Jenni is an oncology nurse practitioner in an outpatient medical oncology clinic. She is meeting with 70-year-old Don after his first cycle of cabozantinib for treatment of metastatic medullary thyroid carcinoma when he asks why the oncologist put him on a pill instead of using IV chemotherapy. “Is it because I don’t have long to live?” Don wonders.

It’s been almost a decade since the Institute of Medicine—now the National Academies of Medicine (NAM)—released The Future of Nursing: Leading Change, Advancing Health report. Although many aspects of the nursing profession have been enhanced, still others are woefully lacking in change. Healthcare workplace safety incidents are still too high—up to 12 times higher than in the overall workforce—educational opportunities are still too expensive, and scope-of-practice authority is still too limiting in many states—all of which are ONS policy priorities.

A provider develops a partnership with a patient and negotiates behaviors to reach an agreement to adhere to oral chemotherapy medication. This is an example of which strategy?

a. Reinforcement

b. Operant conditioning

c. Motivational interviewing

d. Partnership   

To ensure that patients and providers are equipped with the latest, most up-to-date knowledge and resources, ONS routinely works with patient advocacy groups, subject matter experts, and other provider organizations to develop and refine critical information for clinical practice. Following safety standards and meeting patient education requirements are critical to successful oral chemotherapy practice.

As a direct line to the oncology team, the phone conversations between nurses and their patients can help address symptoms, foster valuable patient education, provide useful interventions, encourage side effect reporting, and identify potentially life-threatening situations. Ultimately, successful telephone triage requires a unique skill set for oncology nurses to communicate with their patients and recognize underlying issues.

This is the third in a series detailing some of the general factors to consider around patient adherence to oral medications, and ways to support patients receiving neratinib.

This is the third in a series detailing some of the general factors to consider around patient adherence to oral medications, and ways to support patients receiving neratinib.

AS is a 58-year-old woman who was diagnosed at age 55 with a right infiltrating ductal carcinoma of the breast, identified as grade III, ER and PR positive, and HER2 positive. She had bilateral mastectomy, and tumor size was noted to be 2.8 cm. She had a positive sentinel lymph node. She was staged at IIB (pT2, pN1, M0). Her left breast was noted to have usual ductal epithelial hyperplasia and a 1.2 cm fibroadenoma. AS’s genetic testing revealed a BRCA1 mutation (BRCA1 c.3748G>T [p.Glu1250*]), which may confer an increased risk for breast cancer in the range of 46%–87%, and 39%–63% risk for ovarian cancer by age 70. As her patient history shows, she has some risk factors for nonadherence, including no support at home and some financial issues. Throughout her care, the team worked to communicate and prepare AS to help ensure adherence as much as possible.

The cancer treatment landscape has shifted with the emergence of new, targeted therapies. Development and use of oral oncolytics, targeted cancer therapies that can be taken by patients orally in their own homes, has increased in recent years. This increase is due in part to research in extra- and intracellular signaling pathways. By interfering with or blocking these signals, targeted drugs have become standard agents in cancer therapy. Oral oncolytics currently account for about 25% of the oncology pipeline of drugs in clinical development, and experts project that oral oncoloytic use will continue to rise.

Use of oral therapies requires healthcare teams to monitor patients for issues such as unreported side effects, medication nonadherence, and incorrect administration of medications. Although many patients do very well with this form of treatment, some patients, even with a significant amount of education before starting therapy, may have challenges. 

Oral agents offer many patient benefits, one of which is the freedom to take the medication at home, allowing them to keep their daily routine and gain additional time and independence they would have spent traveling to the clinic for treatment. However, with that freedom comes additional patient responsibilities, and preparation from advanced practice RNs (APRNs) is necessary to ensure patients can self-manage symptoms and adhere to administration regimens. Research shows that patients experience severe symptoms on oral agents that may cause them to miss as many as one-third of the prescribed doses. How can APRNs empower patients to adhere to the treatment plan and ensure safe symptom self-management at home? 

Oncology nurses know the challenges of patient adherence to oral cancer therapies. Every dose a patient misses can affect their outcomes and chance of survival. But in clinical trials, oral adherence has even broader implications: when a study is evaluating the efficacy of a drug, it depends on study participants taking it exactly as the trial outlines.

Oral cancer treatments are effective and practical and can provide a level of flexibility for patients, allowing them to seamlessly continue their treatments without the burden of infusion visits. With many patients receiving oral chemotherapy, oncology nurses must recognize complications that can arise regarding procedure and documentation in practice.  

Administration of chemotherapy drugs has shifted dramatically in the past 15 years from parenteral to oral administration. This change requires patients to self-manage their chemotherapy. Patients need to understand important medication administration tasks: right dose, right time, right route, and right drug.

Oral chemotherapy, like IV chemotherapy, effectively helps patients fight cancer and may have similar side effects to its IV counterparts. Self-administration of oral chemotherapy may be convenient, but it is still chemotherapy and requires extra caution.

Adherence to oral agents for cancer (OACs) is an important issue in the oncology setting. Unlike IV agents, which are typically administered in a controlled environment by oncology nurses, OACs are self-administered at home with little professional oversight. The potential for medication error or nonadherence cannot be underestimated, but oncology nurses are in a key position to spearhead initiatives aimed at improving patient education and adherence for OACs.

As the use of oral oncolytics has increased in cancer care, so has the amount of time oncology nurses spend educating and counseling patients and caregivers on their use. Studies have shown that although it’s challenging for nurses to carve out, the time is well spent.

As chemotherapy administration has shifted from IV delivery in the infusion center to oral delivery at home, so has the burden for the five rights of medication administration.

Oral agents are changing oncology treatment, and along with it, who’s responsible for the safety of those treatments. “With oral agents, the onus is now primarily on patients and their caregivers,” says ONS member Kathy Leifeste. This is quite a shift from the nurse-administered IV chemotherapy and biotherapy we’ve grown accustomed to.