The challenges of oral agents as antineoplastic treatments

Psychometric Properties of the Self Care Oral Anticancer Agents Index (SCOAAI)

OBJECTIVE

To test the Self-Care Oral Anticancer Agents Index (SCOAAI)'s psychometric properties (structural validity, convergent validity, predictive validity, and internal consistency) in a sample of patients with solid tumour on Oral anticancer agents (OAA).

METHODS

A methodological research in five in- or out-patient Italian facilities. Structural validity was tested by confirmatory factor analysis, and internal consistency was assessed through Cronbach's alpha and composite reliability. The Mann-Whitney U-test was used to test associations between SCOAAI scores and patient's emergency room admission, re-hospitalization, mortality, and quality of life measured three months after baseline.

RESULTS

We enrolled 356 patients; mostly were male (52.24%), and mean age was 59.10 years. Analyses demonstrated the SCOAAI's factorial validity and internal consistency. Moreover, patients that experienced emergency room admissions (U = 3484.5; P = .002) and re-hospitalization (U = 2446.0; P = .001) showed lower self-care maintenance scores; those who experienced emergency room admission (U = 3263.5; P = .019) and died at follow-up (U = 700.5; P = .025) had lower self-care monitoring scores; while patients that experienced re-hospitalisation (U = 2931.5; P = .040) and emergency room admission (U = 3285.0; P = .012) had lower self-care management scores. Patients with adequate self-care (≥ 70) reported significantly higher quality of life (self-care maintenance U = 1228.500, P < .001; self-care monitoring U = 3512.500, P < .001; self-care management U = 3287.500, P < .001).

CONCLUSION

According to our findings the SCOAAI is a valid and reliable tool. Patients with inadequate self-care can experience more emergency room accesses, re-hospitalization, death, and lower quality of life.

IMPLICATIONS FOR NURSING PRACTICE

Adequate self-care behaviors can improve patient's outcomes and should be assessed by healthcare providers during the disease pathway.

Factors affecting medication adherence in patients using oral chemotherapy: A descriptive study

IntroductionThe utilization of oral chemotherapy agents for cancer treatment has witnessed a steady rise in recent years. The pivotal determinant for the success of oral chemotherapy lies in the adherence of cancer patients to the prescribed treatment. This study aims to explore oral chemotherapy adherence and identify factors influencing medication adherence among cancer patients.MethodsA total of 103 cancer patients participated in this descriptive study. Data were collected using the Oral Chemotherapy Adherence Scale, the Turkish Translation of the Beliefs about Medicines Questionnaire (BMQ-T) and The Functional Living Index-Cancer.ResultsOf the participants, 66% reported good adherence to oral chemotherapy. Key findings indicate that access to health services (β = -1.473, p = 0.009), cancer stage (β = -1.570, p = 0.015) and the BMQ-T subscale of General Overuse (β = .696, p = 0.041) were independent predictors of medication adherence.ConclusionThe study observed medication non-adherence in one-third of patients undergoing oral chemotherapy. Primary contributors to non-adherence included difficulties in accessing health services, advanced cancer stage and the belief that drugs are over-recommended by doctors. These results underscore the need for a heightened focus on preventable factors, such as improving access to health services and addressing beliefs about drug overuse, to enhance medication adherence in patients receiving oral chemotherapy.

Technology ownership, use, and perceptions of web-based program design features for older adults prescribed oral anticancer medication

INTRODUCTION

Older adults are often prescribed oral anticancer agents (OAAs). Technology-based interventions may offer medication and symptom support. We aimed to evaluate technology ownership, use, and preferred design features of a supportive web-based program using a multimethod design utilizing surveys and semi-structured interviews.

MATERIALS AND METHODS

Patients were recruited from a National Cancer Institute-designated Comprehensive Cancer Center. Eligibility included those: (1) ≥65 years of age; (2) prescribed a Food and Drug Administration-approved OAA; (3) English speaking; (4) able/willing to complete telephone interviews. Interviews were audio-recorded and transcribed verbatim. Cohen's Kappa was used to evaluate inter-rater reliability and calculated at 0.87.

RESULTS

Participants (N = 30) were predominantly female (70 %), White (83.3 %), with metastatic disease (90 %). The mean age was 74.9 years. Ninety percent owned a smartphone, 66.7 % owned a tablet, and 90 % owned a computer. Nearly 57 % reported using smartphones frequently for cancer-related purposes. Four themes with corresponding subthemes were identified: (1) comfort with technology; (2) reasons for technology use for health-related purposes (research of cancer, cancer treatment, and related symptoms/side effects; using the portal to manage health; and appointment and medication reminders); (3) recommended design features for a web-based program (OAA medication-specific information; calendars & medication alarms/reminders; symptom management & symptom trackers; and tutorials and testimonials); and (4) adaptations for older adults (simple navigation; larger font; use of layperson's terms; use of pictures, graphics, and color coding; and voice activation).

DISCUSSION

Older adults use technology for health-related purposes. Specific web-design features and adaptations are needed to enhance usability among older adults.

15 years supporting adherence to oral anti-cancer treatment: use of the MASCC Oral Agent Teaching Tool (MOATT) worldwide, a review for the future

INTRODUCTION

The MASCC Oral Agent Teaching Tool (MOATT®) was developed to address the challenges of patient education and adherence in the context of oral anticancer agents. Despite its evidence-based design and global availability, there is limited documentation on its application in clinical practice and research. This review aims to assess the extent of MOATT usage and evaluate the impact on patient outcomes.

METHODS

A scoping review was conducted following Joanna Briggs Institute and PRISMA-ScR reporting standards. Databases included CINAHL, Embase, PsycInfo, Web of Science, and PubMed. Inclusion criteria were studies published between 2010 and 2023 that used MOATT in clinical practice or research. Two reviewers independently screened and extracted data, with discrepancies resolved by consensus.

FINDINGS

Seventeen studies met the inclusion criteria, from nine countries. The MOATT was most used by nurses and pharmacists to guide patient education when initiating new oral anticancer therapies. Reported outcomes included improved patient knowledge, understanding of medication regimens, and comfort in managing treatments. However, only six studies assessed medication adherence, with mixed results. The tool was adapted in various settings, yet there was a notable lack of detailed reports on its usage and outcomes, highlighting underutilization and potential barriers to broader implementation.

CONCLUSION

The MOATT is a valuable tool for supporting patients on oral anticancer agents yet is underutilized in practice. Future research should focus on understanding the barriers to its adoption, exploring patient and provider perspectives, and integrating implementation science to enhance its use in diverse clinical contexts.

How to Optimize Deimplementation of Sentinel Lymph Node Biopsy?

Background

The omission of sentinel lymph node biopsy in low-risk elderly breast cancer patients has been introduced in several guidelines. Despite evidence to support its safety, this recommendation has not been implemented by many clinicians. We have examined two aspects of this recommendation that may explain why sentinel lymph node biopsy continues to be performed in most of these patients. Firstly, we quantified the proportion of patients diagnosed with axillary metastases postoperatively. Secondly, we examined adherence to antihormonal therapy in the same group of patients.

Methods

In this single-centre retrospective cohort study, the study population comprised 98 patients with breast cancer. Patients were aged ≥70 years and diagnosed with hormone receptor positive breast cancers less than 20 mm (T1). All patients underwent surgery and were subsequently prescribed five years of adjuvant antihormonal treatment.

Results

Axillary lymph node metastases, as confirmed by the postoperative histology report, were seen in 36.3%. Nonadherence was seen in 33.7% of the patients. Primary nonadherence, that is, patients that never collect their first or subsequent prescriptions at the pharmacy, comprised 11.2% of the total study population.

Conclusion

The high proportion of axillary metastases demonstrated suggests that clinical examination of the axilla alone is not sufficient in the preoperative assessment of the axilla. The less-than-optimal adherence rates show that adherence in these patients cannot be taken for granted. We suggest that these factors reflect some of the reluctance among clinicians to omit the sentinel lymph node procedure in these patients.

Current Management and Future Perspectives of Hormone Receptor-Positive HER2-Negative Advanced Breast Cancer

OBJECTIVES

An overview of the best therapeutic approaches for the management of hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer is provided, and emerging treatment advances are discussed. Key nursing considerations and the role of the nurse in the provision of optimal care are explored.

DATA SOURCES

Data sources include peer-reviewed articles sourced in electronic databases.

CONCLUSION

With a multitude of current and emerging treatments for the management of hormone receptor-positive, HER2-negative advanced breast cancer, patients with this subtype have improved overall survival. It is essential that specialist nurses holistically support patients; this will ensure treatment adherence, leading to enhanced longevity and quality of life.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play an important role in patient education and the early identification and management of treatment toxicities. Nurses also need to monitor and facilitate adherence by identifying barriers and implementing strategies to overcome them, ultimately improving patient outcomes.

The use of microtracers in food-effect trials: An alternative study design for toxic drugs with long half-lives exemplified by the case for alectinib

The traditional design of food-effect studies has a high patient burden for toxic drugs with long half-lives (e.g., anticancer agents). Microtracers could be used to assess food-effect in patients without influencing their ongoing treatment. The feasibility of a microtracer food-effect study during steady-state of the therapeutic drug was investigated in an in silico simulation study with alectinib as an example for a relative toxic drug with a long half-life. Microtracer pharmacokinetics were simulated based on a previously published population pharmacokinetic model and used for estimation of a model with and a model without food as a covariate on oral bioavailability of alectinib (assuming a 40% food-effect). Power was defined as the fraction of clinical trials where a significant (p < 0.01) food-effect was identified. The proposed study design of 10 patients on steady-state treatment, 10 blood samples collected within 24 h after administration and an assumed food-effect of 40% had a power of 99.9%. The mean estimated food-effect was 39.8% (80% confidence interval: 31.0%-48.6%). The feasibility of microtracer food-effect studies was demonstrated. The design of the microtracer food-effect study allowed estimation of the food-effect with minimal influence on therapeutic treatment and reducing patient burden compared to the traditional study design for toxic drugs with long half-lives.

Patient-reported outcomes for oral oncolytic therapy: A pilot study utilizing an electronic patient portal in a community cancer center

OBJECTIVE

A pilot project was initiated to determine the feasibility of using an electronic patient portal, MyChart, for documentation of patient-reported outcomes for those receiving treatment with an oral oncolytic.

METHODS

Documentation of patient-reported outcomes within the electronic medical record before and after implementing questionnaires through the use of MyChart was compared. Additional outcomes that were assessed included patient confidence and satisfaction, adherence rate, side effects, and documentation of provider interventions.

RESULTS

Our findings indicate that the use of an electronic patient portal significantly increased the number of encounters documented within the electronic medical record from 1.8% (N = 19 patients; 1 out of 55 potential encounters; retrospective analysis) to 27.5% (N = 15 patients; 14 out of 51 potential encounters; prospective analysis) for those who utilized an electronic patient portal (p < 0.001). Patient confidence and satisfaction were high, the adherence rate was 100% at 4 months, and side effects were generally mild. Provider follow-up was documented in the electronic medical record in 6 out of 8 patients when a flagged response was identified.

CONCLUSIONS

This pilot study indicates that the use of an electronic patient portal, MyChart, was feasible and improved documentation of patient-reported outcomes within the electronic medical record. Several information technologies and patient barriers were encountered throughout. Careful selection of patients who will embrace this technology is important.

Exploring adherence in patients with advanced breast cancer: focus on CDK4/6 inhibitors

Treatment adherence is crucial for optimal outcomes in advanced breast cancer, but can be challenging due to various factors, i.e. patients' attitudes and behavior upon diagnosis, and complex therapies with high adverse effect rates. Our aim was to explore the adherence to oral anticancer medications (OAM) in women with advanced breast cancer, focusing on cyclin-dependent kinase 4 and 6 inhibitors (CDKI), and identify factors associated with the adherence. We conducted a cross-sectional study at the University Hospital Centre Zagreb, Croatia, involving women with stage IV advanced breast cancer receiving OAM. Data collection included a questionnaire assessing socio-demographic and clinical information, Beck Depression Inventory-II for depressive symptoms, Medication Adherence Report Scale (MARS-5) for adherence to OAM, and Beliefs about Medicines Questionnaire. Plasma concentrations of CDKI were confirmed by LC-MS/MS in three randomly selected participants. A total of 89 women were included. The most prescribed OAMs were anti-estrogen (71.3 %) and CDKI (60.9 %). MARS-5 scores (mean: 24.1 ± 1.6) correlated with CDKI plasma concentrations. Forgetfulness was the primary reason for non-adherence (25.9 %). Women receiving CDKI (p = 0.018), without depressive symptomatology (p = 0.043), and with more positive beliefs about medicines were more adherent (p < 0.05). This study enhances understanding of medication adherence in advanced breast cancer and identifies influential factors.

Advanced Messaging Intervention for Medication Adherence and Clinical Outcomes Among Patients With Cancer: Randomized Controlled Trial

BACKGROUND

Medication adherence is crucial for improving clinical outcomes in the treatment of patients with cancer. The lack of adherence and adverse drug reactions can reduce the effectiveness of cancer therapy including the quality of life. The commonly used intervention methods for medication adherence continue to evolve, and the age of fifth-generation (5G) messaging has arrived.

OBJECTIVE

In this study, we conducted a prospective, pilot randomized controlled trial to evaluate the effect of 5G messaging on medication adherence and clinical outcomes among patients with cancer in China.

METHODS

The research population was patients with nonsmall cell lung cancer undergoing pemetrexed chemotherapy who require regular folic acid (FA) and vitamin B12 supplements. The intervention and control groups were assigned to 5G messaging and second-generation (2G) messaging, respectively. The patients' medication adherence and quality of life were assessed at baseline and 1-month and 3-month time points. Moreover, the chemotherapy-related hematologic or nonhematologic toxicities, as well as the serum levels of FA and vitamin B12, were measured.

RESULTS

Of the 567 patients assessed for eligibility between January and May 2021, a total of 154 (27.2%) patients were included. Overall, 80 were randomized to the control group and 74 to the intervention group. The odds of adherence in the 5G messaging intervention group were significantly higher than the control group at the 1-month (62/69, 90% vs 56/74, 76%; adjusted odds ratio 2.67, 95% CI 1.02-7.71) and 3-month (50/60, 83% vs 48/64, 75%; adjusted odds ratio 2.36, 95% CI 1.00-5.23) time points. Correspondingly, the FA and vitamin B12 serum levels of patients in the 5G messaging group were higher than those of the control group. Regarding hematologic toxicities, only the incidence of leukopenia in the intervention group was lower than that in the control group (25/80, 31% in the control group vs 12/74, 16% in the intervention group; P=.04). There were no differences in nonhematologic toxicities and quality of life between the 2 groups.

CONCLUSIONS

In summary, we conclude that compared with conventional 2G text-based messaging, a 5G messaging intervention can better improve medication adherence and clinical outcome among patients with cancer.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200058188; https://www.chictr.org.cn/showproj.html?proj=164489.

Palbociclib Adherence and Persistence in Patients with Hormone Receptor Positive/Human Epidermal Growth Factor Receptor 2 Negative (HR+/HER2-) Metastatic Breast Cancer

Purpose

To assess adherence and persistence with palbociclib therapy in patients with HR+/HER2- metastatic breast cancer (mBC) in a US real-world setting.

Methods

This retrospective study evaluated palbociclib dosing, adherence, and persistence using commercial and Medicare Advantage with Part D claims data from the Optum Research Database. Adult patients with mBC who had continuous enrollment 12 months prior to mBC diagnosis and initiated first-line palbociclib with aromatase inhibitor (AI) or fulvestrant between 02/03/2015 and 12/31/2019 were included. Demographic and clinical characteristics, palbociclib dosing and dose changes, adherence (medication possession ratio [MPR]), and persistence were measured. Adjusted logistic and Cox regression models were used to examine demographic and clinical factors associated with adherence and discontinuation.

Results

Patients (n = 1066) with a mean age of 66 years were included; 76.1% received first-line palbociclib+AI and 23.9% palbociclib+fulvestrant. Most patients (85.7%) initiated palbociclib at 125 mg/day. Of the 34.0% of patients with a dose reduction, 82.6% reduced from 125 to 100 mg/day. Overall, 80.0% of patients were adherent (MPR), and 38.3% discontinued palbociclib during a mean (SD) follow-up of 16.0 (11.2) and 17.4 (13.4) months, for palbociclib+fulvestrant and palbociclib+AI, respectively. Annual income below $75,000 was significantly associated with poor adherence. Older age (age 65-74 years (hazard ratio [HR] 1.57, 95% CI, 1.06, 2.33), age ≥75 years (HR 1.61, 95% CI: 1.08, 2.41)) and bone-only metastatic disease (HR 1.37, 95% CI, 1.06, 1.76) were significantly associated with palbociclib discontinuation.

Conclusion

In this real-world study, >85% of patients started palbociclib at 125 mg/day and 1 in 3 had dose reductions during the follow-up. Patients were generally adherent and persistent with palbociclib. Older age, bone-only disease, and low-income levels were associated with early discontinuation or non-adherence. Further studies are needed to understand the associations of clinical and economic outcomes with palbociclib adherence and persistence.

Patient, provider, and hospital factors associated with oral anti-neoplastic agent initiation and adherence in older patients with metastatic renal cell carcinoma

INTRODUCTION

Oral anti-neoplastic agents (OAAs) for metastatic renal cell carcinoma (mRCC) are associated with increased cancer-specific survival. However, racial disparities in survival persist and older adults have the lowest rates of cancer-specific survival. Research from other cancers demonstrates specialty access is associated with high-quality cancer care, but older adults receive cancer treatment less often than younger adults. We therefore examined whether patient, provider, and hospital characteristics were associated with OAA initiation, adherence, and cancer-specific survival after initiation and whether race, ethnicity, and/or age was associated with an increased likelihood of seeing a medical oncologist for diagnosis of mRCC.

PATIENTS AND METHODS

We used Surveillance, Epidemiology, and End Results (SEER)Medicare data to identify patients ≥65 years of age who were diagnosed with mRCC from 2007 to 2015 and enrolled in Medicare Part D. Insurance claims were used to identify receipt of OAAs within twelve months of metastatic diagnosis, calculate proportion of days covered, and to identify the primary cancer provider and hospital. We examined provider and hospital characteristics associated with OAA initiation, adherence, and all-cause mortality after OAA initiation.

RESULTS

We identified 2792 patients who met inclusion criteria. Increased OAA initiation was associated with access to a medical oncologist. Patients were less likely to begin OAA treatment if their primary oncologic provider was a urologist (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.49-0.77). Provider/hospital characteristics were not associated with differences in OAA adherence or mortality. Patients who started sorafenib (odds ratio [OR] 0.50; 95% CI 0.29-0.86), were older (aged >81 OR 0.56; 95% CI 0.34-0.92), and those living in high poverty ZIP codes (OR 0.48; 95% CI 0.29-0.80) were less likely to adhere to OAA treatment. Furthermore, provider characteristics did not account for differences in mortality once an OAA was initiated. Last, only age > 81 years was statistically and clinically associated with a decreased relative risk of seeing a medical oncologist (risk ratio [RR] 0.87; CI 0.82-0.92).

CONCLUSION

Provider/hospital factors, specifically, being seen by a medical oncologist for mRCC diagnosis, are associated with OAA initiation. Older patients were less likely to see a medical oncologist; however, race and/or ethnicity was not associated with differences in seeing a medical oncologist. Patient factors are more critical to OAA adherence and mortality after OAA initiation than provider/hospital factors.

Comparison of out-of-pocket costs and adherence between the two arms of the prospective, randomized abiraterone food effect trial

PURPOSE

Abiraterone acetate, prescribed for metastatic prostate cancer, has enhanced absorption with food. This effect was exploited in a randomized trial which showed noninferiority of PSA decline for 250 mg abiraterone with a low-fat meal (LOW) compared to 1,000 mg abiraterone fasting (STD). Drug was obtained via patient insurance. Patient out-of-pocket costs and adherence were surveyed.

METHODS

Trial participants were randomized to STD or LOW, and surveys of adherence and out-of-pocket costs were administered at baseline and just before coming off study (follow-up).

RESULTS

Out-of-pocket costs were available from 20 of 36 STD and 21 of 36 LOW patients. Median out-of-pocket costs for a month of drug were $0 (LOW) and $5 (STD); mean costs were $43.61 (LOW) and $393.83 (STD). The two groups did not differ significantly (p = 0.421). Maximum out-of-pocket cost was $1,000 (LOW) and $4,000 (STD). Monthly out-of-pocket costs > $500 were found in 1 LOW and 5 STD patients. For adherence, only 11 STD and 19 LOW patients had questionnaires completed at both baseline and follow-up. STD adherence was 98.18% at baseline and 91.69% at follow-up, differing significantly (p = 0.0078). LOW adherence was 96.52% at baseline and 97.86% at follow-up, not differing significantly (p = 0.3511). Adherence did not correlate with demographics. At follow-up, increasing adherence correlated significantly with decreasing dose (p = 0.013; rho =  - 0.458).

CONCLUSIONS

Out-of-pocket costs did not differ significantly in this limited analysis. Adherence was significantly different in STD as the trial progressed, which was not found in LOW.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01543776; registered March 5, 2012.

Development and implementation of a pharmacist-led telehealth medication management program for veterans receiving oral antineoplastic therapies through the MISSION Act

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Veterans prescribed oral antineoplastic therapies (OATs) by community providers outside the Veterans Health Administration (VA) may lack access to comprehensive medication management. To address this, our multidisciplinary team developed and implemented a pharmacist-led telehealth medication management program for veterans prescribed OATs by community providers.

SUMMARY

The program exclusively uses telehealth to connect veterans with a dedicated board-certified clinical oncology pharmacist who provides comprehensive medication management. The program is based on established pharmacy models found in the research literature. We developed a standard operating procedure, communication templates, patient education materials, and a suite of health information technology tools to help streamline pharmacy processes. The Consolidated Framework for Implementation Research was used to design implementation strategies to promote the adoption of the program. In the first year, 64 veterans from 3 VA medical centers were enrolled in the program. The oncology clinical pharmacist performed 342 encounters and 101 interventions. The program saved an estimated $200,724 in medication-related costs. The veterans we surveyed reported high levels of satisfaction with the pharmacy services provided by the program.

CONCLUSION

The delivery of comprehensive medication management through telehealth is feasible from a healthcare system perspective and beneficial for patients. The board-certified oncology clinical pharmacist provided remote pharmacy services to Veterans across three sites in a large and rural service area for the VA. The program realized several benefits, including positive clinical outcomes, high levels of patient satisfaction, and cost savings on medication-related costs.

A Remote Monitoring System to Optimize the Home Management of Oral Anticancer Therapies (ONCO-TreC): Prospective Training-Validation Trial

Background

A platform designed to support the home management of oral anticancer treatments and provide a secure web-based patient–health care professional communication modality, ONCO-TreC, was tested in 3 cancer centers in Italy.

Objective

The overall aims of the trial are to customize the platform; assess the system’s ability to facilitate the shared management of oral anticancer therapies by patients and health professionals; and evaluate system usability and acceptability by patients, caregivers, and health care professionals.

Methods

Patients aged ≥18 years who were candidates for oral anticancer treatment as monotherapy with an Eastern Cooperative Oncology Group performance status score of 0 to 1 and a sufficient level of familiarity with mobile devices were eligible. ONCO-TreC consisted of a mobile app for patients and a web-based dashboard for health care professionals. Adherence to treatment (pill count) and toxicities reported by patients through the app were compared with those reported by physicians in medical records. Usability and acceptability were evaluated using questionnaires.

Results

A total of 40 patients were enrolled, 38 (95%) of whom were evaluable for adherence to treatment. The ability of the system to measure adherence to treatment was high, with a concordance of 97.3% (95% CI 86.1%-99.9%) between the investigator and system pill count. Only 60% (3/5) of grade 3, 54% (13/24) of grade 2, and 19% (7/36) of grade 1 adverse events reported by physicians in the case report forms were also reported in the app directly by patients. In total, 94% (33/35) of patients had ≥1 app launch each week, and the median number of daily accesses per patient was 2. Approximately 71% (27/38) and 68% (26/38) of patients used the app for messages and vital sign entering, respectively, at least once during the study period.

Conclusions

ONCO-TreC is an important tool for measuring and monitoring adherence to oral anticancer drugs. System usability and acceptability were very high, whereas its reliability in registering toxicity could be improved.

Trial Registration

ClinicalTrials.gov NCT02921724; https://www.clinicaltrials.gov/ct2/show/NCT02921724

Barriers and facilitators to taking CDK4/6 inhibitors among patients with metastatic breast cancer: a qualitative study

PURPOSE

Most studies of adherence to treatment for breast cancer have focused on early-stage patients. Findings from these studies may not generalize to patients with metastatic breast cancer (MBC). The objective of this study was to identify barriers and facilitators of adherence to cyclin-dependent kinase 4/6 (CDK4/6) inhibitors among patients with MBC, guided by the social ecologic model (SEM).

METHODS

Patients with MBC (N = 25), their caregivers (N = 9), and oncology providers (N = 13) completed semi-structured qualitative interviews exploring their experiences with CDK4/6 inhibitors. Interviews were audio-recorded, transcribed verbatim, and analyzed by three raters using a combined deductive and inductive approach.

RESULTS

Qualitative analysis identified barriers and facilitators of adherence at each SEM level. Intrapersonal and interpersonal factors were most frequently discussed. Intrapersonal factors included knowledge/beliefs about CDK4/6 inhibitors, side effects, and establishing a routine. Interpersonal factors included effective communication with/coordination by the care team, support from family and friends, and information from other patients with MBC. Although less frequently discussed, policy factors (i.e., cost of CDK4/6 inhibitors) were of great concern to patients, caregivers, and providers.

CONCLUSION

Barriers to adherence to CDK4/6 inhibitors exist at multiple levels. Our results underscore the potential value of a multilevel intervention (e.g., patient education, evidence-based strategies for symptom management, tips for open and assertive communication with providers, information about financial resources/support available, and so on) to support adherence in this population.

Brief relaxation training is associated with long-term endocrine therapy adherence among women with breast cancer: post hoc analysis of a randomized controlled trial

PURPOSE

Despite life-saving potential, many women struggle to adhere to adjuvant endocrine therapy (AET) for their breast cancer (BCa). Prior research has demonstrated that emotional distress is a barrier to AET adherence. We followed women from a trial to test the long-term effects of two 5-week post-surgical group-based stress management interventions, cognitive behavioral therapy (CBT), and relaxation training versus an attention-matched health education control, on AET adherence.

METHODS

We conducted a long-term follow-up (median = 8 years) of women randomized to CBT, relaxation training, or health education after surgery for stage 0-3 BCa. We measured adherence with the Endocrine Therapy Medication Usage Questionnaire (ETMUQ). First, we established factors on the ETMUQ via confirmatory factor analysis. We then used Bayesian structural equation modeling to regress these factors on study arm, controlling for age and treatments received.

RESULTS

Of those who completed long-term follow-up (n = 59, 44.7%), over half (n = 33; 55.9%) reported problems with adherence generally. Women receiving relaxation training (n = 15) had better adherence than those receiving health education (n = 24) on the Forgetfulness/Inconsistency [B(SE) = 0.25(0.14), p = 0.049] and Intentional Nonadherence [B(SE) = 0.31(0.14), p = 0.018] factors of the ETMUQ. Similar results were observed for those receiving relaxation training compared to CBT (n = 20): Forgetfulness/Inconsistency [B(SE) = - 0.47(0.25), p = 0.031]; Intentional Nonadherence [B(SE) = - 0.31(0.15), p = 0.027].

CONCLUSION

Women receiving relaxation training were less likely to (1) forget to take their AET and (2) intentionally miss doses of AET in the long term compared to women receiving health education or CBT. This is evidence for the need of randomized trials that aim to improve adherence by incorporating theoretically based behavioral change techniques.

TRIAL REGISTRATION AND DATES

Trial 2R01-CA-064710 was registered March 26, 2006.

Development and Refinement of a Telehealth Intervention for Symptom Management, Distress, and Adherence to Adjuvant Endocrine Therapy after Breast Cancer

Adjuvant endocrine therapy (AET) prevents recurrence after early stage, hormone sensitive breast cancer; however, adherence to AET is suboptimal, and efficacious interventions are severely lacking. Barriers to adherence are well established; however, interventions, thus, far have failed to produce meaningful changes in adherence and have generally not followed guiding principles of psychosocial intervention development. The purpose of this paper is to describe the iterative development, using the National Institutes of Health Stage Model for Behavioral Intervention Development, of an evidence-based, patient-centered, telehealth intervention to enhance adherence, improve symptom management, and reduce distress for patients taking AET after breast cancer, with a focus on (1) a small open pilot study which informed modifications and refinement of the intervention based on quantitative and qualitative patient feedback about feasibility and acceptability and (2) the underlying theoretical and empirical rationale for each component of the finalized intervention. Clinical implications and directions for future research are discussed.

Patients' and Nurses' Perceptions of the Effectiveness of an Oral Cancer Agent Education Process: A Mixed-Methods Study

BACKGROUND

The increase in the use of oral cancer drugs implies that nurses take on new roles for which education and support to patients and family members become fundamental for promoting therapeutic adherence.

OBJECTIVE

To describe the patients' and nurses' perceptions on the effectiveness of the educational process in oral cancer treatment.

METHODS

A mixed method with a convergent design was used. Data were collected using a questionnaire (structured according to the Multinational Association of Supportive Care in Cancer Teaching Tool for Patients Receiving Oral Agents for Cancer guidelines) and semistructured interviews with patients. Focus groups were used with the nurses. Quantitative data were analyzed with SPSS 22.0 (IBM SPSS 22.0, Armonk, New York). Qualitative data were analyzed using semantic analysis.

RESULTS

One hundred forty-two questionnaires were analyzed. Patients were usually informed by physicians and nurses (81%), alone (33%) or in the presence of an informal carer (29.6%). Language comprehension was high, with a significant difference between those 70 years or older (P = .04) and those younger than 70 years. From the interviews (n = 16), 3 themes were identified: emotions during communication, feeling reassured by the presence of family members and nurses, feeling welcomed and an active part of the educational process. Three themes were identified from the focus groups (n = 4): prerequisites for an effective therapeutic education, nurses' skills, and educational process barriers.

CONCLUSIONS

Overall, patients were satisfied with the education received. They perceived nurses as people who can help them understand the information they have received and manage their treatment and adverse effects.

IMPLICATIONS FOR PRACTICE

This study highlighted some important points for an effective educational process: having a nurse to refer to, technical relationship competences, joint visits with physicians, and being available by phone.

Patients' Perceived Continuity of Care and Adherence to Oral Anticancer Therapy: a Prospective Cohort Mediation Study

BACKGROUND

Oral anticancer therapy (OACT) poses adherence-related challenges to patients while generating a setting in which both primary care physicians (PCPs) and oncologists are involved in the active treatment of cancer. Continuity of care (COC) was shown to be associated with medication adherence. While maintaining COC is a central role of the PCP, how this affects continuity with oncologists, and jointly affects OACT adherence, is yet unknown.

OBJECTIVES

To explore how aspects of COC act together to promote OACT adherence. Specifically, to examine whether better personal continuity with the PCP leads to better personal continuity with the oncologist, which together lead to better cross-boundary continuity between the oncologist and the PCP, jointly leading to good adherence to OACT.

DESIGN AND SETTING

A prospective cohort study conducted in five oncology centers in Israel. A bootstrapping method was used to test the serial mediation model.

PARTICIPANTS

Adult patients (age > 18 years) receiving a first OACT prescription (n = 119) were followed for 120 days.

MAIN MEASURES

The Nijmegen Continuity Questionnaire was used to assess patients' perceived personal and cross-boundary continuity. The medication possession ratio was used to measure adherence.

KEY RESULTS

Better personal continuity with the PCP was associated with better personal continuity with the oncologist (B = 0.35, p < 0.001), which was associated with better cross-boundary continuity (B = 0.33, p < 0.001), which, in turn, was associated with good adherence to OACT (B = 0.46, p = 0.03). Additionally, the indirect effect of personal continuity with the PCP on adherence to OACT through the mediation of personal continuity with the oncologist and cross-boundary continuity was found to be statistically significant (B = 0.053, 95% CI 0.0006-0.17).

CONCLUSIONS

In a system where the PCP is the case manager, cancer patients' perceived personal continuity with the PCP has an essential role for initiating a sequence of care delivery events that positively affect OACT adherence.

Fatigue in patients on oral targeted or chemotherapy for cancer and associations with anxiety, depression, and quality of life

OBJECTIVES

Oral treatment (targeted or chemotherapy) for cancer is being increasingly used. While fatigue is a known side effect of intravenous chemotherapy, the rate of fatigue and the impact of fatigue on other patient-reported outcomes are not well described.

METHOD

At Massachusetts General Hospital Cancer Center, 180 adult patients prescribed oral targeted or chemotherapy for various malignancies enrolled in a randomized controlled trial of adherence and symptom management. Patients completed baseline self-reported measures of fatigue (Brief Fatigue Inventory; BFI), anxiety and depressive symptoms (Hospital Anxiety and Depression Scale; HADS), and quality of life, including subscales for physical, social, emotional, and functional well-being ([QOL] Functional Assessment of Cancer Therapy - General; FACT-G). We examined clinically relevant fatigue using a validated cut-off score for moderate-severe fatigue (BFI global fatigue ≥4) and tested the associations with anxiety symptoms, depressive symptoms, and QOL with independent samples t-tests.

RESULTS

At baseline, 45 of 180 participants (25.0%) reported moderate-severe fatigue. Fatigued patients experienced more anxiety symptoms (mean diff. 3.73, P < 0.001), more depressive symptoms (mean diff. 4.14, P < 0.001), and worse QOL on the total FACT-G score (mean diff. -19.58, P < 0.001) and all subscales of the FACT-G compared to patients without moderate-severe fatigue.

SIGNIFICANCE OF RESULTS

One in four patients on oral treatment for cancer experienced clinically relevant fatigue that is associated with greater anxiety and depressive symptoms and worse QOL.

Treatment Experiences with CDK4&6 Inhibitors Among Women with Metastatic Breast Cancer: A Qualitative Study

PURPOSE

To describe patients' perspectives on the use of and potential challenges and barriers with adherence/persistence to cyclin-dependent kinase 4 and 6 inhibitors (CDK4&6i's) to treat metastatic breast cancer (MBC).

METHODS

This qualitative study consisted of 60-minute semi-structured telephone interviews with patients with MBC in the US who were either current or recent CDK4&6i users, identified from administrative claims of survey-eligible commercial and Medicare Advantage patients in the HealthCore Integrated Research Database between November 1, 2018 and November 1, 2019. Patients were recruited by email and/or mailed letter. The 60-minute telephone interviews were conducted by a trained facilitator using a study-developed interview discussion guide that included topics impacting treatment choice and adherence/persistence. Interviews were audio-recorded, transcribed, and thematically analyzed.

RESULTS

All 462 eligible patients were sent a recruitment email and/or letter to which 36 patients responded, consented to participate, and met study inclusion criteria; 25 patients scheduled interviews, and 24 completed them. Study participants were predominately white, non-Hispanic (96%) with a mean age of 59.5 years. Participants reported a largely positive experience and mentioned very few adherence/persistence issues. They further reported appreciating the ease and convenience of oral oncolytics, coped with side effects, had strong medical and social support, and experienced few cost issues.

CONCLUSION

The few adherence/persistence issues reported by participants contrasts with other findings of suboptimal oral oncolytic use. Interview themes indicated several factors that likely contributed to the lack of adherence/persistence issues: trusted relationship with oncologist, belief in importance of medication, positive medication views, strong medical and social support, and minimal personal drug cost. Future research should focus on whether and how much these factors impact adherence/persistence in more diverse populations. If adherence/persistence issues are identified in these populations, then it would be appropriate to study the development of interventions that target factors associated with better adherence/persistence.

Factors affecting medication beliefs among patients newly prescribed oral oncolytic agents

BACKGROUND

Prescribing oral oncolytic agents (OAs) for advanced cancers is increasing.

AIMS

To explore changes in medication beliefs and the effects of symptom severity, cognitive effectiveness and depressive symptoms on medication beliefs over 12 weeks.

METHODS

Secondary analysis of a randomized controlled trial, testing an intervention to promote symptom management and adherence [N = 230]. Questionnaires evaluated medication beliefs, symptom severity, depressive symptoms, and cognitive effectiveness. Linear mixed effects models were used for analyses.

RESULTS

OA Necessity beliefs increased over time (mean difference 0.0112, SE = 0.055, p 0.04). Concern beliefs did not change and were lower for advanced cancers (-0.193, SE = 0.067, p < 0.01).Depressive symptoms were related to decreased Necessity beliefs (-0.012, SE = 0.005, p = 0.02), but not Concern beliefs. Medication beliefs were not associated with symptom severity or cognitive effectiveness.

CONCLUSION

Patients with advanced cancer hold different medication beliefs compared to earlier staged cancers, lending insight into potential outcomes beyond adherence.

The Patient's Voice: Adherence, Symptoms, and Distress Related to Adjuvant Endocrine Therapy After Breast Cancer

BACKGROUND

While adjuvant endocrine therapy (AET) for early-stage, hormone-sensitive breast cancer confers a 40-50% reduction in recurrence risk, adherence to AET is suboptimal, and no efficacious interventions exist to improve adherence. A qualitative study was conducted to understand patient experiences on AET, motivators and barriers to adherence, side effects, and distress, with the goal of developing a patient-centered, evidence-based intervention.

METHOD

From November 2017 to November 2018, female patients with early-stage, hormone receptor-positive breast cancer taking AET were recruited. Patients with low and high medication adherence of varying ages, levels of distress, and years taking AET were purposefully enrolled. In-depth semi-structured interviews were conducted, audio recorded, and transcribed. Study staff created a thematic framework, and three independent researchers coded interviews using NVivo 11, achieving high inter-coder agreement (Kappa = .96).

RESULTS

Thirty interviews were conducted with patients who were, on average, 55.13 years old (SD = 12.37) and had been taking AET for a mean of 1.76 years (SD = 0.75). The sample was stratified by adherence level (low = 20; high = 10). Recurrent themes related to adherence included a commitment to AET to prevent recurrence despite distressing side effects, lack of strategies to cope with symptoms and distress, and desire for emotional support from others taking AET. Patients were highly accepting of a proposed psychosocial intervention to manage AET.

CONCLUSION

Patients are committed to taking AET to prevent breast cancer recurrence, but need and desire psychosocial support and skills training. Themes from this study are modifiable targets for a psychosocial, evidence-based intervention to promote adherence, coping with side effects, and distress management.

Enabling sustained communication with patients for safe and effective management of oral chemotherapy: A longitudinal ethnography

AIMS

To examine how patients received, understood, and acted on healthcare professional communication about their oral chemotherapeutic regimen throughout their treatment.

DESIGN

A longitudinal ethnographic study.

METHODS

Over 60 hr of observational data were recorded, in the form of field notes and audio-recordings from interactions among nine oncology doctors, six oncology nurses, eight patients, and 11 family members over a period of 6 months in outpatient departments in one hospital in Northern Ireland. Sixteen semi-structured interviews with patients and three focus groups with healthcare professionals were also carried out. This study took place from October 2013-June 2016. Data were thematically analysed.

RESULTS

Three themes where identified from the data. These were initiating concordance through first communication about oral chemotherapy; which focused on initial communication during oncology consultations about oral chemotherapy, sustained communication of managing chemotherapy side effects; which was about how communication processes supported timely and effective side effect management and un-sustained communication of oral chemotherapy medication-taking practice; when patients and healthcare professionals failed to communicate effectively about chemotherapy medication-taking.

CONCLUSION

The two most important factors in ensuring the optimal management of oral chemotherapeutic medicines are early recognition and appropriate response to side effects and the maintenance of safe and effective medication administration. This study found that oncology doctors and nurses engaged in sustained communication about the side effects of chemotherapy but did not focus their communication on safe administration after the first consultation.

IMPACT

Based on this evidence, we recommend that healthcare professionals who provide oral chemotherapy for home administration should review their processes and procedures. Healthcare professionals need to ensure that they embed frequent communication for the duration of treatment between themselves and patients, including open discussion and advice, about side effects and medication administration.

Satisfaction With an Interactive Voice Response System and Symptom Management Toolkit Intervention to Improve Adherence in Patients Prescribed an Oral Anticancer Agent

OBJECTIVES

To describe patient satisfaction with an interactive voice response (IVR) system to assess adherence and symptom management in patients newly prescribed an oral anticancer agent (OAA).

SAMPLE & SETTING

Patients prescribed a new OAA were recruited from six comprehensive cancer centers in the United States.

METHODS & VARIABLES

Cross-sectional analysis and descriptive statistics were used to summarize patient demographics and satisfaction with the IVR system and symptom management toolkit.

RESULTS

Participants had a mean age of 61.82 years, and gastrointestinal cancer was most prevalent. Participants were either "very" or "highly" satisfied with the IVR weekly calling system to assess symptoms, the IVR system daily OAA adherence reminders, and the symptom management toolkit.

IMPLICATIONS FOR NURSING

Nurses often triage patient-reported issues with OAAs. Nurses are well positioned to lead IVR system symptom management interventions and to be actively involved in the development, implementation, and dissemination of IVR technologies through research and practice.

Relationship between Health Literacy and Medication Adherence of Turkish Cancer Patients Receiving Oral Chemotherapy

Objective:

The aim of this study was to explore the relationship between health literacy and self-report medication adherence of Turkish cancer patients receiving oral chemotherapy.

Methods:

The present research was a descriptive and cross-sectional study and conducted with 100 voluntary cancer patients who were admitted to the medical oncology outpatient clinic and received oral chemotherapy. The data were collected through a questionnaire form consisting of the Oral Chemotherapy Adherence Scale and the Turkish Health Literacy Scale (TSOY-32). The collected data were analyzed using descriptive statistics, one-way ANOVA, and Pearson's correlation coefficient.

Results:

The results revealed that 57% of the patients were female, 35% were primary school graduates, 51% were breast cancer, and 36% took capecitabine. The mean index scores of the participants on both scales were calculated as 12.39 ± 1.51 and 73.25 ± 6.18, respectively. Overall, a positive and strong correlation was found between oral chemotherapy adherence and health literacy of the participants (r = 0.707, P = 0.000).

Conclusions:

Medication adherence and health literacy levels among the cancer patients in Turkey are alarming so that patient-centered interventions and training are required to overcome the barriers to medication adherence.

Assessment of patients' understanding of and adherence to oral anticancer medication (OAM): Results of a cross-sectional institutional pilot study

BACKGROUND

Although oral anticancer medications (OAM) provide opportunity for treatment at home, challenges include prescription filling, monitoring side effects, safe handling, and adherence. We assessed understanding of and adherence to OAM in vulnerable patients.

METHODS

This 2018 pilot study defined vulnerable patients based on Chinese language, older age (≥65 years), and subsidized insurance. All participants had a cancer diagnosis and were taking an OAM filled through the hospital's specialty pharmacy. Participants reported on OAM taking (days per week, times per day, special instructions) and handling (handling, storage, disposal). The specialty pharmacist classified patient-reported responses about OAM taking and handling as adequate or inadequate. OAM regimens were classified by complexity.

RESULTS

Of 61 eligible patients, 55 participated. Mean age was 68 years (standard deviation [SD] = 12) and 53% were female. Patient subgroups were: 27% Chinese, 64% ≥65 years, and 9% subsidized insurance. Forty-nine percent were on frontline therapy and median time on OAM was 1 year (Quartile 1 = 0.4, Quartile 3 = 1.7). Adequacy of OAM taking (30%) and handling (15%) were low; 15% had adequacy in both. Adequacy of OAM taking and handling did not vary by patient subgroup or regimen complexity. Mean patient-reported adherence was high (5.4, SD = 1, possible range 1-6) and did not vary by adequacy of OAM taking or handling.

CONCLUSIONS

Understanding of OAM taking and handling in this group of vulnerable patients was low and did not align with patient-reported adherence. Future interventions should ensure that patients understand how to safely take and handle OAM, thereby optimizing their therapeutic potential.

The Critical Role of the Oncology Nurse as a Partner in the Management of Patients With Advanced Kidney Cancer: Toxicity Management, Symptom Control, and Palliative Care

The treatment of advanced renal cell carcinoma has changed dramatically since 2005 with the approval of 12 regimens including oral, intravenous, and combination strategies. These approvals have changed the treatment paradigm for these patients and developed new challenges and a critical role for oncology nurses to ensure that the treatment plan and adverse events are managed effectively. The majority of these regimens include an oral anticancer drug, which requires patients and their caregivers to understand the medication, the potential adverse events, the importance of medicine adherence, and the importance of early and ongoing education with the oncology team to maximize clinical outcomes. The evolution of the role of the nurse in meeting this need and its critical contribution to the comprehensive care of the kidney cancer patient will be reviewed.

Patient Experiences With Oral Chemotherapy: Adherence, Symptoms, and Quality of Life

BACKGROUND

Oral therapies are increasingly common in oncology care. However, data are lacking regarding the physical and psychologic symptoms patients experience, or how these factors relate to medication adherence and quality of life (QoL).

MATERIALS AND METHODS

From December 2014 through August 2016, a total of 181 adult patients who were prescribed oral targeted therapy or chemotherapy enrolled in a randomized study of adherence and symptom management at Massachusetts General Hospital Cancer Center. Patients completed baseline assessments of adherence with electronic pill cap, QoL, symptom severity, mood, social support, fatigue, and satisfaction with clinicians and treatment. Relationships among these factors were examined using Pearson product-moment correlations and multivariable linear regression.

RESULTS

At baseline, the mean electronic pill cap adherence rate showed that patients took 85.57% of their oral therapy. The most commonly reported cancer-related symptoms were fatigue (88.60%), drowsiness (76.50%), disturbed sleep (68.20%), memory problems (63.10%), and emotional distress (60.80%). Patients who reported greater cancer-related symptom severity had lower adherence (r= -0.20). In a multivariable regression, greater depressive and anxiety symptoms, worse fatigue, less social support, lower satisfaction with clinicians and treatment, and higher symptom burden were associated with worse QoL (F[10, 146]=50.53; adjusted R2=0.77). Anxiety symptoms were most strongly associated with clinically meaningful decrements in QoL (β= -7.10; SE=0.22).

CONCLUSIONS

Patients prescribed oral therapies struggle with adherence, and cancer-related symptom burden is high and related to worse adherence and QoL. Given perceptions that oral therapies are less impairing, these data underscore the strong need to address adherence issues, symptom burden, and QoL for these patients.

Real-World Clinical and Economic Outcomes Associated with Palbociclib for HR-Positive/HER2 Negative Metastatic Breast Cancer: A Commentary

Despite the achieved advancement in pharmacological cancer treatments, the majority of postmenopausal women with hormone receptor-positive metastatic breast cancer (mBC) will experience disease progression. Research into alternative therapies with improved efficacy and reduced side effects has led to the development of a new class of oral anticancer medications, the cyclin-dependent kinase (CDK) 4/6 inhibitors, which include palbociclib, ribociclib, and abemaciclib. Nonetheless, there is growing evidence that the effectiveness of oral anticancer medications is sub-optimal, being influenced by low adherence, sociodemographic factors, and adverse effect profiles. In addition, there is a disconnect between the high price tags of CDK 4/6 inhibitors and their observed effectiveness, raising questions about their value. Currently, the existing knowledge base on the effectiveness and cost-effectiveness of newer oral anticancer medications in understudied populations with possible health disparities is scant. This commentary discusses what is known about palbociclib's clinical effectiveness, safety, and adherence and suggests the need for further studies of real-world effectiveness and cost-effectiveness to help establish the value of newer oncologic drugs, such as palbociclib. DISCLOSURES: No funding supported the writing of this article. The authors have nothing to disclose.

Challenges of Caregivers of Cancer Patients who are on Oral Oncolytic Therapy

OBJECTIVE

To describe the major challenges faced by caregivers of patients receiving oral oncolytic therapy (OOT).

DATA SOURCES

Published literature, national clinical practice guidelines, standards of care.

CONCLUSION

Caregivers of patients receiving OOT have unmet needs. Caregivers need standardized OOT education and coping support to improve patient outcomes through enhanced drug safety practices, better management of complex treatment regimens and adherence, patient symptoms, treatment side effects, care decision-making, and financial assistance for costly OOT.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are well-positioned to take leadership roles in facilitating optimal utilization of multidisciplinary health care resources necessary to support caregivers and improve outcomes in patients receiving OOT.

Conceptualisation of medication beliefs among patients with advanced cancer receiving oral oncolytic agents using a theory derivation approach

OBJECTIVE

This paper describes a derived model that provides a conceptual framework for understanding medication beliefs among patients with advanced cancer receiving oral oncolytic agents.

METHODS

Theory derivation was used to (a) examine the phenomenon of medication beliefs in cross-disciplinary research; (b) select a parent theory for derivation; (c) identify parent theory concepts and/or structure to use in derivation; and (d) redefine parent theory concepts and structure to create a derived model.

RESULTS

Medication beliefs are shaped by previous experiences, including cognitive and emotional factors, past health and illness encounters, and medication-taking behaviours. Medication beliefs are defined within a larger mental model of illness representation for which medication was prescribed. Individuals independently hold both positive and negative medication beliefs at the same time. This distinction is critical to understanding how dichotomous components of medication beliefs change over time as they are influenced by varying treatment-related factors.

CONCLUSION

This paper contributes to conceptual knowledge regarding the phenomenon of medication beliefs and their impact on health behaviour. Findings can support oncology interventions to improve patient outcomes including medication adherence.

Food Effect Study Design With Oral Drugs: Lessons Learned From Recently Approved Drugs in Oncology

Evaluation of the effect of food on the pharmacokinetics of oral oncology drugs is critical to drug development, as food can mitigate or exacerbate toxicities and alter systemic exposure. Our aim is to expand on current US Food and Drug Administration (FDA) guidance and provide data-driven food-effect study design recommendations specific to the oncology therapeutic area. Data for recently approved small-molecule oncology drugs was extracted from the clinical pharmacology review in the sponsor's FDA submission package. Information on subject selection, meal types, timing of the study relative to the pivotal trial, and study outcomes was analyzed. The number of subjects enrolled ranged from 12 to 60, and the majority of studies (19 of 29) were conducted in healthy volunteers. Using AstraZeneca cost data, healthy volunteer studies were estimated to cost 10-fold less than cancer patient studies. Nine of 29 (31%) studies included meals with multiple levels of fat content. Analysis of a subset of 16 drugs revealed that final results for the food-effect study were available before the start of the pivotal trial for only 2 drugs. Conducting small food-effect studies powered to estimate effect, rather than confirm no effect, with only a standardized high-fat meal according to FDA guidance may eliminate unnecessary studies, reduce cost, and improve efficiency in oncology drug development. Starting food-effect studies as early as possible is key to inform dosing in pivotal trials.

Reliability and validity of the Hebrew version of the Nijmegen Continuity Questionnaire for measuring patients' perceived continuity of care in oral anticancer therapy

To assess the validity and reliability of the Nijmegen Continuity Questionnaire in Hebrew (NCQ-H) for measuring patients' perceived continuity of care in the multiprovider setting of oral anticancer therapy (OACT). Following forward-backward translation of the original instrument into Hebrew, the NCQ-H was administered to adult cancer patients in five oncology centres in Israel, 2-3 months after initiation of OACT (either targeted, hormonal or chemotherapy). Confirmatory factor analysis and Cronbach's alpha were used to assess the validity and reliability of the NCQ-H respectively. A total of 135 patients completed the questionnaire. The postanalysis models for measuring "personal continuity with care provider" (eight items for each provider: the oncology specialist and the primary care physician), and "team/cross-boundary continuity" (four items for each setting: within the oncology team, and between the oncology specialist and the primary care physician) showed good fit for the observed data (root-mean-square error of approximation (RMSEA) = 0.02; RMSEA = 0.015; for each model respectively). Cronbach's alpha was 0.79-0.95 for all subscales. Conclusions. This study provides preliminary evidence for the reliability and validity of the NCQ-H in assessing cancer patients' experience with continuity of care and for its usability in the context of OACT.

Initiatives to Improve Safety of Oral Anticancer Agents Delivered by Community Pharmacists

With the recent growth in oral anticancer agents (OAA), pharmacists working in the community have recognised the urgent need to develop safe and effective systems to administer and manage these drugs. For community pharmacists, education regarding OAA can be challenging, with a number of international surveys showing that many believe they have received inadequate education regarding OAA and feel uncomfortable educating their patients about these drugs. Patients prescribed OAA have also reported feeling unsupported, and this lack of support could lead to both under and overadherence to OAA, with an impact on efficacy and adverse events. Poor adherence can result in disease progression, treatment complications, reduced functional ability, and premature death. The current review, written by international authors from Europe, North America, and East Asia, set out to identify worldwide initiatives to support community pharmacists working with patients taking OAA. The authors identified one project, the Oral Anticancer Therapy – Safe and Effective initiative, that was developed in Germany in 2011 to aid community pharmacists in their interactions with patients prescribed OAA. The initiative, which has been rolled out across Germany, includes the creation of training programme content that can be delivered at regional meetings and monographs, which can be downloaded to educate both community pharmacists and their patients about individual OAA. As part of the Empowering Patients to Improve Health Care for Oral Chemotherapy (EPIC) programme, the European Society of Oncology Pharmacy (ESOP) has extended the German initiative to Slovenia and Estonia, with plans to launch the scheme in additional European countries in the autumn of 2018. Ultimately, it is hoped that better support of cancer patients in the community will improve adherence to OAA.

Oral Agents: Challenges With Self-Administered Medication Adherence in Clinical Trials

BACKGROUND

In oral agent clinical trials, patients may not be adherent to self-administration of study medication; this nonadherence can affect validity and reliability. Many factors contribute to nonadherence to protocol requirements, and managing patients with fidelity issues is the responsibility of the research team.

OBJECTIVES

The aim is to identify which group (patients, physicians/principal investigators, nurses, or other personnel) research nurses report as most responsible for protocol nonadherence and to characterize the most observed causes and contributors to nonadherence within each group.

METHODS

Sixty-seven protocol nurses completed a nine-question survey developed from pilot data. Descriptive statistics and ordinal regressions addressed the objectives of the study.

FINDINGS

More than half of the nurses observed clinical trial nonadherence in their practices. Nurses identified challenges regarding physician, patient, and nurse factors. The most frequently identified causes included patients' forgetfulness, refusal to undergo study procedures, inadequate family or caregiver support to complete study activities, ineffective communication, and collaboration within the research team.

How are health literacy principles incorporated into breast cancer chemotherapy education? A review of the literature

BACKGROUND

Chemotherapy is commonly used in combination with other treatments for breast cancer. However, low adherence to chemotherapy is a growing concern, particularly among breast cancer patients. Side effects such as nausea and vomiting, fatigue, and arthralgia can contribute to reduced adherence. Other factors such as provider communication and limited insurance coverage can affect adherence. Studies have shown that as much as 28% of patients with breast cancer did not continue with their prescribed dose of chemotherapy. Research suggests that chemotherapy education materials can be critical to addressing problems with non-adherence, and may include written materials, verbal instruction, and multimedia programs. Despite this wide variety, the effectiveness and benefit of chemotherapy education hinges on the patients' health literacy. Breast cancer patients with low health literacy may be unclear about chemotherapy or face difficulty adhering to treatment if they do not understand the information provided to them. Thus, this scoping review summarizes the existing research on how health literacy principles are incorporated into breast cancer chemotherapy education materials.

METHODS

Using a combination of keywords (e.g. chemotherapy, education) and Medical subject headings (MeSH) terms (e.g., drug therapy, antineoplastic agents), we searched five databases (1977-2017): CINAHL, PubMed, PsycINFO, Cochrane Library, and Web of Science.

RESULTS

Eight of 4,624 articles met the inclusion criteria. Five articles incorporated health literacy principles (e.g., plain language, maintaining an active voice, using white space) into the development of written materials. Few articles used a theoretical framework to guide education material development (n = 3). Of the three articles that described pilot-testing of educational materials, two used post-tests only and one used a pre/post-test design.

CONCLUSIONS

Findings indicated that limited research exists regarding the use of health literacy principles in chemotherapy education materials. Much of the development of chemotherapy education is not grounded in theory and the application of health literacy principles is limited. Implementing health literacy principles may improve overall comprehension of education thereby increasing adherence.

The Effect of Structured Education to Patients Receiving Oral Agents for Cancer Treatment on Medication Adherence and Self-efficacy

OBJECTIVE

This study was conducted to examine the effect of structured education on medication adherence and self-efficacy through the use of the MASCC Oral Agent Teaching Tool (MOATT) for patients receiving oral agents for cancer treatment.

METHODS

This quasi-experimental study has been conducted at two hospitals; 41 patients were included in the study. Data were obtained using a questionnaire, medication adherence self-efficacy scale (MASES), memorial symptom assessment scale, and a follow-up form (diary). Patients were educated through the use of the MOATT at a scheduled time; drug-specific information was provided along with a treatment scheme and follow-up diary. Phone interviews were completed 1 and 2 weeks after the educational session. At the next treatment cycle, the patients completed the same questionnaires.

RESULTS

Majority of the patients were receiving capecitabine (90.2%; n = 37) as an oral agent for breast (51.2%; n = 21) and stomach cancer (24.6%; n = 10) treatment. About 90.2% of patients (n = 37) stated that they did not forget to take their medication and experienced medication-related side effects (78%; n = 32). The total score of MASES was increased after the education (66.39 vs. 71.04, P < 0.05).

CONCLUSIONS

It was shown that individual education with the MOATT and follow-up for patients receiving oral agents for cancer treatment increased patient medication adherence self-efficacy.

The oral education clinic: A pharmacist- and nurse-led clinic to support patients starting oral systemic anti-cancer treatments

With the increased number of oral systemic anti-cancer treatments available, patients need to be managed safely and effectively in line with national guidance. In response to guidance in 2011, Oxford University Hospitals NHS Foundation Trust implemented an 'Oral Education Clinic'. This nurse- and pharmacist-led clinic facilitates the delivery of patient education, highlighting key safety aspects of drug administration and management, and ensures follow-up is arranged as per protocol. Patients have found this service to be effective and it has had a positive impact on the running of outpatient units, the volume of triage calls, emergency admissions and workload associated with consenting patients to an oral systemic anti-cancer treatments.

Treatment Satisfaction and Adherence to Oral Chemotherapy in Patients With Cancer

Purpose:

Although patients with cancer overwhelming prefer oral to intravenous chemotherapy, little is known about adherence to oral agents. We aimed to identify the rates and correlates of adherence in patients with diverse malignancies.

Materials and Methods:

Ninety patients with chronic myeloid leukemia or metastatic renal cell carcinoma, non–small-cell lung cancer, or breast cancer enrolled in this prospective, single-group, observational study of medication-taking behaviors. Adherence was measured via self-report and with an electronic pill cap (Medication Event Monitoring System cap). Patients completed surveys regarding symptom distress, mood, quality of life, cancer-specific distress, and satisfaction with clinician communication and treatment at baseline and 12-week follow-up.

Results:

As measured by the Medication Event Monitoring System, patients took, on average, 89.3% of their prescribed oral chemotherapy over the 12 weeks. One quarter of the sample was less than 90% adherent, and women were more adherent than men (mean difference, 9.59%; SE difference, 4.50%; 95% CI, −18.65 to −0.52; P = .039). Improvements in patient symptom distress (B = −0.79; 95% CI, −1.41 to −0.18), depressive symptoms (B = –1.57; 95% CI, –2.86 to –0.29), quality of life (B = 0.38; 95% CI ,0.07 to 0.68), satisfaction with clinician communication and treatment (B = 0.73; 95% CI, 0.49 to 0.98), and perceived burden to others (B = −1.28; 95% CI, −2.20 to −0.37) were associated with better adherence. In a multivariate model, improved treatment satisfaction (B = 0.71; 95% CI, 0.48 to 0.94) and reduced perceived burden (B = −0.92; 95% CI, −1.76 to −0.09) were the strongest indicators of better adherence.

Conclusion:

Women and patients who reported increased treatment satisfaction and reduced burden to others were more adherent to oral chemotherapy. Interventions that help patients improve communication with clinicians and reduce burden may optimize oral chemotherapy adherence.

Self-Administered Premedication: Improving Taxane Chemotherapy Treatment

BACKGROUND

Patients receiving taxane therapy are at risk for hypersensitivity reactions without appropriate premedication management. Patients must understand the importance of taking premedications as prescribed to prevent reactions.
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OBJECTIVES

The objectives of this study were to implement and evaluate a multidisciplinary practice protocol comprised of standardized nursing documentation of premedication regimens, teaching, and patient adherence to at-home premedication in an electronic health record (EHR).
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METHODS

A new process was developed to provide standardized prescriptions, a personalized instruction sheet for patients and families, and a standardized approach to document adherence and teaching in the EHR. Pre- and post-EHR audits were used twice to evaluate the practice changes.
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FINDINGS

The findings of the first audit suggested improvement in all practice changes. After the first audit, reinforcement of the changes occurred within the group and with one-on-one meetings. The goal of 90% adherence was met at the second audit.