To adhere or not to adhere: Rates and reasons of medication adherence in hematological cancer patients

Comprehensive medication management (CMM): Application of a new pharmaceutical practice in onco-hematology

The integration of a large number of drugs, such as antineoplastic agents and cancer-related supportive care drugs, into the management of cancer patients exposes them to an increased number of drug-related problems (DRP). Clinical pharmacists contribute to drug management by actively intervening in detected DRP. The aim of this study is to assess the impact of the applying a clinical pharmacist-driven comprehensive medication management (CMM) service to onco-hematology patients. This prospective interventional study was carried out over six-month duration, specifically from November 06, 2022 to April 5, 2023 in the oncology and hematology departments of the EHU Oran. The adherence to treatment was evaluated using the 8-item Morisky Medication Adherence Scale (MMAS). Whereas data related to the patient's general condition and medication history was assessed using the Pharmaceutical Care Network Europe (PCNE) Classification for Drug-Related Problems V9.1. Among the 130 patients included in the study, a total of 879 DRP were identified, with a mean of 6.78 (±1.72) DRP/patient, half of which were related to efficacy (51%). Almost half of our sample (44.6%) did not adhere to their treatment. The most frequent cause of DRP, accounting for (19.9%) of the cases, was the inappropriate administration by a health professional. A total of 875 pharmaceuticals interventions (PI) were proposed, 67.2% of which were focused at the drug level. The PI acceptance rate was 94.1%. The integration of CMM services in onco-hematology played an important role in optimizing dosing regimen and treatment administration methods, as well as preventing iatropathology in the management of cancer patients.

Treatment adherence and adverse event management in chronic lymphocytic leukemia: challenges and strategies for the future

INTRODUCTION

There has been a paradigm shift in the treatment of chronic lymphocytic leukemia (CLL) over the past decade. With the advent of self-administered targeted oral anticancer agents (OAAs), the treatment of CLL has begun to shift from the infusion clinic to the patient's home. This introduced new challenges including patient non-adherence, class-specific adverse effects, and financial toxicity to treatment. In this paper, we discuss a structured approach to identifying and addressing barriers to optimal patient outcomes.

AREAS COVERED

We will ground our discussion using the five dimensions of adherence as defined by the World Health Organization (WHO): therapy factors, health-system factors, condition-related factors, social/economic factors, and patient factors. We discuss how each of these domains present in patients with CLL. We will also discuss how we can prevent and address these barriers in through the various phases of treatment.

EXPERT OPINION

A multidisciplinary program to support patients on OAAs is critical for patients with CLL. This team should involve pharmacists and social workers in addition to nursing, advanced practitioner and physician colleagues. The program should aim to identify, prevent, and address patient-specific barriers by offering individualized solutions. We describe how such a program can be designed and implemented.

Compliance with medical regimen among hematological cancer patients and its association with symptoms of posttraumatic stress disorder and adjustment disorder

Background

Hematological cancer patients must comply with extensive medical instructions to prevent cancer progression or relapse. Psychological comorbidities and patient characteristics have been shown to affect compliance. However, the impact of posttraumatic stress disorder (PTSD) and adjustment disorder (AjD) on compliance in cancer patients remains unclear. This study aims to evaluate compliance in hematological cancer patients more comprehensively and to investigate its association with PTSD and AjD symptomatology as well as sociodemographic and medical factors.

Methods

Hematological cancer patients were cross-sectionally assessed via validated questionnaires for PTSD (PCL-5) and AjD (ADMN-20), and three internally developed items on compliance with medical regimen, with two referring to compliance behavior and one item assessing perceived difficulties with complying. Each compliance item was analyzed descriptively. Multiple linear regression models tested the association between compliance and PTSD and AjD symptomatology, sociodemographic and medical factors.

Results

In total, 291 patients were included (response rate 58%). Nine out of ten patients reported to either never (67%) or rarely (25%) change their medical regimen. However, 8% reported to change it once in a while or often. Compliance behavior was mostly rated as very easy (36%) or easy (45%) to implement. Nevertheless, 19% perceived it to be partly difficult or difficult to follow medical regimen. Symptoms of AjD (β = 0.31, p < 0.001) were associated with more difficulties to comply. Higher compliance behavior in turn was associated with stem cell transplantation (SCT) treatment (β = -0.21, p < 0.001) and lower education (β = -0.19, p = 0.002).

Conclusion

Although most patients indicated that they comply with medical regimen, a considerable subgroup of patients indicated subjectively perceived difficulties and thus seem to require additional support in implementing medical instructions possibly through improved medical communication and patient health literacy or shared decision-making.

Effectiveness of digital care platform CMyLife for patients with chronic myeloid leukemia: results of a patient-preference trial

BACKGROUND

Two most important factors determining treatment success in chronic myeloid leukemia (CML) are adequate medication compliance and molecular monitoring albeit still being suboptimal. The CMyLife platform is an eHealth innovation, co-created with and for CML patients, aiming to improve their care, leading to an increased quality of life and the opportunity of hospital-free care.

OBJECTIVE

To explore the effectiveness of CMyLife in terms of information provision, patient empowerment, medication compliance, molecular monitoring, and quality of life.

METHODS

Effectiveness of CMyLife was explored using a patient-preference trial. Upon completion of the baseline questionnaire, participants actively used (intervention group) or did not actively use (questionnaire group) the CMyLife platform for at least 6 months, after which they completed the post-intervention questionnaire. Scores between the intervention group and the questionnaire group were compared with regard to the within-subject change between baseline and post-measurement using Generalized Estimating Equation models.

RESULTS

At baseline, 33 patients were enrolled in the questionnaire group and 75 in the intervention group. Online health information knowledge improved significantly when actively using CMyLife and patients felt more empowered. No significant improvements were found regarding medication compliance and molecular monitoring, which were already outstanding. Self-reported effectiveness showed that patients experienced that using CMyLife improved their medication compliance and helped them to oversee their molecular monitoring. Patients using CMyLife reported more symptoms but were better able to manage these.

CONCLUSIONS

Since hospital-free care has shown to be feasible in time of the COVID-19 pandemic, eHealth-based innovations such as CMyLife could be a solution to maintain the quality of care and make current oncological health care services more sustainable.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04595955 , 22/10/2020.

Adherence to Oral Anticancer Medications Among Women With Breast Cancer in Africa: A Scoping Review

PURPOSE

Oral anticancer medications (OAMs) improve treatment outcomes and survival in women with breast cancer (BC). However, adherence to OAM therapy remains suboptimal. This scoping review provides evidence of adherence to OAMs among African women with BC.

METHODS

We searched four databases and gray literature, using guidance from the Joanna Briggs Institute. Thirteen studies on adherence rates, determinants, and interventions were included. NVivo 12 software was used to perform thematic analysis of the included studies. The determinants (barriers and facilitators) associated with adherence were analyzed according to the five dimensions of the WHO multidimensional adherence model.

RESULTS

Most studies (n = 11, 85%) focused on endocrine medication. Depending on the definition, measurements, and assessment period, the nonadherence rates ranged from 4.3% to 65.4% for endocrine medications, 80.9% for cytotoxic chemotherapies, and 32.7% for combined medications. The significant barriers associated with adherence include Islamic religion, concurrent comorbidities, mastectomy, anastrozole treatment, side effects, unawareness of treatment insurance coverage, and seeking treatment from traditional healers. Thorough therapeutic communication regarding treatment, neoadjuvant chemotherapy, and adequate social support significantly facilitate adherence. A randomized controlled trial of breast nursing interventions reported improved patient adherence.

CONCLUSION

The evidence mapped from studies that evaluated OAM adherence in women with BC indicates that nonadherence to OAMs is common. Applying context-specific standardized measures to assess adherence and facilitators or strategies targeting the identified barriers can optimize adherence and treatment outcomes. Effective interventions to improve adherence are limited. Therefore, further empirical and interventional studies in Africa are required to enhance the evidence.

Prior Cardiovascular Treatments-A Key Characteristic in Determining Medication Adherence After an Acute Myocardial Infarction

Objective: To investigate long-term adherence to guideline-recommended cardioprotective medications following hospitalization for an acute myocardial infarction (AMI), and identify characteristics associated with adherence.

Methods: An Australian population-based cohort study was used to identify participants who had their first AMI between 2006 and 2014 and were alive after 12 months. Linked routinely collected hospital, and prescription medication claims data was used to study adherence over time. Predictors and rates of adherence to both lipid-lowering medication and renin-angiotensin system blockade at 12 months post-AMI was assessed.

Results: 14,200 people (mean age 69.9 years, 38.7% female) were included in our analysis. At 12 months post-AMI, 29.5% (95% CI: 28.8–30.3%) of people were adherent to both classes of medication. Individuals receiving treatment with both lipid-lowering medication and renin-angiotensin system blockade during the 6 months prior to their AMI were over 9 times more likely to be adherent to both medications at 12 months post-AMI (66.2% 95% CI: 64.8–67.5%) compared to those with no prior medication use (treatment naïve) (7.1%, 95% CI: 6.4–7.9%). Prior cardiovascular treatment was the strongest predictor of long-term adherence even after adjusting for age, sex, education and income.

Conclusions: Despite efforts to improve long-term medication adherence in patients who have experienced an acute coronary event, considerable gaps remain. Of particular concern are people who are commencing guideline-recommended cardioprotective medication at the time of their AMI. The relationship between prior cardiovascular treatments and post AMI adherence offers insight into the support needs for the patient. Health care intervention strategies, strengthened by enabling policies, are needed to provide support to patients through the initial months following their AMI.

Adherence to Oral Targeted Anti-Lung Cancer Therapy: A Qualitative Interview Study

OBJECTIVE

Oral targeted antineoplastic drugs (OTADs) are becoming more and more acceptable for lung cancer treatment due to their advantages such as the convenience of administration and milder side effects. However, medication adherence represents a major issue for prolonged OTAD treatment. In this study, the factors associated with treatment adherence to OTAD were explored through the Adherence Influencing Factor Framework suggested by WHO. Based on these results, we further examined the potential factors related to social psychological cognition in OTAD adherence in patients with lung cancer.

METHODS

This qualitative study was conducted in public hospitals in Henan, China. Data were collected through semi-structured interviews with selected lung cancer patients. Face-to-face interviews were audio-recorded and transcribed for thematic analysis.

RESULTS

Of the 21 patients interviewed, 17 were males and 4 were females. The analysis of the data led to four themes, ie, patient-related factors (medication-taking introspection, family structure, weigh the pros and cons of OTAD treatment), medication-related factors (medication experience, adverse reactions, information access), physician/nurse-related factors (shared decision making, doctor's reaction, nurse's inquiry) and society-related factors (fear, stigma).

CONCLUSION

Family structure, weigh the pros and cons of OTAD treatment, information access, shared decision making, nurse's inquiry are potential factors affecting OTAD adherence in lung cancer patients. Providing drug information support to patients, inviting patients to join in shared decision-making and strengthening doctor-patient-nurse cooperation are important for improving medication adherence. Further research should be conducted to help healthcare providers to promote the medication adherence of lung cancer patients to OTAD treatment.

Primary Localized Gastrointestinal Stromal Tumors: Medication Adherence and Prognosis According to Gender

OBJECTIVE

Gender is associated with medication adherence for imatinib, but whether it is related to the prognosis of primary localized gastrointestinal stromal tumors (GISTs) is unclear. The goal of this study was to clarify the relationship between gender and prognosis in GIST patients, with differences in medication adherence considered.

METHODS

The data of 320 GIST patients were retrospectively collected from the First Affiliated Hospital of Chongqing Medical University. Survival analysis was performed using the Kaplan-Meier method (Log rank test) and the risk factors of recurrence were determined using Cox multivariate analysis. Medication adherence-stratified analyses were performed to control for confounding factors.

RESULTS

Kaplan-Meier analysis revealed that among patients who received postoperative adjuvant imatinib therapy, men had a higher recurrence rate than women (P<0.01). Pearson's chi-square test revealed better medication adherence in women than in men (P<0.01). Cox regression analysis revealed that gender was not an independent risk factor for recurrence-free survival (RFS; P=0.25), but medication adherence was (P<0.01). Among GIST patients with a medication possession ratio (MPR) of less than 90%, 62.86% of male patients took imatinib irregularly or not at all due to limited understanding of the disease, whereas 55.74% of female patients' took imatinib irregularly because they could not tolerate adverse drug reactions.

CONCLUSION

Adherence was poorer in male than in female patients, which might explain the worse prognoses of the former among patients who received adjuvant treatment with imatinib. The gender difference in the degree of adherence should be considered in postoperative pharmacotherapy for patients with primary localized GISTs.

Consensus guidelines for improving patients' understanding of invasive fungal disease and related risk prevention in the haematology/oncology setting, 2021

Patients with invasive fungal disease (IFD) are at significant risk of morbidity and mortality. A productive partnership between patients, their carers/families, and the multidisciplinary team managing the infection and any underlying conditions, is essential. Sharing information and addressing knowledge gaps are required to ensure those at risk of IFD avoid infection, while those with suspected or confirmed infection optimise their therapy and avoid toxicities. This new addition to the Australian and New Zealand consensus guidelines for the management of IFD and antifungal use in the haematology/oncology setting outlines the key information needs of patients and their carers/families. It specifically addresses risk factor reduction, antifungal agents and adherence, and the risks and benefits of complementary and alternative therapies. Knowledge gaps are also identified to help inform the future research agenda.

Assessment of Oral Chemotherapy Nonadherence in Chronic Myeloid Leukemia Patients Using Brief Measures in Community Cancer Clinics: A Pilot Study

The purpose of this pilot study was to assess Chronic Myeloid Leukemia (CML) patients’ adherence to, beliefs about, and barriers to oral anticancer agents (OAC) using brief self-report measures in community-based cancer clinics. Patients completed a structured interview including a health literacy assessment, a Brief Medication Questionnaire, two single-item self-report adherence questions, and the Medications Adherence Reasons Scale. Of the 86 participants, 88.4% were white; 55.8% male; mean age, 58.7 years; and 22.1% had limited health literacy. Nonadherence (missing at least one dose in the last week) was reported by 18.6% of participants and associated (p < 0.003) with less-than-excellent perceived ability to take CML medications (16.3%). Black participants reported more difficulty taking CML medications than white participants (28.6% vs. 8.3%, p = 0.053). Among all participants, 43.0% reported their CML medicine was ineffective and 24.4% that taking CML pills was somewhat to very hard. The most common reasons for missing a dose were simply missed it (24.4%) and side effects (18.6%). Most patients perceived their ability to take CML medication was good to excellent, yet nearly one in five reported missing at least one dose in the last week. Brief, no-cost self-report assessments to screen CML patients’ OAC adherence, barriers, and beliefs could facilitate counseling in busy community cancer clinics.

A mixed method study design to explore the adherence of haematological cancer patients to oral anticancer medication in a multilingual and multicultural outpatient setting: The MADESIO protocol

Background

Patients with haematologic malignancies are increasingly treated by oral anticancer medications, heightening the challenge of ensuring optimal adherence to treatment. However, except for chronic myelogenous leukaemia or acute lymphoid leukaemia, the extent of non-adherence has rarely been investigated in outpatient settings, particularly for migrant population. With growing numbers of migrants in Belgium, identifying potential differences in drug use is essential. Also, previous research regarding social determinants of health highlight important disparities for migrant population. Difficulties in communication between health caregivers and patients from different cultural and ethnic backgrounds has been underlined.

Methods

Using a sequential mixed method design, the MADESIO protocol explores the adherence to oral anticancer medications in patients with haematological malignancies and among first and second generation migrants of varied origin. Conducted in the ambulatory setting, a first quantitative strand will measure adherence rates and associated risk factors in two sub-groups of patients with haematological malignancies (group A: first and second generation migrants and group B: non-migrants). The second qualitative strand of this study uses semi-structured interviews to address address the patients’ subjective meanings and understand the statistical associations observed in the quantitative study (strand one). MADESIO aims to provide a first assessment of whether and why migrants constitute a population at risk concerning adherence to oral anticancer medications.

Discussion

Our protocol is designed to provide a comprehensive understanding of adherence in a specific population. The methodological choices applied allow to explore adherence among patients from diverse linguistic and cultural backgrounds. A particular emphasis has been paid to minimize the biases and increase the reliability of the data collected. Easily reproductible, the MADESIO design may help healthcare services to screen adherence to Oral anticancer medications and to guide providers in choosing the best strategies to address medication adherence of migrants or minority diverse population.

The role of family confidants and caregivers in the care of older cancer patients: Extending the concept of "shared decision-making"

BACKGROUND AND AIMS

Family caregivers play an important role in assisting their family members with cancer, but their influence on the treatment decision-making process has not yet been adequately investigated. This exploratory study approached this topic via reconstructive methodology, focusing on assessing patient-caregiver relationships.

METHODS

We conducted semi-structured interviews with 37 mostly elderly cancer patients (median age: 74 years) about the context of their diagnosis, treatment decision, and family support. Additionally, we interviewed 34 caregivers of cancer patients. Of these, 25 were related to patients interviewed. We analyzed the interviews via a multi-step coding method informed by Grounded Theory methodology toward characterizing patient-caregiver relationships, the treatment decision-making process, and the caregivers' role therein.

RESULTS

In the majority of cases (86%), patients were being supported by caregivers. We categorized patient-caregiver relationships in regards to the caregivers' involvement in the therapy decision-making process. We found patient-caregiver interaction patterns that indicate the potential of caregivers to decidedly influence the therapy decision-making process. Yet, only in 38% of cases, a caregiver attended relevant patient-physician-consultations.

CONCLUSION

Depending on the nature of the patient-caregiver relationship, the traditional concept of shared decision-making, which assumes a dyadic relationship, needs to be extended toward a more dynamic concept in which caregivers should be involved more frequently. This could enable physicians to better understand a patient's reasons for or against a therapy proposal and ensure that the patient's wishes are communicated and considered. On the other hand, strong caregiver-involvement bears risks of over-stepping elderly patients' wishes, thus violating patient autonomy.

Oral therapy adherence and satisfaction in patients with multiple myeloma

The transition to oral therapies in patients with multiple myeloma (MM) offers potential benefits to patients; however, they must self-manage their medication and adherence plays an important role in patient care. It has been shown that patient satisfaction with their medication has a strong positive correlation with adherence in chronic diseases. The aim of this study was to estimate adherence rate of oral antimyeloma therapies and to identify risk factors for medication non-adherence. This observational, prospective, and multicentre survey based on a self-report questionnaire enrolled MM patients with at least 3 months of oral therapy. The 6-item Girerd scale and the medication possession ratio (MPR) were used for measuring medication adherence and the SATMED-Q® questionnaire was used for measuring satisfaction. An analysis of risk factors for non-adherence to oral therapy was performed using univariate analysis. A total of 101 patients participated in the survey, yielding a response rate of 87%. The prevalence of adherence to oral antimyeloma therapy was estimated at 51.5% using the Girerd questionnaire. According to the MPR, adherence was evaluated at 96% (i.e. MPR ≥ 0.80). Both methods combined, adherence was estimated at 50.5%. One risk factor for medication non-adherence was identified: Eastern Cooperative Oncology Group Performance Status > 2 (p = 0.007). One predictive factor for high medication adherence was identified: high satisfaction with treatment (p = 0.01). Identifying patients at higher risk for non-adherence allows clinical pharmacists to personalise therapeutic information and education and to improve the quality of healthcare overall.

It Takes a Team to Make It Through: The Role of Social Support for Survival and Self-Care After Allogeneic Hematopoietic Stem Cell Transplant

Background

Social support plays an important role for health outcomes. Support for those living with chronic conditions may be particularly important for their health, and even for their survival. The role of support for the survival of cancer patients after receiving an allogeneic hematopoietic cell transplant (alloHCT) is understudied. To better understand the link between survival and support, as well as different sources and functions of support, we conducted two studies in alloHCT patients. First, we examined whether social support is related to survival (Study 1). Second, we examined who provides which support and which specific support-related functions and tasks are fulfilled by lay caregivers and healthcare professionals (Study 2).

Methods

In Study 1, we conducted a retrospective chart review of alloHCT patients (N = 173, 42.8% female, age: M = 49.88) and registered availability of a dedicated lay caregiver and survival. In Study 2, we prospectively followed patients after alloHCT (N = 28, 46.4% female, age: M = 53.97, 46.4% ethnic minority) from the same hospital, partly overlapping from Study 1, who shared their experiences of support from lay caregivers and healthcare providers in semi-structured in-depth interviews 3 to 6 months after their first hospital discharge.

Results

Patients with a dedicated caregiver had a higher probability of surviving to 100 days (86.7%) than patients without a caregiver (69.6%), OR = 2.84, p = 0.042. Study 2 demonstrated the importance of post-transplant support due to patients’ emotional needs and complex self-care regimen. The role of lay caregivers extended to many areas of patients’ daily lives, including support for attending doctor’s appointments, managing medications and financial tasks, physical distancing, and maintaining strict dietary requirements. Healthcare providers mainly fulfilled medical needs and provided informational support, while lay caregivers were the main source of emotional and practical support.

Conclusion

The findings highlight the importance of studying support from lay caregivers as well as healthcare providers, to better understand how they work together to support patients’ adherence to recommended self-care and survival.

Tyrosine Kinase Inhibitors and the Relationship With Adherence, Costs, and Health Care Utilization in Commercially Insured Patients With Newly Diagnosed Chronic Myeloid Leukemia: A Retrospective Claims-Based Study

OBJECTIVE

To examine the association among tyrosine kinase inhibitor (TKI) out-of-pocket costs, adherence, and health care costs and utilization in a large group of commercially insured patients with chronic myeloid leukemia (CML).

MATERIALS AND METHODS

Patients with CML aged 18 to 64 years were identified using IBM MarketScan Commercial Database between April 1, 2011 and December 31, 2014. Patients were required to be continuously enrolled 3 months before and 12 months after TKI (imatinib, dasatinib, or nilotinib) initiation. TKI adherence is estimated using the proportion of days covered (PDC), defined as the percentage of the PDC by the prescription fill during the 12-month study period (adherent patients have PDC ≥80%). Health care cost differences between adherent and nonadherent patients were estimated using generalized linear models. Health care utilization was compared using negative binomial regression models. All models were controlled for potential confounding factors.

RESULTS

The study sample consisted of 863 patients, where 355 (41.1%) patients were classified as adherent. Over the study period, nonadherent patients incurred US$10,974 more in medical costs (P<0.001), and US$1663 more in non-TKI pharmacy costs (P<0.01). Adherent patients incurred US$28,184 more in TKI pharmacy costs (P<0.001) that resulted in US$18,305 more in overall total health care costs (P<0.001). Adherent patients, however, were estimated to be less likely to have all-cause hospitalizations (incidence rate ratio, 0.32; P<0.001), or CML-specific hospitalizations (incidence rate ratio, 0.31; P<0.01).

CONCLUSIONS

Patients with CML with better adherence experienced fewer hospitalizations, resulting in medical service cost savings. These lower medical costs, however, were more than offset by higher TKI medication costs observed during the first year of TKI therapy.

Adherence to oral chemotherapy: Evidence from a randomised clinical trial

OBJECTIVE

To evaluate the efficacy of a reinforcement message (RM) administered by a hospital pharmacist on adherence, through a randomised study involving patients undergoing oral chemotherapy from which an objective outcome measure and patients' subjective opinions were collected. A secondary aim was to detect which psychological or clinical factors influence adherence.

METHODS

Forty patients were enrolled and randomised to an experimental group (EG) or a control group (CG). The EG received a 10-minute RM provided by a hospital pharmacist with a doctor and a nurse. The CG received the standard of care. To measure adherence, plasma drug concentration and subjective evaluation were taken during the visits, in addition to a psychological assessment (coping strategies, psychological distress and personality traits).

RESULTS

The EG reported higher drug levels and a statistically significant higher mean score on the subjective evaluation. A linear regression model highlighted statistically significant differences in the plasma drug concentration, after considering toxicity and dose reduction and controlling for the Reward Dependence Scale of the Temperament and Character Inventory between the EG and the CG.

CONCLUSION

Adequate information and education on the therapy, using an RM strategy provided by a hospital pharmacist, seems to positively influence adherence to the treatment.

Metacognitive Beliefs, Positive States of Mind, and Emotional Approach Coping as the Predictors of Medical Compliance in Patients with Cancer

Background: Medical compliance plays an essential role in the control of cancer and psychological factors such as metacognitive beliefs, positive psychology, and coping styles which are among the predictors of medical compliance. Objectives: The aim of this study was to determine how much metacognitive beliefs, positive states of mind, and emotional approach coping can predict medical compliance in patients with breast cancer. Methods: This was a descriptive correlational study. By available sampling method, 154 women with breast cancer who were medically treated and had inclusion criteria, responded to the Morisky Medication Adherence scale (MMAS), Metacognitive Beliefs questionnaire (MCBQ), Positive states of mind (PSOM) scale, and emotional approach coping (EAC) scale. Stepwise multiple regression analysis by SPSS statistics version 24 was applied for data analysis. Results: There was a significant correlation between positive states of mind and metacognitive beliefs and between emotional approach coping with medical compliance (P < 0.05). Positive states of mind and metacognitive beliefs were the best predictors of medical compliance (P < 0.001), while the emotional approach coping could not predict medical compliance. Results also showed that positive states of mind (β = 0. 51) have the greatest predictive power to medical compliance, and the variable of emotional approach coping is not effective in predicting. Conclusions: Research findings suggest that positive states of mind and orientation toward metacognitive beliefs can control anxiety among patients and predict medical compliance in patients with breast cancer but research about emotional approach coping needs to more investigation.

Response and Adherence to Nilotinib in Daily practice (RAND study): an in-depth observational study of chronic myeloid leukemia patients treated with nilotinib

Introduction

This comprehensive observational study aimed to gain insight into adherence to nilotinib and the effect of (non)adherence on exposure (C_min) and treatment outcomes.

Methods

Chronic myeloid leukemia (CML) patients using nilotinib were followed for 12 months. Adherence was measured by Medication Event Monitoring System (MEMS), pill count, and Medication Adherence Report Scale (MARS-5). Nilotinib C_min and patient-reported outcomes (i.e., quality of life, side effects, beliefs, satisfaction) were measured at baseline, 3, 6, and 12 months.

Results

Sixty-eight patients (57.5 ± 15.0 years, 49% female) participated. Median adherence to nilotinib (MEMS and pill count) was ≥ 99% and adherence < 90% was rare. Self-reported nonadherence (MARS-5) increased in the first year of treatment to a third of patients. In line with the strong beliefs in the necessity of taking nilotinib, forgetting to take a dose was more prevalent than intentionally adjusting/skipping doses. Nilotinib C_min were generally above the therapeutic target in 95% of patients. Patients reported a variety of side effects, of which fatigue was most frequent. The mean C_min was higher in patients who reported severe itching and fatigue. The overall 1-year MMR rate ranged from 47 to 71%.

Conclusion

Substantial nonadherence (< 90%) to nilotinib was rare and nilotinib C_min were generally above the therapeutic target. Lack of response in our group of patients was not related to nonadherence or inadequate C_min. Nevertheless, a considerable number of patients experienced difficulties in adhering to the twice daily fasted dosing regimen, emphasizing the importance of continuous support of medication adherence in CML.

Clinical trial registration

NTR3992 (Netherlands Trial Register, www.trialregister.nl)

Electronic supplementary material

The online version of this article (10.1007/s00228-020-02910-3) contains supplementary material, which is available to authorized users.

Non-prescription medicines may contribute to non-adherence to prescription medicines in people living with chronic health conditions

BACKGROUND

Non-adherence to prescribed medicines is linked to adverse health outcomes in people living with chronic health conditions (CHCs). Multiple factors are known to contribute to non-adherence to medicines including polypharmacy, demographic features and disease and health systems. Both non-prescription and prescription medicines contribute to polypharmacy; however, there is limited data on the influence of non-prescription medicines to non-adherence.

AIM

Therefore, the aim of the study was to investigate the influence of non-prescription medicines to non-adherence in an Australian population.

METHODS

Data from the 2016 National Survey of a random sample of Australian adult residents were utilised in this study to investigate factors associated with non-adherence. Descriptive statistics, χ² , regression and generalised linear models were used to assess the relationships between variables of interest. Narrative response and comments were used to provide further insight.

RESULTS

This study recruited 1217 participants to explore factors associated with non-adherence to medicines. Weak but statistically significant correlations were identified showing the number of CHCs, patient's age, number of prescription medicines, number of non-prescription medicines and total number of medicines associated with non-adherence.

DISCUSSION

The findings suggest that people living with CHCs and taking multiple medicines, including non-prescription medicines, are likely to be non-adherent to prescription medicines. This study shows the possible involvement of non-prescription medicines in contributing to non-adherence in an Australian population and suggests that future studies with a broader demographic are warranted.

Interventions to Enhance Adherence to Oral Antineoplastic Agents: A Scoping Review

BACKGROUND

As new targeted oral antineoplastic therapies have emerged in recent years, the development of effective strategies that promote optimal adherence to cancer medication regimens has become an important priority.

METHODS

We conducted a scoping literature review to search for English language articles published through July 15, 2019, to identify studies that reported the testing and/or evaluation of interventions to improve adherence to oral antineoplastic agents.

RESULTS

A total of 56 articles were selected for review. Of the studies evaluated, 14 were randomized trials. All interventions except two targeted adult patients. Thirty-three studies enrolled fewer than 100 patients. Most interventions were education- and counseling-based and centered on provision of information about the drug and strategies to manage side effects. Only eight studies used an mHealth tool and/or text messages to target nonadherence. Among studies with a comparison sample, fewer than one-half (44.7%) reported statistically significant improvements in adherence or persistence associated with the intervention; however, some pharmacist-directed programs, particularly those that integrated monitoring or routine follow-up with a provider, did demonstrate efficacy.

CONCLUSION

Although the development of adherence-promoting interventions for oral antineoplastic therapies has increased recently, few have been rigorously tested. The nascent literature suggests those that are pharmacist directed and use regular monitoring show promise, though additional prospective studies are needed. Study methodology, population selection, and potential challenges that may be encountered in the implementation and dissemination phases should be considered when developing new interventions to address nonadherence to oral antineoplastic treatment.

Tyrosine Kinase Inhibitors Initiation, Cost Sharing, and Health Care Utilization in Patients with Newly Diagnosed Chronic Myeloid Leukemia: A Retrospective Claims-Based Study

BACKGROUND

For newly diagnosed chronic myeloid leukemia (CML) patients, early access to tyrosine kinase inhibitors (TKIs) is a consistent predictor of adherence and optimal response. The expense of targeted therapies, however, may result in high out-of-pocket costs for initiating therapy that could be a barrier to starting treatment.

OBJECTIVE

To examine the association between TKI out-of-pocket costs, initiation, and health care utilization and costs among patients who initiated TKI within 12 months after initial CML diagnosis.

METHODS

Individuals aged 18-64 years with an initial diagnosis of CML were identified in the IBM MarketScan Commercial Database between April 11, 2011, and December 31, 2014. The association between cost sharing and TKI initiation was evaluated using a multivariable logistic regression model applied to patients receiving therapy within a month of diagnosis and within 1-12 months after diagnosis. Health care utilization was compared using negative binomial regression models. Health care cost differences between the 2 patient groups were estimated using generalized linear models. All models were controlled for potential confounding factors.

RESULTS

The study sample consisted of 477 patients, with 397 (83.2%) patients initiating TKI within the first month of CML diagnosis and 80 (16.8%) after the first month. Out-of-pocket costs for the initial 30-day supply of TKI medications were not found to be a significant predictor of TKI initiation time. Patients initiating therapy within a month were less likely to have all-cause hospitalizations (IRR = 0.35; P = 0.02) or CML-specific hospitalizations (IRR = 0.27; P < 0.01). Over the 12-month follow-up period, they incurred $9,923 more in TKI pharmacy costs (P < 0.05), but patients initiating therapy after the first month of diagnosis incurred $7,582 more in medical costs, $218 more in non-TKI pharmacy costs, and $2,680 more in total health care costs (P > 0.05).

CONCLUSIONS

Patients with TKI initiation within the first month of diagnosis had higher TKI pharmacy costs that were partially offset by lower medical and non-TKI pharmacy costs, resulting in lower overall total health care costs. Findings suggest that earlier TKI initiation may reduce the risks of hospitalizations, which could result in potential medical cost savings in the first 12 months of treatment.

DISCLOSURES

No outside funding supported this study. The authors have no relationships or financial interests to report with any entity that would pose a conflict of interest with the subject matter of this article. A poster presentation of the study was made at the 11th American Association for Cancer Research (AACR) Conference on The Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved, on November 2-5, 2018, in New Orleans, LA.

Temporary Stoppages and Burden of Treatment in Patients With Cancer

OBJECTIVES

To examine the effect of burden of treatment and multimorbidity on the relationship between baseline characteristics and oral oncolytic agent (OOA) temporary stoppages.

SAMPLE & SETTING

272 patients newly prescribed OOAs at six National Cancer Institute-designated comprehensive cancer centers.

METHODS & VARIABLES

Patients were randomly assigned to an adherence and symptom management group or a usual care/control group. Temporary OOA stoppages, symptom interference, OOA regimen complexity, and multimorbidities were explored. Data were collected at four-week intervals for 12 weeks.

RESULTS

Burden of treatment variables and multimorbidity had no significant effect on OOA temporary stoppages. Women and those prescribed kinase inhibitors were significantly more likely to experience a temporary stoppage.

IMPLICATIONS FOR NURSING

Oncology nurses are in a crucial position to educate patients on self-management of OOAs and symptoms. Nurses should be aware of patients who may be more susceptible to severe symptoms, including those with multimorbidities. Future research is needed to better understand OOA stoppages and factors associated with preventing stoppages.

A Systematic Review of Rates, Outcomes, and Predictors of Medication Non-Adherence Among Adolescents and Young Adults with Cancer

Nonadherence to medications in cancer treatment protocols may be a particular concern among adolescents and young adults (AYAs) with cancer and predictive of poor health outcomes, but data supporting this claim remain limited. The purpose of this article was to systematically review the rates, outcomes, and predictors of oral medication nonadherence among AYAs with cancer. PubMed (i.e., MEDLINE), CINAHL, and PsycINFO databases were searched in 2018 using terms related to medication adherence and cancer. A total of 37,884 records representing 34,006 unique articles were identified and reviewed. Thirteen articles representing 12 studies met inclusion criteria and examined medication adherence among AYAs with cancer. Results of these studies suggest that 21%-60% of AYAs are nonadherent to oral medications, likely placing them at increased risk for poor health outcomes (i.e., relapse, infection/fever, and death). Psychosocial factors (i.e., knowledge, beliefs about capabilities, beliefs about consequences, environmental context and resources, and emotion) were related to nonadherence and warrant future study. Of note, demographic, disease, and family composition variables did not predict nonadherence. Clinical implications as well as limitations and resulting future directions are discussed.

The potential health gain and cost savings of improving adherence in chronic myeloid leukemia

Healthcare costs are rising due to an increase in chronic diseases, including chronic myeloid leukemia (CML) due to improved survival. In CML care, patient adherence and physician adherence are key elements. We assessed the potential health gain and cost savings when both are improved, using a decision analytic model that integrated various sources of evidence. The current situation was compared to a theoretical situation in which either patient or physician adherence is improved, in terms of costs and quality-adjusted life years (QALYs). Current patient adherence rate is 74%, improvement to 100% resulted in 0.1031 QALYs gained and a saving of €17,509 per patient over a 25-year period. Improving physician adherence from 72% to 100%, resulted in 0.0380 QALYs and €7606. Enhancement of either adherence results in substantial health gain and cost savings. Regarding the rising healthcare costs, new strategies should focus on improving adherence to keep healthcare affordable in the future.

Exploring behaviors, treatment beliefs, and barriers to oral chemotherapy adherence among adult leukemia patients in a rural outpatient setting

Objective

Adherence to oral chemotherapy is essential for patients with chronic myeloid leukemia (CML) and multiple myeloma (MM) to remain in remission. Few studies have used a Likert-type scale to measure medication adherence in CML and MM patients. We applied a validated treatment adherence tool, the ASK-12 (Adherence Starts with Knowledge^®) survey, which assessed inconvenience and forgetfulness, treatment beliefs, and medication-taking behaviors recorded on a five-point Likert-type scale at two visits.

Results

A medication adherence survey was administered to 42 newly diagnosed or pre-existing CML or MM patients at two outpatient oncology clinics affiliated with an academic medical center in rural eastern North Carolina. Thirty-one patients completed surveys at visit 1 and visit 2 (median 4.5 months apart). Most patients were treated for MM (65%), were non-Hispanic black (68%) and female (58%). Within subscales, mean adherence scores decreased between visits, signaling better adherence. Overall, visit scores were correlated (0.63, p = 0.001). Forgetting to take medication sometimes was the most common reason for non-adherence. Medication costs were not a barrier for MM patients. Greater patient–provider informed decision-making was identified as an opportunity for quality improvement among CML patients. The ASK-12 survey provided a strategy to obtain robust information on medication adherence.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3935-z) contains supplementary material, which is available to authorized users.

Physician and Pharmacist Medication Decision-Making in the Time of Electronic Health Records: Mixed-Methods Study

Background

Primary care needs to be patient-centered, integrated, and interprofessional to help patients with complex needs manage the burden of medication-related problems. Considering the growing problem of polypharmacy, increasing attention has been paid to how and when medication-related decisions should be coordinated across multidisciplinary care teams. Improved knowledge on how integrated electronic health records (EHRs) can support interprofessional shared decision-making for medication therapy management is necessary to continue improving patient care.

Objective

The objective of our study was to examine how physicians and pharmacists understand and communicate patient-focused medication information with each other and how this knowledge can influence the design of EHRs.

Methods

This study is part of a broader cross-Canada study between patients and health care providers around how medication-related decisions are made and communicated. We visited community pharmacies, team-based primary care clinics, and independent-practice family physician clinics throughout Ontario, Nova Scotia, Alberta, and Quebec. Research assistants conducted semistructured interviews with physicians and pharmacists. A modified version of the Multidisciplinary Framework Method was used to analyze the data.

Results

We collected data from 19 pharmacies and 9 medical clinics and identified 6 main themes from 34 health care professionals. First, Interprofessional Shared Decision-Making was not occurring and clinicians made decisions based on their understanding of the patient. Physicians and pharmacists reported indirect Communication, incomplete Information specifically missing insight into indication and adherence, and misaligned Processes of Care that were further compounded by EHRs that are not designed to facilitate collaboration. Scope of Practice examined professional and workplace boundaries for pharmacists and physicians that were internally and externally imposed. Physicians decided on the degree of the Physician-Pharmacist Relationship, often predicated by colocation.

Conclusions

We observed limited communication and collaboration between primary care providers and pharmacists when managing medications. Pharmacists were missing key information around reason for use, and physicians required accurate information around adherence. EHRs are a potential tool to help clinicians communicate information to resolve this issue. EHRs need to be designed to facilitate interprofessional medication management so that pharmacists and physicians can move beyond task-based work toward a collaborative approach.

Identifying Tyrosine Kinase Inhibitor Nonadherence in Chronic Myeloid Leukemia: Subanalysis of TAKE-IT Pilot Study

BACKGROUND

There are inconsistencies in reports on correlates for nonadherence (NA) to tyrosine kinase inhibitors (TKIs) in chronic myeloid leukemia (CML). The diagnostic accuracy of subjective adherence measures using electronic monitoring (EM) as the reference standard is yet to be determined. This study aimed to evaluate correlates of TKI NA using EM and test the diagnostic accuracy of subjective adherence measures.

PATIENTS AND METHODS

CML patients receiving a TKI for any duration were enrolled at 4 hematology institutes, and adherence was measured for 4 months. EM adherence was the reference adherence measure, expressed as the percentage of days with the drug taken as prescribed. Subjective adherence was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) self-report and clinician-reported visual analog scale (VAS) at 2 time points. Baseline theory-derived correlates of NA were identified using single and multiple regression analysis. The diagnostic accuracy of BAASIS and clinician-reported VAS was tested against an exploratory EM NA cutoff of < 95%.

RESULTS

The median EM adherence (n = 55) was 97.5% (range, 48-100%), while the 25th percentile was 92.1%. Lack of membership in a CML patient support group, living alone, and third-line treatment were associated with EM NA on multiple regression analysis. The BAASIS self-report (n = 94) had a sensitivity of 67% and a specificity of 71% for diagnosing NA, while clinician-reported VAS (n = 89) had a sensitivity of 78% and specificity of 42%.

CONCLUSION

A quarter of patients had potentially clinically meaningful NA. These NA correlates and the BAASIS provide a basis for identifying nonadherent patients who can be targeted by interventions.

Use of a Smartphone Application for Prompting Oral Medication Adherence Among Adolescents and Young Adults With Cancer

OBJECTIVES

To explore the feasibility and acceptability of use of a smartphone medication reminder application to promote adherence to oral medications among adolescents and young adults (AYAs) with cancer.
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SAMPLE & SETTING

23 AYAs with cancer from a Children's Oncology Group-affiliated children's hospital and a National Cancer Institute-designated comprehensive cancer center in Salt Lake City, UT.
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METHODS & VARIABLES

Participants were asked to use the application for eight weeks. Data on application usage were obtained from a cloud-based server hosted by the application developers. Weekly self-report questionnaires were completed. Feasibility was assessed through participants' usage and responses. Acceptability was assessed through participants' perceived ease of use and usefulness.
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RESULTS

Almost all participants used the application at least once. More than half reported that they took their medications immediately when they received reminders. Participants also reported that the application was easy to set up and use, and that it was useful for prompting medication taking.
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IMPLICATIONS FOR NURSING

Nurses could continue to test the efficacy of integrating e-health modalities, such as smartphone applications, into efforts to promote medication adherence.

Treatment strategies for adolescent and young adult patients with acute myeloid leukemia

Adolescents and young adults (AYAs) form a unique group of patients with newly diagnosed acute myeloid leukemia (AML). They differ in terms of disease biology, psychosocial challenges, survival, and in other important respects from children as well as from middle-aged and older adults. AYAs may be treated using pediatric protocols developed in trials composed primarily of younger patients, or using adult protocols developed in trials composed primarily of older patients. After reviewing the distinguishing characteristics of AYAs with AML, we compare and contrast the chemotherapy approaches and argue that neither the pediatric nor adult approaches may be ideally suited for AYAs and the development of AYA-specific approaches merits further consideration. We finish by putting forth ideas for future research to optimize chemotherapy treatment of AYAs with AML.

Side effects and medication adherence of tyrosine kinase inhibitors for patients with chronic myeloid leukemia in Taiwan

Nonadherence is common in patients with chronic myeloid leukemia (CML) and leads to treatment failure and poor outcomes. Side effects due to treatment are also common in patients with CML. However, no study has investigated the link between side effects and medication adherence for patients with CML in Taiwan. Therefore, the aim of our study was to explore the influence of side effects on medication adherence in Taiwanese patients with CML.CML in chronic-phase patients treated with breakpoint cluster region-Abelson murine leukemia viral oncogene homolog 1 tyrosine kinase inhibitors were recruited. We designed a questionnaire to collect baseline patient information, medication adherence (measured using the 8-item Morisky Medication Adherence Scale), and side effects. Clinical outcomes were assessed by the 3-month early molecular response rate and the 12-month major molecular response rate. Statistical comparisons of different parameters between adherent and nonadherent groups were conducted.Fifty-eight patients were enrolled in this study, and 31% of them had poor adherence. The lack of information about treatment and medication was the major reason for poor medication adherence. Patients who were younger and unmarried were prone to poor adherence. The occurrence of side effects carried no statistically significant influence on adherence. Poor adherence resulted in a poor treatment response (lower 3-month early molecular response rate and lower 12-month major molecular response rate).Poor adherence is common in Taiwanese patients with CML. The main reason for a decrease in the adherence rate is the lack of comprehensive information about treatment and medication, particularly in young and single population. The next urgent step is to educate patients about their treatment and management of side effects to improve adherence and treatment outcome for patients with CML in Taiwan.

Adherence to Oral Anticancer Medications: Evolving Interprofessional Roles and Pharmacist Workforce Considerations

Interprofessional care is exhibited in outpatient oncology practices where practitioners from a myriad of specialties (e.g., oncology, nursing, pharmacy, health informatics and others) work collectively with patients to enhance therapeutic outcomes and minimize adverse effects. Historically, most ambulatory-based anticancer medication therapies have been administrated in infusion clinics or physician offices. Oral anticancer medications (OAMs) have become increasingly prevalent and preferred by patients for use in residential or other non-clinic settings. Self-administration of OAMs represents a significant shift in the management of cancer care and role responsibilities for patients and clinicians. While patients have a greater sense of empowerment and convenience when taking OAMs, adherence is a greater challenge than with intravenous therapies. This paper proposes use of a qualitative systems evaluation, based on theoretical frameworks for interdisciplinary team collaboration and systems science, to examine the social interactionism involved with the use of intravenous anticancer treatments and OAMs (as treatment technologies) by describing patient, organizational, and social systems considerations in communication, care, control, and context (i.e., Kaplan’s 4Cs). This conceptualization can help the healthcare system prepare for substantial workforce changes in cancer management, including increased utilization of oncology pharmacists.

Prevalence and associated factors of medication non-adherence in hematological-oncological patients in their home situation

BACKGROUND

Medication non-adherence is associated with poor health outcomes and increased health care costs. Depending on definitions, reported non-adherence rates in cancer patients ranges between 16 and 100%, which illustrates a serious problem. In malignancy, non-adherence reduces chances of achievement of treatment response and may thereby lead to progression or even relapse. Except for Chronic Myeloid Leukemia (CML), the extent of non-adherence has not been investigated in hematological-oncological patients in an outpatient setting. In order to explore ways to optimize cancer treatment results, this study aimed to assess the prevalence of self-administered medication non-adherence and to identify potential associated factors in hematological-oncological patients in their home situation.

METHODS

This is an exploratory cross-sectional study, carried out at the outpatient clinic of the Department of Hematology at the VU University medical center, Amsterdam, the Netherlands between February and April 2014. Hematological-oncological outpatients were sent questionnaires retrieving information on patient characteristics, medication adherence, beliefs about medication, anxiety, depression, coping, and quality of life. We performed uni- and multivariable analysis to identify predictors for medication non-adherence.

RESULTS

In total, 472 participants were approached of which 259 (55%) completed the questionnaire and met eligibility criteria. Prevalence of adherence in this group (140 male; 54,1%; median age 60 (18-91)) was 50%. In univariate analysis, (lower) age, (higher) education level, living alone, working, perception of receiving insufficient social support, use of bisphosphonates, depression, helplessness (ICQ), global health, role function, emotional function, cognitive function, social functioning, fatigue, dyspnea, diarrhea were found to be significantly related (p = <0.20) to medication non-adherence. In multivariable analysis, younger age, (higher) education level and fatigue remained significantly related (p = <0.10) to medication non-adherence.

CONCLUSIONS

This cross-sectional study shows that 50% of the participants were non-adherent. Lower age, living alone and perception of insufficient social support were associated factors of non-adherence in hematological-oncological adult patients in their home-situation.

Adherence and Coping Strategies in Outpatients With Chronic Myeloid Leukemia Receiving Oral Tyrosine Kinase Inhibitors

PURPOSE/OBJECTIVES

To assess adherence and coping strategies in outpatients with chronic myeloid leukemia (CML) on oral tyrosine kinase inhibitors (TKIs).
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DESIGN

Prospective, descriptive.
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SETTING

An interdisciplinary oncology outpatient clinic in Germany.
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SAMPLE

35 outpatients with CML on oral TKIs.
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METHODS

Adherence and coping strategies were assessed with questionnaires. Clinical data were extracted from medical charts.
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MAIN RESEARCH VARIABLES

Adherence rates, main coping strategies, and frequency and contents of single coping strategies.
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FINDINGS

18 patients showed adherence according to the applied screening instrument. Main coping strategies were spirituality and search for meaning. The two single items most frequently specified were adhering to medical instructions and trusting in the medical personnel involved.
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CONCLUSIONS

The low adherence rate of 51% most likely resulted from using the Basel Assessment of Adherence Scale as the questionnaire of choice. The relevance of spirituality and search for meaning as main coping strategies has not been shown previously in outpatients with CML. Most patients wish to obey medical instructions accurately and put trust in their oncologists; this introduces a resource that should gain relevance considering the increasing number of oral anticancer drugs.
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IMPLICATIONS FOR NURSING

Nurses are encouraged to routinely assess adherence and spiritual needs in outpatients with CML. Spirituality and search for meaning represent pivotal coping strategies in this group, which has an excellent prognosis. Oncology nurses may help provide tailored support, thereby ameliorating care for these patients.

eHealth in the future of medications management: personalisation, monitoring and adherence

BACKGROUND

Globally, healthcare systems face major challenges with medicines management and medication adherence. Medication adherence determines medication effectiveness and can be the single most effective intervention for improving health outcomes. In anticipation of growth in eHealth interventions worldwide, we explore the role of eHealth in the patients' medicines management journey in primary care, focusing on personalisation and intelligent monitoring for greater adherence.

DISCUSSION

eHealth offers opportunities to transform every step of the patient's medicines management journey. From booking appointments, consultation with a healthcare professional, decision-making, medication dispensing, carer support, information acquisition and monitoring, to learning about medicines and their management in daily life. It has the potential to support personalisation and monitoring and thus lead to better adherence. For some of these dimensions, such as supporting decision-making and providing reminders and prompts, evidence is stronger, but for many others more rigorous research is urgently needed.

CONCLUSIONS

Given the potential benefits and barriers to eHealth in medicines management, a fine balance needs to be established between evidence-based integration of technologies and constructive experimentation that could lead to a game-changing breakthrough. A concerted, transdisciplinary approach adapted to different contexts, including low- and middle-income contries is required to realise the benefits of eHealth at scale.

How can we help haematological cancer survivors cope with the changes they experience as a result of their cancer?

Haematological cancer often necessitates that individuals make significant lifestyle and behaviour changes to protect themselves against infections. It is essential that haematological cancer survivors receive the support and information they require to adjust to such changes. This cross-sectional survey of 259 haematological cancer survivors found that over two thirds of haematological cancer survivors would like to receive more detailed information or help with: diet and nutrition that takes into account their diagnosis and treatment, how to manage the symptoms from the cancer and/or treatment, signs and symptoms to be aware of that may indicate a possible infection and appropriate exercise. Over a third of survivors reported that they had to make changes to reduce their chance of infection, with social restriction the most commonly reported area of change survivors made. Improving communication and access to care and providing additional emotional support may assist survivors in making these additional changes. Healthcare providers should use this information to better support haematological cancer survivors in dealing with the effects haematological cancer has on their life.