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, RN, MSN, AOCN®, an oncology nurse educator at Overlook Medical Center in Summit, NJ. This is quite a shift from the nurse-administered IV chemotherapy and biotherapy we’ve grown accustomed to.
“With traditional IV chemotherapy, safe handling is primarily the role of the healthcare provider, the pharmacist preparing and dispensing the drug, the nurse administering the drug, and those responsible for disposal of the equipment used in the process of delivering the drug,” Leifeste explains. “With home administration of oral agents, now the oncology nurse’s role transitions to providing comprehensive education to patients and their caregivers to ensure that the only person being exposed to the drug is the patient.”
Safety Outside of the Infusion Center
Many patients enjoy being untethered from IV treatments, but do they understand how to safely handle and dispose of oral agents? According to ONS member Debra Winkeljohn, RN, MSN, AOCN®, CNS, a clinical nurse specialist and research nurse at Hematology Oncology Associates in Albuquerque, NM, the answer is no. “Many believe it is just another pill and that they can handle and mix them with other meds in a pill box. Ideally, they would have been educated by the pharmacists, but I do not see that happening often.”
So what are the basics that patients and caregivers should know? Leifeste says that she instructs her patients that “the drug should be stored in a secure area, out of reach of pets and children. It may need to be protected from light or kept in the refrigerator. Some drugs require desiccants to prevent breakdown from moisture.”
Caregivers should be extra cautious, Leifeste adds. “If caregivers are administering the drug, efforts must be made to protect them from exposure. Gloves should be worn when handling the drug. If the drug is provided in a blister pack, care should be taken when opening the packet to avoid breathing in any powder that may be aerosolized.”
Online Course Prepares You to Safely Care for Patients Receiving Oral AntineoplasticsWinkeljohn tells her patients to “put the medication in a cup, then take it; don’t touch it with your bare hands. I also prefer to have my patients bring in their prescription when they get it to verify the drug and instructions or at least call the office when they receive it to read it off to me. Safe handling also should include the double check system for dosing, which is often hard in private clinics.”
Disposal is also a little tricky at home. “In the ideal world, the blister pack and gloves should be disposed of in a chemotherapy waste container, but the main concern for the home setting is the drug itself. If the drug has been discontinued, the drug should be returned to the healthcare provider so that it can be disposed of appropriately. It should not be flushed down the toilet or placed in the trash,” Leifeste says.
Oncology Nurses’ Role in Educating Patients About Safe Handling
“Oncology nurses should be primarily responsible for educating patients and their families,” Leifeste says. “Safe handling education should be reinforced at each visit. The pharmacist can certainly reinforce the teaching, but the nurse is well positioned to assess patients’ and families’ learning needs and to address them appropriately, provide the initial education, and continue reinforcing with each follow-up visit.”
In contrast, Winkeljohn says, “In our private practice, often times the physician is the one who starts the conversation. Currently we are trying then to follow up with a mid-level provider such as myself to do the official teaching. I also then have a follow-up appointment made for the patient weekly, with labs during their first month to monitor the side effects. Patients receive written information along with a review of handling, safety, side effects, and how often we plan to see them.”
Monitoring Side Effects of Oral Agents
With reduced patient contact during oral treatment, keeping tabs on side effects can be a challenge. “Many patients do not understand that it is still chemotherapy and we need to be kept up to date on side effects to be able to manage them sooner. Some side effects show within two weeks of starting treatment,” Winklejohn says.
“Clear parameters should be provided to the patient on when to call with certain symptoms,” Leifeste adds. “It is essential to emphasize the importance of reporting problems and of not being stoic and continuing to take the drug when the drug should be held or the dose modified. The consequences of forging on despite symptoms can increase morbidity and potentially be fatal.”
Winklejohn tries to arrange seeing her patients in the office more often. “I feel, if you can, you should set eyes on patients. If they are doing well, I explain that they can cancel an appointment with me. You often have to stress the need to monitor symptoms more closely when some patients are not seen as often. I also stress our triage and that we always have someone on call, 24 hours a day.”
Ensuring Patient Adherence to Oral Therapies
“Adherence can be a big problem, and it is difficult to study and monitor,” Winkeljohn says. “Generally, patients should know the importance of their medication and how it is treating their cancer. If they do not take the medication, then their cancer may grow and progress. If I know a patient is going on an oral chemotherapy, I make notes to follow the progress of their prescription and make sure they are scheduled to be seen accordingly.”
Leifeste agrees. “Nurses should act as coaches for patients. They need to assess patients’ understanding of the importance of the drug as a part of their treatment regimen. They should not be judgmental but should rather work with patients to help them find the best strategies to ensure their adherence to the treatment regimen.”
Winkeljohn’s successful strategies for optimizing adherence with oral agents include “identifying the appropriate patients and making sure patients and providers have a good relationship. Sometimes we recommend they bring in their bottles of medication to count, but that is not necessarily proof that they are taking their medication.” She also encourages patients to use a calendar to mark off days of therapy and track symptoms.
Some patients may skimp on treatments in an effort to stretch out the expensive drugs. “Ensuring financial issues are handled is the most important step in adherence,” Leifeste says. “The price of oral therapy can cost thousands of dollars a month.”
She adds, “It is essential that every effort be made to obtain a patient’s drug seamlessly and that patients have the drug in hand before they are to begin therapy. This ensures that everyone is clear of the starting date for the drug.”
You Tell Us! What are your successful strategies for getting patients to adhere to their oral agents?