The ONS GuidelinesTM to Support Patient Adherence to Oral Anticancer Medications provide evidence-based recommendations for nurses to remove barriers that prevent patients from taking their oral treatments as prescribed. The full guideline by Belcher et al. was advance published in the July 2022 issue of the Oncology Nursing Forum.
Recommended Oral Adherence Research Priorities
- Target populations identified as being most at risk.
- Explore bidirectional relationships between financial hardship and adherence, including treatment points that may exacerbate vulnerabilities.
- Identify policies and system support to bolster patients’ ability to obtain and pay for oral medications.
- Develop and test valid, reliable, practical, and common subjective and objective measures and use them as study outcomes.
- Assess intervention timing and how it affects outcomes.
- Investigate the impact of financial difficulties and interventions for financial support.
- Assess time, personnel, acceptability concerns, and resources to implement interventions.
- Evaluate multicomponent interventions.
- Revise quality metrics as new data emerge.
- Focus on measurable metrics that demonstrate positive patient outcomes.
- Conduct quality improvement reports of existing adherence programs, including cost-benefit analyses.
- Assess needs and barriers for implementing community programs and improving access (e.g., partnerships, payer funding).
- Analyze interventions for medically underserved patients to eliminate disparities, achieve health equity, and improve health for all groups.
- Identify, examine, and target interventions for health inequities (e.g., environment, social determinants, racism).
- Include populations historically underrepresented in research.
- Conduct interprofessional research and cross-discipline clinical collaboration.
Many factors influence a patient’s compliance with their prescribed oral cancer treatments, Belcher et al. explained, and those related to socioeconomics, therapies, conditions, and health systems are often outside of a patient’s sphere of control. Examples include challenging administration schedules, beliefs about a medication’s effectiveness, adverse events, forgetfulness, costs, insurance issues, and difficulty in obtaining the medication.
However, under- or overadherence to cancer therapies has implications for patient outcomes, toxicities, and healthcare costs, making support interventions a critical component of care. “Nurses and pharmacists are uniquely positioned to support optimal adherence in patients with cancer,” Belcher et al. said. “Using evidence-based interventions to inform best practices for supporting patients taking oral anticancer medications is important.”
The ONS Guidelines panel conducted a systematic review of the research supporting nursing interventions and their effect on patient adherence to oral therapies to serve as a foundation for the recommendations. The panel graded their findings based on the strength of available evidence.
Recommended interventions: Conduct an adherence assessment in addition to usual care when patients are beginning a new oral anticancer medication and ongoing adherence risk assessments in addition to usual care in patients on continued oral anticancer therapies. The Guidelines panel classified both recommendations as conditional with a very low quality of evidence based on studies that associated risk assessments with higher rates of patient adherence.
For patients taking oral anticancer medications, provide adherence education, active follow-up for adherence, coaching, and motivational interviewing in addition to standard education and care alone. With the exception of motivational interviewing, which had a low quality of evidence, the Guidelines panel classified the recommendations as conditional with a very low quality of evidence. The evaluated studies suggested that those interventions improve patients’ knowledge of dosage and frequency, dosage schedule, management of missed doses, general adherence, perception of medication efficacy, medication possession ratio, quality of life, and satisfaction.
Finally, institute a structured home-, clinical-, or pharmacy-based oral anticancer medication program, which the panel classified as a conditional recommendation with a very low quality of evidence. Studies suggested that such programs improve patients’ adherence, cancer-related morbidity, quality of life, and satisfaction.
ONS Resources for Oral Adherence
Oncology Nursing Podcast Episode 16: Navigating the Challenges of Oral Chemotherapy
Oral Adherence Video
Oral Anticancer Medication Learning Library
Oral Anticancer Therapy Toolkit
Not enough evidence: The Guidelines panel identified a knowledge gap surrounding use of interactive or noninteractive technology to support oral adherence. Some studies reported improvements in adherence—but only in conjunction with primary health care follow-up—medication possession ratio, and quality of life. Considering technology’s burden of costs for patients and institutions, the panel petitioned scientists and researchers to develop additional evidence before it can recommend technology as an intervention.
Belcher et al. explained that the Guidelines panel’s evaluation of the evidence covered the full trajectory of treatment and establishes a framework for clinicians to use with patients who are receiving oral cancer treatments. However, they noted that new evidence is constantly emerging and cited several study results that were published after the panel’s review.
One of the new studies found that intensive clinical pharmacy care (e.g., medication management, patient counseling, ongoing assessment) decreased side effects and therapy discontinuation and increased adherence and patient satisfaction. A second new study reported that an oral chemotherapy management program (i.e., standardized management and documentation) improved adherence and decreased overall incidence of adverse events, emergency department visits, and hospitalizations.
The panel also outlined priorities for future research, including finding specific interventions targeted to specific patients or specific regimens; identifying strategies to address patient and system factors, such as financial toxicity; and creating clinical infrastructure that involves a dedicated team of clinicians, information technology, and electronic health record pathways (see sidebar).
“However, with the number of oral therapies being developed, and the number of cancers being treated with them, healthcare systems should be supporting patients now, while additional research is ongoing,” the Guidelines panel implored.
Refer to the article by Belcher at al. for the full context of the ONS Guidelines to Support Patient Adherence to Oral Anticancer Medications.
