Adherence to oral chemotherapies is not a new concept. In this time of cancer treatment there are more available oral therapies than ever before and because there has been broad expansion of oral therapies many patients believe that these drug therapies are safer than medications that they would traditionally receive in an ambulatory clinic or in a physician’s office. Some of the big differences with oral chemotherapies are the fact that it really relies on patients to self-administer their medications and, with that, the responsibility shifts from physicians, who typically would be providing oversight, that shifts now to the patient being responsible for being able to acquire the medication, to store and to handle the medication, to be able to self-administer the medication and also to be able to monitor for some of the possible toxicities that can occur. With that come some concerns. So now we are relying on the patient to take the medications as instructed, so patients now have to be responsible for reading the instructions and taking the medications themselves. There is concern about what other medications patients are taking, so are there possibilities now for potential drug-drug interactions. One of the biggest areas are the cost of these oral therapies. The cost is now incurred by the patient and that can cause some issues, depending on their prescription drug treatment plan. So those costs burdens are also to be considered with some of these oral therapies.
How can you predict how adherent a patient will be with their treatment?
When it comes to adherence with oral chemotherapies I always like to assess how adherent a patient was to their existing drug therapy. So if they have diabetes, if they have high blood pressure, if they have high cholesterol how are they managing their current medications? That provides some additional information to see how adherent will they be with their new cancer treatments. Some of the areas that are of concern when it comes to adherence is the type of toxicities that the patients might be experiencing with their cancer treatment. So their cancer treatment therapies that are now in the oral formulation, maybe they might cause nausea and vomiting, maybe they might cause issues in terms of affecting their blood counts, maybe they might cause issues with the patient having a lot of diarrhoea which can cause dehydration. So we need to make sure that the patients are able to either self-monitor or be able to contact their physicians to see if they should come into the office. I think all of those things put together can affect how well the patient is able to take their medication. So it really does require a bit of education for the patient to be able to manage their medications appropriately.
Are there any concerns with patients taking medications at home?
What happens is when physicians are administering cancer therapies intravenously they’re actually able to see the patient so they’re able to perform physical exams. When patients are taking their medications at home orally you do have less patients visiting the office so then you really are going to be relying on that patient to call into the office if they’re having side effects. So some of that face-to-face contact can be compromised when patients are self-administering. So now the physician might not fully know what’s going on with the patient. So that’s also an area of concern that I think that oral treatments are really an option for those select patients that can actually communicate with their physician so that the physician stays informed.
So there should be more face to face check-ups?
That is important because sometimes that is not done as efficiently as it should be. So there is an opportunity an,d even if it’s not a physician, for a clinician or a mid-level clinician, whether it be a nurse practitioner, to be able to reach out and either done phone conversations with the patient to be able to check in if there is less frequent physician office visits when it comes to oral treatments.
Is there anything you’d like to add?
Even when we use the term medication adherence it’s very, very difficult to define because there is not consistency in the literature in terms of how do you define adherence. Are you going by patients’ self-report so are you relying on the patient to tell you if they’re adherent or not adherent or there are some limitations with that? Are you asking the patients to bring in their pill bottles so are you able to count how many pills are left in the bottle to capture if they are adherent? Are you calling or contacting the patient’s pharmacy to see how frequently they are refilling their medications? So there is variability in how we even define adherence and because there is variability with how we define adherence there is really going to be variability in how we’re capturing whether or not a patient is adherent. So that’s one of the areas that still remains unanswered.