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.

Conversation With Wendy H. Vogel, MSN, FNP, AOCNP®

Q: Why are there potential challenges with oral oncolytic adherence?

A: I think the basic one is a lack of knowl­edge on the part of the patient and some­times the provider, or whoever is educating the patient. Inadequate follow-up is another challenge. I know our practice is extremely busy, as are other practices, and it’s hard to even find a spot for some of these patients. The third challenge is that patients perceive oral therapy as being safer and less toxic, but they also don’t realize the impact on outcome from missing “just one dose.”

Q: What are the main factors that affect adherence to oral agent administration in oncology?

A: The biggest thing is the lack of a cheer­leader. When we give IV therapy, we’ve got oncology nurses at their chairside encourag­ing them while they’re getting their treat­ment; patients are kind of out in their own world at home making decisions for them­selves on finding a treatment, how they’re going to take it, what they’re going to take it with, and so on. They don’t have that con­stant reinforcement while they’re getting that treatment. I think that’s huge in having that cheerleader, and it goes along with adequate follow-up.

Inadequate triage can also occur. If you’ve got an oncology chemotherapy nurse on triage who’s not as familiar with oral oncolytics, that can be huge—especially when we’re talking about specific side effects that can come with orals that are different, like the diarrhea with neratinib. A lot of our orals just have some weird, different side effects that many nurses are not familiar with. The other factor that affects adherence is adequate education. We need to tell patients, “So this, this, and this, you need to call me about. This, this, and this, you need to go to the emergency department. This, this, and this can wait until the morning but don’t hesitate to call for any reason.” I think edu­cation about when to call is huge; don’t wait until your next appointment, and then we find out that you’ve been off your medicine for two weeks.

Q: As oncology treatments become easier to administer and more home-based, so does a patient’s responsibility to orally take oncolytics. What processes does your practice, or do you personally, have in place to support patients that are pre­scribed oral oncolytics?

A: I’m really proud of our practice and what we’ve put into place with our oral oncolytics. We have an Epic system for our electronic medical records (EMR), and as a part of this we have put our oral oncolyt­ics into a treatment plan just like we do our IV drugs. Up front, when the provider prescribes an oral oncolytic, a treatment plan is immediately initiated. Whatever supportive home medications they need are prescribed as well. The oral oncolytic goes to a specific one of two people in our office who then begin to work on insur­ance coverage. Once we’ve got insurance coverage, the patient receives the drug but is instructed not to start it until they have specific education on the drug.

They will meet with the oncology nurse educator who will go over with them what the medicine looks like, how many to take, and other essential education, with the med­icine in front of them. The other part of that prework to this is that as soon as the drug is ordered, our pharmacists get an email to review for drug-drug interactions. I think that’s really key because some of our special­ty pharmacies only know what information we give them or what patients give them in terms of what other drugs patients are on.

Our pharmacists are looking at every patient on an oral oncolytic to review for drug-drug interaction. In fact, we had one who was on a cardiac agent that absolutely was contraindicated with the oral oncolyt­ics that we ordered. So, we contacted the cardiologist to see if there were alternatives for what the patient was on, or we would not prescribe the drug.

Patients are scheduled for a follow-up appointment with a provider who is usually the advanced practitioner in our practice within one to two weeks, depending upon the drug.

We look at the median onset of symptoms and try to see them about that time, before probably or certainly after. Based on that follow-up appointment at one to two weeks, then we’ll schedule them back weekly or whatever is appropriate for that patient. All of the advanced providers in our practice are responsible for ordering and refilling; the initial order triggers automatic refills, so we are reviewing the chart before every pre­scription goes through, making sure that the dose hasn’t changed and that they’re doing okay side-effect wise.

A week after patients start taking the drug, Epic prompts one of our nurses to call and check on the patient. Every patient gets a follow-up call within the week of starting an oral agent. Depending on how they’re doing, they’ll schedule follow-up calls sooner than their appointment.

About two months into therapy, the phar­macist gets another request to do a drug-drug interaction check; that is ongoing throughout this process. We have a really nice setup that we’ve built into our Epic EMR so the right person gets the right prompt at the right time, and each healthcare practitioner involved knows the right thing to do.

Q: What has been your experience with neratinib and oral adherence?

A: It’s been okay so far. This is more of a unique patient population because patients with breast cancer are usually more moti­vated than other patients; I think, overall, patients with breast cancer probably have better adherence.

My personal experience with neratinib has not been bad. I will say that one patient who was prescribed neratinib did struggle and didn’t take the drug because of cost, which is really sad. Her income was high enough that she did not qualify for any assistance and so her first month’s copay was going to be about $2,500. After that, it was going to be about $100 a month, and she declined therapy purely on cost.

NOTE: The Puma Patient Lynx™ support program is available to assist patients and healthcare providers with reimbursement sup­port and referrals to resources that can help with financial assistance for neratinib.

Read the other articles in this series:

ONS member Wendy H. Vogel, MSN, FNP, AOCNP®, is an oncology nurse practitioner at Wellmont Cancer Institute in Kingsport, TN. She received her BS in Nursing at Tennessee Technological University and her MS in Nursing in the Family Nurse Practitioner Program at East Tennessee State University. Vogel is an advanced oncology certified nurse practitioner through the Oncology Nursing Certification Corporation and a certified family nurse practitioner through the American Nurses Credentialing Center.

Vogel has experience in oncology, educa­tion, cancer prevention, and public speak­ing. She is an associate editor of the Journal of the Advanced Practitioner in Oncology and has also published in several other journals and newsletters. She is a founding board member of APSHO, the Advanced Practitioner Society in Hematology and Oncology. She received the 2012 ONS Mary Nowotny Excellence in Cancer Nursing Education Award and the American Journal of Nursing Book of the Year award for co-editing the Advanced Oncology Nursing Certification Review and Resource Manual: Instructor’s Resource. She has lectured at national and international conferences on oncology topics.