The Case of the PARP Inhibitor Adherence Assistance
This article was produced by ONS and is sponsored by AstraZeneca.
Mei is a 67-year-old patient who recently underwent an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and tumor debulking. Her surgical specimens were sent for pathology review and germline biomarker testing. Based on the findings, Mei was diagnosed with stage IIIC, high-grade serous epithelial ovarian cancer with a BRCA1 pathogenic germline variant.
Her medical history includes thyroid disorder and hypertension. Mei had a complete response following six cycles of platinum-based chemotherapy with a taxane and bevacizumab and began maintenance therapy with a poly adenosine diphosphate-ribose polymerase (PARP) inhibitor, olaparib, and bevacizumab to prevent or delay recurrence. During her pretreatment assessment, Mei tells you that she is excited about her response to chemotherapy and beginning maintenance therapy, but she is distressed about how much the PARP inhibitor costs and that she may not be able to afford it.
What Would You Do?
Oral anticancer medications are a convenient option for patients to manage their cancer treatment at home. However, adherence can be challenging and requires diligent nursing monitoring. Oral adherence may be affected by (https://doi.org/10.1016/j.ygyno.2021.08.025):
- Patient factors (e.g., physical or cognitive impairments, comorbidities that can exacerbate impairments)
- Social factors (e.g., financial resources, lack of social support)
- Healthcare-related factors (e.g., lack of communication)
- Therapy-related factors (e.g., compounding side effects like anemia and fatigue, drug-drug interactions)
Ongoing monitoring and early identification of barriers allows for prompt interventions and limits the impact on adherence.
As you consider financial support resources, you ask Mei questions to better understand her individual situation. Mei tells you the cost of the medication will affect her ability to afford personal expenses such as housing, food, and transportation. You share information about financial assistance programs from drug manufacturing companies and philanthropic organizations, such as copay cards or reimbursement programs (https://www.ons.org/clinical-practice-resources/oral-adherence-toolkit), confirm that she has a computer at home, guide her on how to access the services, and advise other members of her care team about connecting her to financial resources. You also provide education and resources from the ONS Oral Anticancer Medication Toolkit (https://view.ons.org/89RhRf), which includes financial resources. Mei is able to obtain copay assistance through the drug manufacturer and is very thankful.
Other Barriers to Oral Adherence
Although financial toxicity is a big factor in oral adherence, it’s not the only potential barrier: Two weeks later, Mei returns for a follow-up visit. She presents today with nausea and feeling fatigued when performing basic functions.
You start by asking questions so you can grade her fatigue. You remember that fatigue and anemia are common PARP inhibitor side effects (https://doi.org/10.1016/S1470-2045(18)30786-1) and that she has a history of thyroid disorder. You consult the provider and obtain orders for a thyroid panel as part of Mei’s routine complete blood cell count, but the results reveal that her hemoglobin and thyroid panel are both within normal limits. Turning your approach to symptom management, you share with Mei the National Comprehensive Cancer Network’s (https://nccn.org/) (NCCN’s) recommended ways to improve fatigue, such as:
- Monitor her fatigue levels to plan activities when she feels she has the most energy.
- Limit napping to maintain quality sleep at night.
- Engage in light physical activity (e.g., walking, yoga, swimming).
Mei tells you that the nausea has been distressing because she loves to bake. As you ask questions to grade her nausea, you learn that she received a prescription for a 5-HT3 receptor antagonist from her provider but was unsure when to take it. You educate her to take the antiemetic with a small meal (https://doi.org/10.1016/S1470-2045(18)30786-1) 60 minutes prior to taking her PARP inhibitor and advise eating small meals throughout the day (https://www.ons.org/books/chemotherapy-and-immunotherapy-guidelines-and-recommendations-practice) and avoiding foods with strong odors. In addition, because the NCCN antiemesis guidelines (https://nccn.org/) link regular use of a 5-HT3 receptor to increased risk of constipation, you recommend that she monitor her bowel movements and begin a preventive bowel routine. Lastly, you advise her to call the provider if she experiences constipation, vomiting, or weight loss or if her nausea persists despite interventions.
Throughout the visit, you allow time for Mei to ask questions, reinforce any education, and provide her with additional resources. At her next visit, Mei reports that following the interventions has improved her fatigue and nausea and she has not missed any doses because of her symptoms.
Nurses can help patients maintain adherence by assessing, educating, communicating, proactively discussing, and supporting them at each encounter. Tailor your discussions by evaluating your patient’s specific side effects and how they are managing them, barriers to obtaining the PARP inhibitor and taking it as prescribed, and coping mechanisms, then provide strategies to prevent them from interfering with treatment.