In an era when oral drugs are increasingly becoming a part of our approach to care for patients with cancer, adherence to prescribed therapy is essential. Yet the statistics cited by Dr Hansen are a stark reminder that despite our best intentions, cancer patients do not and will not always take oral medications the way in which they are directed. For the clinician, this poses a challenge as to how best to confront this troublesome issue in order to improve outcomes for the patients entrusted to our care. The details of such an effort may vary from cancer center to cancer center. While there is no clear recipe for success, what follows are some practice-based suggestions for improving adherence to oral medications.
First, healthcare providers must be suitably engaged with their patients so as to identify factors that have commonly been associated with poor medication adherence. These issues include medication cost, complexity of treatment regimen, poor communication between healthcare provider and patient, significant requirement for change of lifestyle or behavior, inadequate or nonexistent support system, history of nonadherence, etc.1,2
Additionally, providers should carefully consider establishing procedures to overcome these common barriers associated with medication nonadherence. In our practice, we have implemented specific strategies for patient education that are intended to address several of the risk factors discussed here and improve compliance. When new oral medications are prescribed, the patient and family are strongly encouraged to be equal participants in medication counseling sessions. During the time spent with the clinical pharmacist, patients are provided with calendars that include times for drug administration and other patient-specific directions. This is done in an effort to simplify complex regimens. If substantial concern exists or a there is a proven history of nonadherence, patients are often provided with pillboxes, which in many cases are initially filled by the pharmacist. Furthermore, we encourage a culture of accountability between the patient and family members or caregivers so that all of the involved parties feel comfortable reporting to our staff any concerns they may have regarding the patient’s care (including adherence issues). Finally, patients are reeducated at each clinic visit about the purpose and goals of any oral medication, directions for use, duration of therapy, and the need for a strong pattern of medication adherence. While we have not conducted an assessment related to adherence to oral cancer therapies, we feel that these steps have been successful in reducing the incidence of poor medication adherence among our patients.
Finally, providers should use good clinical judgment when determining the appropriateness of oral therapy. For some malignant diseases, oral medications may be the standard of care (ie, imatinib for chronic myeloid leukemia), and alternative therapies may not offer the same degree of efficacy or quality-of-life maintenance. However, in diseases for which clinical trials have demonstrated similar efficacy between oral and intravenous (IV) therapies, those patients not considered good candidates for oral drugs should be treated with IV formulations. For example, the phase 3 X-ACT trial sought to establish noninferiority of oral capecitabine versus IV fluorouracil for patients with stage III colon cancer. When evaluating disease-free survival, the 2 formulations of drug were determined to be equivalent.3 While a reliable, competent patient may be treated with capecitabine without cause for concern regarding efficacy, those patients for whom concern of nonadherence exists would be better served with IV fluorouracil.
In the future, as the absolute number of oral oncology drugs increases along with the number of disease-related indications for these drugs, providers will be forced to consider mechanisms to increase adherence to these drugs or risk poorer outcomes compared with those previously achieved with standard-of-care IV therapies. As these transitions in care occur, the role of the oncology pharmacist (along with that of physicians and nurses) may shift to one of “gatekeeper,” ensuring that these new oral wonder drugs reach the patients who are most likely to remain adherent and derive benefit. Ultimately, we must remember that absolute compliance can only be ensured when the patient is observed receiving the medication—a task that we can truly monitor only in our infusion rooms with IV therapies. For all other patients, there will always remain the lingering question: “Did our patient take the medication as prescribed?”
References
- Partridge AH, Avorn J, Wang PS, et al. Adherence to therapy with oral antineoplastic agents. J Natl Cancer Inst. 2002;94:652-661.
- Hohneker J, Shah-Mehta S, Brandt PS. Perspectives on adherence and persistence with oral medications for cancer treatment. J Oncol Pract. 2011;7:65-67.
- Twelves C, Wong A, Nowacki MP, et al. Capecitabine as adjuvant treatment for stage III colon cancer. N Engl J Med. 2005;352:2696-2704.