Putting evidence into practice: evidence-based interventions for oral agents for cancer

Patient Adherence to Oral Anticancer Agents: A Mapping Review of Supportive Interventions

The development and use of oral anticancer agents (OAAs) continue to grow, and supporting individuals on OAAs is now a priority as they find themselves taking these drugs at home with little professional guidance. This mapping review provides an overview of the current evidence concerning OAA-supportive adherence interventions, identifying potential gaps, and making recommendations to guide future work. Four large databases and the grey literature were searched for publications from 2010 to 2022. Quantitative, qualitative, mixed-method, theses/dissertations, reports, and abstracts were included, whereas protocols and reviews were excluded. Duplicates were removed, and the remaining publications were screened by title and abstract. Full-text publications were assessed and those meeting the inclusion criteria were retained. Data extracted included the year of publication, theoretical underpinnings, study design, targeted patients, sample size, intervention type, and primary outcome(s). 3175 publications were screened, with 435 fully read. Of these, 314 were excluded with 120 retained. Of the 120 publications, 39.2% (n = 47) were observational studies, 38.3% (n = 46) were quasi-experimental, and 16.7% (n = 20) were experimental. Only 17.5% (n = 21) were theory-based. Despite the known efficacy of multi-modal interventions, 63.7% (n = 76) contained one or two modalities, 33.3% (n = 40) included 3, and 3.3% (n = 4) contained four types of modalities. Medication adherence was measured primarily through self-report (n = 31) or chart review/pharmacy refills (n = 28). Given the importance of patient tailored interventions, future work should test whether having four intervention modalities (behavioral, educational, medical, and technological) guided by theory can optimize OAA-related outcomes.

Investigation of intervention solutions to enhance adherence to oral anti-cancer medicines in adults: an overview of reviews (Preprint)

Background

Adherence to anticancer medicines is critical for the success of cancer treatments; however, nonadherence remains challenging, and there is limited evidence of interventions to improve adherence to medicines in patients with cancer.

Objective

This overview of reviews aimed to identify and summarize available reviews of interventions to improve adherence to oral anticancer medicines in adult cancer survivors.

Methods

A comprehensive search of 7 electronic databases was conducted by 2 reviewers who independently conducted the study selection, quality assessment using the A Measurement Tool to Assess Systematic Reviews 2, and data extraction. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 checklist was adapted to report the results.

Results

A total of 29 reviews were included in the narrative synthesis. The overall quality of the systematic reviews was low. The 4 main strategies to promote adherence were focused on education, reminders, behavior and monitoring, and multicomponent approaches. Digital technology–based interventions were reported in most reviews (27/29, 93%). A few interventions applied theories (10/29, 34%), design frameworks (2/29, 7%), or engaged stakeholders (1/29, 3%) in the development processes. The effectiveness of interventions was inconsistent between and within reviews. However, interventions using multiple strategies to promote adherence were more likely to be effective than single-strategy interventions (12/29, 41% reviews). Unidirectional communication (7/29, 24% reviews) and technology alone (11/29, 38% reviews) were not sufficient to demonstrate improvement in adherence outcomes. Nurses and pharmacists played a critical role in promoting patient adherence to oral cancer therapies, especially with the support of digital technologies (7/29, 24% reviews).

Conclusions

Multicomponent interventions are potentially effective in promoting patient adherence to oral anticancer medicines. The seamless integration of digital solutions with direct clinical contacts is likely to be effective in promoting adherence. Future research for developing comprehensive digital adherence interventions should be evidence-based, theory-based, and rigorously evaluated.

Medication Adherence Barriers: Development and Retrospective Pilot Test of an Evidence-Based Screening Instrument

BACKGROUND

Adherence to a prescribed medication regimen is often critical to successful comorbid disease management and decreased risk for adverse outcomes. The barriers that result in nonadherence are often multilayered and complex, making them difficult to address in an outpatient clinic setting.

OBJECTIVES

The primary objective of this project was to develop an evidence-based observational screening instrument and determine its potential to identify barriers to medication adherence.

METHODS

Medication adherence barriers were divided into five categories. These barriers provided the foundation for the screening instrument. To pilot test the instrument, a retrospective, quasiexperimental, observational comparison study was designed. The pilot study evaluated retrospective data of the Oncology Care Model (OCM).

FINDINGS

Of 250 OCM patient records, 184 (74%) revealed potential medication adherence barriers for patients with uncontrolled comorbid illness or events.

The effect of a mobile application on treatment adherence and symptom management in patients using oral anticancer agents: A randomized controlled trial

PURPOSE

The use of mobile health technologies in the management of oral anticancer agents (OAA) can be beneficial in terms of treatment adherence and symptom management. This study was conducted to investigate the effect of a mobile application developed for patients using OAA on treatment adherence and symptom management.

METHOD

The study was conducted using a randomized controlled trial design, and it was carried out on 77 patients. Data were collected from the Oral Chemotherapy Adherence Scale (OCAS), and the Memorial Symptom Assessment Scale (MSAS). Data were collected at the beginning of the research, and face-to-face interviews were conducted after one, three, and six months. Patients in the intervention group were followed up for six months using the mobile application.

RESULTS

It was found that there was no difference between the intervention and control groups in the baseline OCAS mean scores (p > 0.05), and the mean score of the intervention group increased over the first, third- and sixth-month measurements (p < 0.05). It was found that there was no difference between the intervention and control groups in the MSAS mean scores (p > .05), and there was a decrease in the mean MSAS score of the intervention group between the third- and sixth-month follow-up (p < .05).

CONCLUSION

The present study results showed that the mobile application is effective in managing symptoms and increasing treatment adherence. A well-designed mobile health application that increases treatment adherence, decreases symptom severity, and supports patients' self-management could be beneficial for patients using OAA. CLINICALTRIALS.

GOV IDENTIFIER

NCT04626830.

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.

Design Considerations in the Development of App-Based Oral Anticancer Medication Management Systems: a Qualitative Evaluation of Pharmacists' and Patients' Perspectives

Smartphone apps can potentially help in enhancing oral anticancer medication (OAM) adherence. Patient adoption and efficacy of such apps depends on inclusion of user-centred and evidence-based features. The objective of this study was to identify important design considerations from the perspectives of patients taking OAMs, caregivers and oncology pharmacists. The study employed a qualitative study design. Data were collected using in-depth interviews with patients (n = 15), caregivers (n = 3) and pharmacists (n = 16). Interviews were audio-recorded, transcribed verbatim and inductive thematic analysis approach was used in data analysis. Monitoring medication-related problems, medication information, replacement of or integration with current systems and accessibility of app content on devices other than smartphones were the key themes identified in the analysis. Flexible input methods for monitored data, glanceability of monitored reports/information, near real-time adherence enhancing and symptom management interventions and customisable reminder options were design considerations identified under the monitoring medication-related problems theme. Participants suggested the provision of focused and easily understandable medication information with a potential for personalisation. Integration of app-based adherence systems with patients' electronic medical records with added mechanisms for alerts in the dispensing system was also suggested as a key design requirement to improve quality of patient care and facilitate adoption by clinicians. Finally, smartphones were the most favoured platform with optional accessibility of app content on other devices. In conclusion, important design considerations were identified through a user-centred design approach. The findings will help developers and clinicians in the design of new app-based systems and evaluation of existing ones.

Patients' Perception of App-based Educational and Behavioural Interventions for Enhancing Oral Anticancer Medication Adherence

Well-designed smartphone apps can potentially help in enhancing adherence to oral anticancer medications (OAMs). The objective of this study was to evaluate patients' perception on inclusion of various adherence-enhancing strategies as features of an app and their interest in using such app. A cross-sectional survey was conducted at the National Cancer Centre Singapore. A structured self-administered questionnaire was used to collect data from patients taking OAMs. Final analysis was based on 409 surveys and most of the respondents were female (291, 71.1%), Chinese (332, 81.2%), married (296, 72.4%) and breast cancer patients (211, 51.6%). Close to two-thirds of respondents rated medication information (65.0%), disease information (60.2%) and side effect self-management (60.2%) features as having the highest level of importance in an adherence app. Three hundred thirty-two (81.2%) of the respondents owned a smartphone, among which 92 (27.7%) reported using health-related apps. From respondents with smartphones, 219 (66.0%) were interested in using an app for OAM adherence. Age 65 and older compared to 21-54 years old (adjusted OR = 0.34; 95% CI = 0.15-0.76) and current use of a health app (adjusted OR = 1.91; 95% CI = 1.07-3.41) were significant predictors of interest to adopt an adherence app. In conclusion, patients value the inclusion of educational and behavioural interventions in adherence apps. Developers of adherence apps should consider including tools for side effect self-management and provision of information to educate patients on their medications and disease condition.

Preventing Treatment-Related Functional Decline: Strategies to Maximize Resilience

The majority of patients with cancer are older adults. A comprehensive geriatric assessment (CGA) will help the clinical team identify underlying medical and functional status issues that can affect cancer treatment delivery, cancer prognosis, and treatment tolerability. The CGA, as well as more abbreviated assessments and geriatric screening tools, can aid in the treatment decision-making process through improved individualized prediction of mortality, toxicity of cancer therapy, and postoperative complications and can also help clinicians develop an integrated care plan for the older adult with cancer. In this article, we will review the latest evidence with regard to the use of CGA in oncology. In addition, we will describe the benefits of conducting a CGA and the types of interventions that can be taken by the interprofessional team to improve the treatment outcomes and well-being of older adults.

User acceptance of an app-based adherence intervention: Perspectives from patients taking oral anticancer medications

Background

Widespread adoption by patients is imperative for the success of app-based interventions for enhancing adherence to oral anticancer medications. Patients' attitudes and beliefs should be evaluated to understand determinants of their acceptance and adoption of such interventions.

Objective

To identify factors that influence cancer patients' intention to adopt an app-based system for enhancing oral anticancer medication adherence.

Methods

This study was conducted as part of the usability evaluation of an app-based system for enhancing adherence. We followed the grounded theory approach employing audio-recorded face-to-face interviews for data collection from patients taking oral anticancer medications (n = 15) and caregivers of such patients (n = 3). Data analysis involved verbatim transcription of all interviews, coding of the transcripts and field notes, detailed memo writing, and constant comparative evaluation of emergent categories.

Results

A conceptual framework of facilitating and hindering factors for users' adoption intention for an oral anticancer medication adherence app was developed. Findings suggest that facing difficulties in maintaining adherence and patients' perceived superiority of the app over their current methods facilitate adoption intention. In contrast, having to pay, lack of language options and users' perception of low competence in using an app were the hindrance factors.

Conclusion

This study showed that adoption of adherence apps could be explained by technology acceptance constructs, such as performance expectancy. Adoption intention was also facilitated by patients perceived vulnerabilities in maintaining adherence to their medications, which was a health behaviour construct. Implementation of app-based programs should address patients' perceived vulnerabilities and relative advantage of the app over their current methods. Clinicians and app developers should also consider the financial, technological and language barriers for end users.

Medication Adherence in Hematopoietic Stem Cell Transplantation: A Review of the Literature

Adherence to oral medications has been repeatedly shown to fall below the recommended 80% to 95% in pediatric and adult cancer populations. The purpose of this review is to report the state of the science about oral medication adherence during the acute phase of hematopoietic stem cell transplantation across the lifespan. An exhaustive search of the literature yielded 5 records for inclusion in the review. Two studies examined adherence in pediatrics, 2 in adults, and 1 included both pediatric and adult patients. Three studies were descriptive and 2 were interventional in design. The rate of adherence to oral medications ranged from 33% to 94.7%. Adherence decreased over time in all studies except in 1 pharmacist-led intervention study. Different methods were used to measure adherence, but most relied on self-report. Further research is needed in medication adherence in hematopoietic stem cell transplantation to better understand facilitators, barriers, and relationships to health outcomes.

The Evolution of Gero-Oncology Nursing

OBJECTIVES

This article summarizes the evolution of gero-oncology nursing and highlights key educational initiatives, clinical practice issues, and research areas to enhance care of older adults with cancer.

DATA SOURCES

Peer-reviewed literature, position statements, clinical practice guidelines, Web-based materials, and professional organizations' resources.

CONCLUSION

Globally, the older adult cancer population is rapidly growing. The care of older adults with cancer requires an understanding of their diverse needs and the intersection of cancer and aging. Despite efforts to enhance competence in gero-oncology and to develop a body of evidence, nurses and health care systems remain under-prepared to provide high-quality care for older adults with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must take a leadership role in integrating gerontological principles into oncology settings. Working closely with interdisciplinary team members, nurses should utilize available resources and continue to build evidence through gero-oncology nursing research.

Self-reported adherence to oral cancer therapy: relationships with symptom distress, depression, and personal characteristics

BACKGROUND

Therapeutic cancer chemotherapy is most successful when complete dosing is achieved. Because many newer therapeutic agents are oral and self-administered by the patient, adherence is a concern. The purpose of our analysis was to explore relationships between adherence, patient characteristics, and barriers to adherence.

METHODS

This secondary analysis utilized self-reported data from a randomized trial of self-care management conducted at two cancer centers in the US. Symptom distress was measured using the 15-item Symptom Distress Scale (SDS-15) and depression with the Patient Health Questionnaire-9 (PHQ-9). Adherence to oral medication was self-reported using the 8-item Morisky Medication Adherence Scale (MMAS-8). Measures were collected via Web-based, study-specific software ~8 weeks after treatment start date. Odds of low/medium adherence (score <8) were explored using univariate logistic regression. Given the number of factors and possible relationships among factors, a classification tree was built in lieu of a multivariable logistic regression model.

RESULTS

Of the eligible participants enrolled, 77 were on oral therapy and 70 had an MMAS score. Forty-nine (70%) reported a high adherence score (=8). Higher odds of low/medium adherence were associated with greater symptom distress (P=0.09), more depression (P=0.05), chemotherapy vs hormonal oral medication (P=0.03), being female (P=0.02), and being randomized to the control group in the parent trial (P=0.09). Conversely, high adherence was associated with working (P=0.08), being married/partnered (P=0.004), and being older (P=0.02). Factors identified as significantly related to low/medium adherence from the univariate logistic regression analyses were supported by the classification tree results.

CONCLUSION

Nonadherence to therapeutic oral medications in patients with cancer was associated with being unmarried/unpartnered, symptom distress, younger age, not working, and female sex. These findings may help to identify patients at risk for nonadherence and for whom supportive interventions to enhance adherence may be needed.