By Suzanne Walker, CRNP, MSN, AOCN®, BC

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. 

Barriers to Adherence

The reasons for nonadherence to OACs may be complex and variable. ONS member Mary K. Anderson, RN, BSN, OCN®, an oral chemotherapy nurse clinician at Norton Cancer Institute in Louisville, KY, says she’s noticed that patient comprehension has been the greatest challenge. 

“Patients may not necessarily be missing doses, but they may be taking them incorrectly. This may include taking too few or too many pills, taking them at the incorrect time, or taking them inappropriately with food,” Anderson says. She adds that other issues such as cost and medication toxicities may be a factor. 

ONS member Sandra Spoelstra, PhD, RN, a prolific researcher at Grand Valley State University in Allendale, MI, and internationally recognized expert on OAC adherence, agrees that the reasons for nonadherence may be multipronged. “Problems such as a lack of patient understanding, drug costs and side effects, polypharmacy, and lack of formalized structured programs may all contribute to nonadherence.” 

Although nonadherence may imply under adherence (i.e., taking less than the prescribed dose), Spoelstra cautions nurses to also be aware of over adherence, when patients take more than the prescribed dose (i.e., taking an extra dose to make up for a missed dose). 

Strategies to Improve Adherence

Both Spoelstra and Anderson recognize the important role that oncology nurses play in managing OACs. Spoelstra says that nurses are essential participants in any oral adherence program because of the close relationships they have developed with patients. 

Anderson concurs. “Our oral chemotherapy adherence program at Norton Cancer Institute is nurse-driven, with nurses providing the majority of patient education and follow-up encounters.” 

What Works to Promote Patient Adherence to Oral Chemotherapy?  

In an article published in the June 2015 issue of the Clinical Journal of Oncology Nursing, Putting Evidence Into Practice committee members looked at various oral chemotherapy adherence management techniques and identified the following as effective interventions.

Recommended for Practice

  • Patient monitoring and feedback: calendars, asking patients how and if they are taking their medication
  • Multicomponent interventions: patient education, counseling, reminder devices, packaging, and physician or patient feedback 
  • Likely to Be Effective
  • Text messaging 
  • Automated voice response
  • Treatment of underlying depression

The effectiveness of education, psychoeducation, cognitive-behavioral therapy, motivational interviewing, less frequent dosing, and technology (reminders, apps, and automated dispensers) could not be established.

Spoelstra cites proper assessment and more consistent nursing education around OACs as critical components of any oral adherence program. She is currently developing a standardized program that will address pertinent topics such as patient safety, drug education, and adherence. 

Anderson agrees that nursing education is also a key component of successfully managing patients on OACs. She stresses that nurses should continually educate themselves on the many new OACs that are entering the market. 

“Nurses should not be afraid of these medications. Many of these drugs have side effects that nurses are already familiar with managing, such as diarrhea and nausea and vomiting,” Anderson says. “Some patients may have the misconception that oral chemotherapy has fewer side effects than IV chemotherapy. Patient education and safety in the home should be a top priority for oncology nurses.”

The ONS Putting Evidence Into Practice (PEP) guideline for OACs, published in June 2015 and coauthored by Spoelstra, provides evidence-based recommendations for nurses to improve adherence. 

One of the recommendations revolves around the use of a text messaging system to provide reminders to patients about medication dosing. According to Spoelstra, “Text messaging provides an avenue for not only improving medication adherence, but also impacting symptom management.” 

Other PEP recommendations include patient monitoring and feedback, the use of automated voice response, treatment of underlying depression when present, and multicomponent interventions. 

 Positive reinforcement and human touch can go a long way in improving adherence, Anderson notes. “I recommend face-to-face encounters when feasible, and regular congratulations on a job well done when patients work diligently to remain adherent to their prescribed therapy.” 

The Funding Dilemma

Because most OACs are funded through prescription plans, oncology practices that have historically relied on IV chemotherapy reimbursements to cover costs now have the potential to lose revenue. These changes could have significant implications for oncology nurses, whose positions may be supported by infusion revenues. Some centers have subsequently opened their own specialty pharmacies that may offset costs and streamline care. 

What Should Patients Know About Oral Chemotherapy Parity? 

Oral chemotherapy parity is a law requiring health plans to cover oral cancer pills at a rate no less favorable than standard IV chemotherapy. Insurers generally cover IV chemotherapy as a medical benefit, with a modest patient copay and a limit on annual out-of-pocket costs. Oral chemotherapy is treated as a prescription drug benefit, requiring some patients to pay a significant portion of the drug’s cost, with no annual out-of-pocket limit. Oral chemotherapy parity helps ensure that all forms of chemotherapy are accessible and affordable to cancer patients. 

As of June 2015, 39 states plus the District of Columbia had enacted oral chemotherapy parity laws. A federal bill is currently under review in Congress. 

According to Anderson, “Our center has had its own specialty pharmacy for approximately eight years. The close proximity of the pharmacy allows for efficient interdisciplinary collaboration.” 

Spoelstra also recognizes the need for funding of OAC education programs and has identified the insurance industry as a potential partner. “Some insurance companies are now investigating the reimbursement of oncology practices for use of their nursing staff, rather than the insurance company case manager, to provide patient education for OACs,” she says. “Not only will this approach provide revenue support for oncology nursing positions, but there will also be better continuity of care for patients.” 

Future Directions

“We are entering a very exciting time in the treatment of cancer,” Anderson says. “With improvements in our understanding of the genetic and molecular makeup of cancer, we will continue to see more targeted therapies, many of which are oral. 

“One of the ways that our center has sought to enhance our oral chemotherapy program is through the use of technology and the electronic medical record (EMR),” she continues. “We currently use our EMR to house individual OAC protocols and consents so that all team members have access to them. In the future, I envision expanding the capabilities of our EMR platform to include built-in OAC protocols, as well as patient self-reporting options.” 

Spoelstra also recognizes the important role of technology as cancer care evolves to include more OACs. “Some of my present work focuses on collaborating with specialty pharmacies to incorporate a text messaging system to improve patient adherence to OACs,” she says. “I am also investigating the provision of standardized training programs to specialty pharmacies that dispense OACs.” 

The growth of molecular genomics has led to an influx of OACs into the marketplace over the past several years. These changes may have significant consequences for the way oncology care is delivered in the future. 

“Oncology nurses will see a shift in focus and responsibilities from caring for the patient at the chairside to ensuring patient safety and adherence in the home setting,” Anderson concludes. The inherent challenges associated with these changes will continue to evolve over time.