Mobile adherence apps are a great boon to patients who face the responsibility of taking oral chemotherapy drugs as directed without in-person supervision by clinicians.


Much of our progress to date in improving cancer survival rates has been attributed to breakthrough medications, including oral chemotherapy agents that patients can take at home. This trend shows no sign of stopping, with many exciting drugs introduced in early 2015 and more in the pipeline. Recently approved oral therapies include Ibrance (palbociclib) for metastatic breast cancer and Farydak (panobinostat) for multiple myeloma.

That’s good news for patients, who generally prefer oral therapy over intravenous (IV) therapy. Oral therapy eliminates the hassles of receiving IV therapy in a clinical setting, which may be especially important for patients who have transportation issues, work, or other obligations to travel frequently, or live a significant distance from a treatment center. Clinicians are also generally supportive of oral therapy, since it is not accompanied by complications such as infections and clotting, which can be caused by IV therapy.

Nonadherence Challenges with Oral Therapies
One of the positive aspects of traditional IV therapy, however, is that patients are closely monitored by clinicians who administer this treatment directly, ensuring adherence. Conversely, oral chemotherapy agents can put more responsibility on patients, caregivers, and/or family members in terms of ensuring that individuals take these medications on time and as directed.

One might assume that patients with cancer would adhere to their medication regimens simply due to the serious and life-threatening nature of their illness, but this is often untrue. These patients may be on complex treatment regimens and have many emotional and physical issues related to their condition—all of which can make medication nonadherence (especially due to forgetfulness) a common problem. Oncology drugs frequently cause a mental fog referred to by many as “chemo brain,” meaning that the therapy itself may be contributing to lower adherence rates. Patients may also simply feel better and stop taking their medication. Alternatively, they could be bothered by adverse effects (AEs) or concerned about the high cost of therapy.

In a survey of 418 oncology patients regarding obstacles in cancer treatment, it was revealed that 10% of these individuals stopped taking their medication, 7% never filled their original prescription, and 9% did not regularly refill their medication.1 The results of another study showed that 24% of 53 breast cancer patients missed at least 1 dose of tamoxifen per week, with a patient survey indicating that forgetting doses was the most common reason for nonadherence.2 Given that nonadherence negatively affects the ability of a drug regimen to control or eradicate cancer, this is a serious issue. The good news is that among patients who stopped taking their medications, nearly half indicated that additional counseling or intervention would have corrected their behavior.

Research also shows that nonadherence to anticancer agents has become more prevalent due to the increased number of agents and required duration of use, increased combinations of oral therapy with different patterns of administration, polypharmacy, and the advancing age of patients with cancer.3 Together, these issues have created a “perfect storm” of challenges that affect a significant percentage of patients. As such, the issue of adherence has been cited by the World Health Organization as the single most important yet modifiable factor that can affect treatment outcomes.4

Strategies to Engage and Support Patients
The issues related to adherence in oncology patients are clear, but limited research has been done to determine which approaches and interventions have a measurable impact on adherence rates. Also, given that the drivers of nonadherence are extremely varied, interventions must be targeted to address each patient’s specific issues.

For example, today’s new technologies—from apps to portals to mobile monitoring devices—may help address forgetfulness and memory issues, which are among the most common causes of nonadherence. Education and support from pharmacists can help patients understand the importance of taking medication as directed and assist these individuals in dealing with AEs. Delving into these opportunities further, we can see a whole host of potential strategies that can be integrated into a total adherence management program.

Mobile Apps Put Adherence Resources in Patients’ Hands
The popularity of mobile health care apps makes them a strong potential platform for high-tech adherence interventions. The field of mobile health is growing exponentially in response to consumer demand. More than 100,000 mobile health apps have already been published for smartphones worldwide. Consumers are also showing specific interest in using new tools for their medication management needs. More than 72% of all individuals recently surveyed said they would like to refill prescriptions through digital channels.5

Although clinical studies are still in development to test the measurable impact of mobile adherence apps in the oncology space, other research has been done to determine their potential for different population segments. For example, the results of a recent study conducted by Avella Specialty Pharmacy and mscripts showed that patients with HIV using mobile adherence apps that feature refill and dosage reminders were 2.9 times more likely to be adherent with antiretroviral therapies.6 These reminders took the form of in-app notifications, e-mails, and text messages.

In addition to offering reminder functionality, these apps (along with patient portals for those who prefer nonmobile access) can be used to track adherence data at the pharmacy and provider levels. These data can be valuable in helping to monitor adherence, identify challenges, and intervene in cases where patients are struggling to take medication as prescribed.

Text messaging programs are also showing promise in improving adherence for patients with chronic conditions. One study’s findings suggest that members opting into a text message reminder program have significantly higher chronic oral medication adherence compared with members opting out of text message reminders and that the use of a text message reminder program assists in preserving higher rates of adherence over time.7

Mobile Monitoring Devices
New mobile monitoring and other adherence technologies are also emerging as an innovative way to support patients with complex health care and drug therapy needs. The mobile monitoring space includes a wide variety of tools: from in-home scales that send data to providers for real-time monitoring of congestive heart failure patients to mobile-optimized glucose monitors that collect and share information about a patient’s blood sugar control.

In the area of medication adherence, “smart” pill bottles and medication boxes are among the recent product introductions. For example, the GlowCap, created by technology provider Vitality, is a pill bottle cap designed to replace the conventional cap provided by pharmacies. The electronic cap flashes and plays a subtle ringtone when it is time for the next dose and its wireless transmitter sends a signal to a reminder light plug that also flashes. If the cap is not opened, the transmitter dials the patient’s telephone with an additional reminder such as “It’s time to take the pill in your green GlowCap bottle.” The cap also creates weekly adherence reports that can be e-mailed to family members or caregivers and monthly reports that can be submitted to a health care provider.

A recent study of the GlowCap technology tested the impact of this product on patients with gastrointestinal stromal tumors (GISTs), a cancer of the gastrointestinal tract.8 Patients were being treated with Gleevec (imatinib), which is indicated by the FDA for treatment of patients with KIT-positive GISTs that cannot be surgically removed and/or have spread to other parts of the body. In these Gleevec-treated GIST patients, increased adherence was documented over the course of a 4-month period. Patients using the technology maintained higher adherence levels month after month, with the lowest level at 83% during the fourth month compared with 73.3% for the control group. In turn, increased adherence led to fewer hospitalizations, reduced inpatient length of stay, and lower medical costs.

While there is a greater cost associated with these devices compared with text messaging and mobile apps, the impressive results achieved by products like these may warrant investment from health care organizations. Some pharmacies and pharmaceutical manufacturers are already partnering to make these products available to oncology patients for certain drug therapies at no additional charge.

Electronic pill bottles and packaging may be just the beginning of smart adherence technologies. Some companies are now developing edible “chips” that can be implanted into medication and which send a signal to a receiver located in a skin patch. The receiver records medication-related information, including the date, time, and dose taken. It is likely, however, that many patients would have concerns associated with “ingesting” their adherence technology—even through devices that are safety tested. As a result, it remains to be seen whether these advances can achieve a high level of adoption in chronically ill patients.

High-Touch and Operational Efforts
Technology alone will likely not solve the adherence dilemma for oncology patients. Some patients may be struggling with issues beyond simply forgetting to take their medication on time or make timely requests for refills. Instead, they may have serious concerns about the medication itself, misconceptions about drug therapy, or financial issues that make it difficult to pay for the cost of these drugs. These are all reasons why highly trained specialty pharmacists will never be replaced by today’s technology. These clinical experts provide a level of care, education, and guidance that cannot be underestimated. This is especially critical in offering support to oncology patients who are dealing with serious medical issues that may sometimes feel overwhelming. Staff members who offer both compassion and clinical expertise can serve as a critical extension of a patient’s overall care team. For example, pharmacists can help patients understand what to expect from their medication regimen, what AEs are common, and what to do if these AEs become a serious issue.

If patients are having trouble affording the cost of their medications, specialty pharmacies can step in to help. Financial assistance is available to many patients through pharmaceutical programs and nonprofit groups. Patients are typically not aware of these programs and will not know how to navigate the application process. In addition, by working with payers and pharmacy benefit managers for prior authorization assistance, specialty pharmacies can help patients get access to the drugs at a more affordable price.

While the impact of “high-touch” interventions isn’t always as measurable, the results of some small studies suggest they can make a real difference in adherence rates over time. A randomized trial tested the effectiveness of a tailored intervention to promote adherence to oral chemotherapeutic agents in 45 adult patients with cancer. After receiving education and coaching support, 80% of the patients receiving this intervention refilled their medications after 2 months compared with 65% of the control group.9

Removing Other Obstacles to Adherence
An unexpected finding from the study cited above is that system barriers also interfered with adherence. These are factors that were not related to the patient’s actions or physical/emotional state. Examples of system barriers include late specialty pharmacy deliveries, ordering of incompatible medications, and unclear instructions regarding when to start oral agents. This is why specialty pharmacies must have expertise and experience not just in clinical matters, but also in fulfillment and operations-related functions. They must also work closely with a patient’s own health care provider to ensure that clear instruction and treatment planning are carried out from the day a prescription is submitted until treatment is no longer needed.

Improving Outcomes for Patients in Need
While innovative oncology drugs continue to fill the pipeline, it is clear that improving outcomes for these patients is a multifaceted challenge beyond just providing the right drug therapy. This is a challenge, however, that our industry is now willing and able to take on. Specialty pharmacies will play a large role in these efforts over time, just as they have taken on greater responsibilities in providing patient education, care, and support.

Empowerment of pharmacists and engagement of patients themselves may also be accomplished, in part, through use of the latest technologies, which are being introduced at a rapid pace. While adherence is a widespread challenge, it stands to reason that oncology patients—who are dealing with serious, often life-threatening health issues—should be among the early adopters of these new tools and devices. SPT

References
  1. Trends in the 2012 Eisai Oncology Digest: insurance and cost obstacles in cancer treatment. Am J Manag Care. Published online: November 20, 2012. www.ajmc.com/journals/evidence-based-oncology/2012/2012-2-vol18-n5/Trends-in-the-2012-Eisai-Oncology-Digest-Insurance-and-Cost-Obstacles-in-Cancer-Treatment.
  2. Murthy V, Bharia G, Sarin R. Tamoxifen non-compliance: does it matter? Lancet Oncol. 2002;3(11):654. doi: http://dx.doi.org/10.1016/S1470-2045(02)00895-1.
  3. Lester J. Safe handling and administration considerations of oral anticancer agents in the clinical and home setting. Clin J Oncol Nurs. 2012;16(6)192-197.
  4. Annex I: behavioural mechanisms explaining adherence. In: Sabato E, ed. Adherence to Long-Term Therapies—Evidence for Action. Geneva, Switzerland: World Health Organization; 2003. www.who.int/chp/knowledge/publications/adherence_annexes.pdf.
  5. Is healthcare service online enough to satisfy patients? The Accenture Conncected Health Pulse Survey. Accenture; 2012. www.accenture.com/SiteCollectionDocuments/PDF/Accenture-Is-Healthcare-Self-Service-Online-Enough-to-Satisfy-Patients.pdf.
  6. Avella and mscripts to present mobile health study findings at the 2015 Armada Specialty Pharmacy Summit [press release]. Phoenix, Arizona: Avella Specialty Pharmacy. April 14, 2015. http://news.avella.com/news/armada-specialty-pharmacy-summit-2015.
  7. Foreman KR, Stockl KM, Le LB, et al. Impact of text messaging program on patient medication adherence. Clin Ther. 2012;34(5):1084-1091. doi: 10.1016/j.clinthera.2012.04.007. www.ncbi.nlm.nih.gov/pubmed/22554973.
  8. Patient Adherence Comparison: Avella GlowCap Users vs Non-users. Phoenix, Arizona: Avella Specialty Pharmacy. https://avella.uberflip.com/h/i/17209907-avella-glowcap-case-study.
  9. Banks MA, Persily GL. Campus perspective on the National Institutes of Health public access policy: University of California, San Francisco, library experience. J Med Libr Assoc. 2010;98(3):256-259. doi:10.3163/1536-5050.98.3.015. www.ncbi.nlm.nih.gov/pmc/articles/PMC2901012.



About the Author
Kelly Mathews earned her PharmD degree from the University of Arizona in 2009. She completed a PGY1 community pharmacy residency at The Apothecary Shops in affiliation with Midwestern University in 2010. Kelly is director of clinical services at Avella Specialty Pharmacy National Distribution pharmacy in Phoenix, Arizona, where her responsibilities include overseeing specialty disease patient management programs and precepting pharmacy students across the country.