care of racial, ethnic, and social minority populations they can eliminate any unconscious bias, and develop a more patient-centered communication style that fosters greater adherence.

E — Evaluate. To be sure patients are adhering to their medication, providers have to follow up with them. In phone calls, emails and/or doctor visits they should ask about adherence behavior, review the patient’s medication containers and renewal dates, and use biochemical tests to measure serum or urine medication levels as needed.  All of these checkpoints can help identify a patient who is at risk of going off their medication.

One way to help mitigate these risks is to involve oncology clinical nurse educators (CNE) in discussions with patients about their treatment process. An oncology CNE can provide the oncology patients with education and support about the correct use of oral oncology medications, and help them address any access and adherence issues in partnership with their healthcare team. This additional line of support may greatly increase the rate of adherence and improve the patient experience with these oral oncology medications.

By following this SIMPLE plan, physicians and CNEs in combination can address many of the barriers to adherence and create a more confident and empowered patient population.

Topics in this blog post: Healthcare, Oncology, Patient-centered, World Cancer Day