A variety of strategies can help increase patient adherence to oral chemotherapy.
With advances in chemotherapy, oral oncolytic prescribing is increasingly common, providing a more convenient option that enables patients to manage their therapy at home.1
Oral oncolytics have especially become important during the COVID-19 pandemic, as they help keep high-risk patients safely at home and out of clinics and hospitals. Ultimately, oral chemotherapy can improve patients’ quality of life and reduce the burden of care.1,2
Although evidence demonstrates that patients prefer oral chemotherapy to intravenous infusions, studies suggest that adherence rates can vary for oral oncolytics.2 One observational study of 90 oncology patients found that mean oral chemotherapy adherence was less than 90%, and almost a quarter of the study participants were classified as poorly adherent.2 A systematic review found that medication adherence rates to oral oncolytics varied widely, ranging from 46% to 100%.3
Unfortunately, poor medication adherence can result in cancer recurrence, increased hospitalization, and higher risk of mortality.2 Barriers to adherence include low health literacy, limited patient knowledge, complex administration instructions, adverse effects (AEs), and high out-of-pocket drug costs.1
Pharmacists can play an important role as part of an interdisciplinary team to improve adherence to oral oncolytics.
Strategies to Improve Adherence to Oral Oncolytics
Evidence demonstrates that pharmacist-led collaborative medication management programs for oral oncolytics may improve patient adherence through clinical interventions.4
According to a systematic review of data from 12 studies, successful programs included oncology pharmacists who were responsible for making clinical interventions such as patient education, AEs monitoring, and dose modifications.4 Additionally, all the studies reported at least 1 positive outcome such as improved medication adherence, safety, cost savings, and patient satisfaction.4 Ambulatory oral chemotherapy clinics involving oncology pharmacists can manage complex regimens to improve adherence.4
Additionally, it is critical for pharmacists and physicians to have open lines of communication regarding their patients’ pharmacotherapy regimen to monitor for AEs and potential toxicities that could impact adherence.
The Hematology/Oncology Pharmacist Association Standards Committee organized an oncology pharmacist specialist group to create practice standards for managing oral oncolytic therapies.1 These standards include defining the pharmacist’s role on the cancer team and creating strategies to improve patient health outcomes, with adherence being one of the key components.1
The American Society of Clinical Oncology Quality Practice Initiative also emphasizes the importance of monitoring oral chemotherapy adherence following initiation of therapy as a quality measure.5
One study evaluating the efficacy of an integrated oral chemotherapy program found that patients who were contacted twice a month to discuss their medications had higher adherence rates to treatment than those who were not called.6
Evidence demonstrates that 40% to 80% of the medical information patients are provided during a consultation is forgotten immediately, and almost half of the information is not accurately retained.7 For this reason, establishing reminder systems can also help to address nonadherence issues that may result from patients forgetting important information regarding their treatment.1
As medication experts, pharmacists are well trained to be adherence champions by providing patient education and developing ongoing adherence assessments. Providing adequate social support that incorporates acknowledgment of cultural beliefs and potential language barriers is critical to improve medication adherence.1
This includes providing patients with pharmacist contact information for medication questions and translator support.1
A variety of tools can help improve medication adherence, and pharmacists can identify the best strategies by using a patient-specific approach. For example, medication event monitoring systems are caps that fit on standard medicine bottles, which record the date and time each bottle is opened and closed.1 This is a very precise adherence tool that can track medication patterns, but they are expensive.1
Patient-reported adherence using a diary or calendar is a low-cost method to assess adherence, and it can be shared with pharmacists at medication therapy management consultations. However, one of the disadvantages of this approach, is that patients may forget to document their medication information on a daily basis.
On the technological front, phone alarms and smartphone medication reminder apps can be useful tools for adherence. For example, Medisafe is a free app that is available for Apple and Android devices, with a variety of adherence and safety tools such as personalized medication and refill reminders, drug interaction warnings, and alerts for family members or caregivers.8
However, patients without smartphones will be unable to utilize apps as adherence tools. Pharmacists can also assess reports on patients’ refill history through the pharmacy and assist with medication synchronization, patient assistance programs or coupons for cost issues, and, if potentially useful, a switch from a 30-day to a 90-day supply to improve adherence.
The Institute for Safe Medication Practices provides a variety of free medication safety and adherence tools that pharmacists can share with patients, including a resource on oral chemotherapy, with a variety of recommendations.9
Patients should be empowered to keep a list of their oral oncolytic medications either in print or digitally on their smartphone that can be shared at all pharmacist and physician consultations. This can also help ensure patients have the appropriate dosing schedule documented to prevent medication errors that can have a negative impact on medication adherence.
Jennifer Gershman, PharmD, CPh, PACS is a drug information pharmacist and Pharmacy Times® contributor who resides in South Florida.
1. Mackler E, Segal EM, Muluneh B, Jeffers K, Carmichael J. 2018 Hematology/Oncology Pharmacist Association best practices for the management of oral oncolytic therapy: pharmacy practice standard. J Oncol Pract. 2019;15(4):e346-e355. doi:10.1200/JOP.18.00581
2. Jacobs JM, Pensak NA, Sporn NJ, et al. Treatment satisfaction and adherence to oral chemotherapy in patients with cancer. J Oncol Pract. 2017;13(5):e474-e485. doi:10.1200/ JOP.2016.019729
3. Greer JA, Amoyal N, Nisotel L, et al. A systematic review of adherence to oral antineoplastic therapies. Oncologist. 2016;21(3):354-376. doi:10.1634/theoncologist.2015-0405
4. Passey DG, Healy R, Qualls J, Halwani A, Sauer BC. Pharmacist-led collaborative medica- tion management programs for oral antineoplastic therapies: a systematic literature review. J Am Pharm Assoc (2003). 2021;61(3):e7-e18. doi:10.1016/j.japh.2020.12.005
5. QOPI 2022 reporting tracks. American Society of Clinical Oncology Quality Oncology Practice Initiative. Accessed February 11, 2022. https://practice.asco.org/sites/default/files/ drupalfiles/2022-02/2022-QOPI-Round-1-Reporting-Track-Public-Posting.pdf
6. Morgan KP, Muluneh B, Deal AM, Amerine LB. Impact of an integrated chemotherapy program on patient adherence. J Oncol Pharm Pract. 2018;24(5):332-336. doi:10.1177/1078155217703792
7. Health Literacy Universal Precautions Toolkit, 2nd edition: use the teach-back method: tool #5. Agency for Healthcare Research and Quality. Accessed February 11, 2022. https://www. ahrq.gov/health-literacy/improve/precautions/tool5.html
8. Medisafe. Accessed February 11, 2022. https://www.medisafeapp.com/
9. Oral chemotherapy: not just an ordinary pill. Institute for Safe Medication Practices. Accessed February 11, 2022. https://consumermedsafety.org/assets/ISMP115-ConsmrMed-Oral_Chemo-BLEED-030216-2.pdf