Oral oncolytics represent 25% to 35% of the drugs in the oncology pipeline.1 They are patient friendly, allow patients to manage their treatment, and overall, have a less disruptive effect on patient's everyday lives. In addition, fewer clinic visits are needed, and scheduled visits are shorter because there is no need to wait for an intravenous infusion to be completed. Many patients with myeloma can also continue working through their treatment, and traveling is more convenient. Oral oncolytics offer the ease of self-administration to patients. There is no prodding for stubborn veins, and no need for a port. Therefore, oral therapies empower patients, and often lead to improved quality of life.
However, there are also challenges associated with oral oncolytics use in patients with myeloma. With patients being responsible for the administration of their own therapy, the issues of adherence and side effect management need to be addressed. There is a 37% rate of nonadherence to oral cancer agents2; overadherence, or taking more medication than prescribed, can lead to increased toxicities, whereas patients who forget or choose to take less than the prescribed dose can be at higher risk for disease progression.
Efforts need to be made to overcome these challenges. Clinical trials assessing adherence rates routinely show that a good patient-healthcare provider relationship increase adherence.3 Because patient's taking oral oncolytics need to visit the clinic less often, greater effort is needed to cultivate the patient-healthcare provider relationship. Patient's with myeloma should have an oncology nurse or nurse navigator specifically assigned to them. The oncology nurse or nurse navigator should intentionally engage with patients and caregivers, especially at the onset of their treatment journey.
Oncology nurses or nurse navigators should have a thorough understanding of the oral therapy that their patient is taking. This "nursing buddy" should initiate contact with the patient and caregiver frequently in the beginning weeks of treatment. A once-monthly check-in at the end of a treatment cycle is not enough when the patient is starting a new protocol. Contact can be made through phone calls, e-mails, text messages, video calls (eg, Skype, FaceTime), patient portals, or drop-in visits whichever is best for the patient and caregiver. During these planned interventions, the oncology nurse or nurse navigator should educate his or her patient, assess financial needs, share side effect management tips, evaluate psychological state, and discuss family life. Patients should be given an easy-to-read, written summary of everything that was discussed during these conversations. Through meaningful contact, a trusting patient-healthcare provider relationship will develop.
The oncology nurse or nurse navigator should also direct the patient and caregiver to the appropriate online and in-person support communities and mentoring organizations. Ongoing support, especially from someone who is following the same oral protocol, can be extremely helpful.
In addition to developing a trusting relationship, there are other ways to incorporate compliance to oral therapy into the daily routine of patients with myeloma. Education is critical. Patients need to be educated about their disease and the available treatment options to make informed decisions. If patients are a part of this decision-making process, they will feel a sense of ownership, and will be more likely to comply. Patients need to understand the goal of treatment, the duration of treatment, and what may happen if they stop or adjust their dose without discussing this decision with their physician. Patients should also understand how their response to treatment is being monitored. When patients are educated on side effect management and reporting, they may be less likely to discontinue therapy because of preventable complications.
Electronic reminders via text messages, smartphone applications, or e-mails may be helpful, especially if the medication is not taken daily. Pillboxes can be used when appropriate as a self-check system. Having a friend or family member help support medication adherence at home may also be beneficial; 2 sets of eyes are better than 1! Treatment calendars that outline complicated dosing schedules should be employed. These calendars can be paper, electronic, or application-based on smartphones.
The ease of getting the prescription filled also needs to be evaluated. Can the medication be picked up at the clinic or local pharmacy, or is a specialty pharmacy needed? Who is responsible for ordering the medication? How long will it take the prescription to be filled? If the medication is delivered to the patient's home, will a signature be needed? Is there a 24-hour pharmacist available to answer questions? Patients cannot take their medication if they do not physically have it in their possession.
Finally, access issues need to be addressed. Patients often stop or spread out the doses of their medication because costs can be astronomical. The oncology nurse or nurse navigator should discuss the various financial assistance programs that are available, and should help patients apply for assistance. All stakeholders, including healthcare providers, patients, caregivers, pharmaceutical companies, and payers, must work together to ensure adherence to oral oncolytic therapy.
1. Schwartzberg L, Streeter SB, Husain N, Johnsrud M. Abandoning oral oncolytic prescriptions at the pharmacy: patient and health plan factors influencing adherence. Poster presented at: 47th Annual American Society of Clinical Oncology Meeting; June 3-7, 2011; Chicago, IL.
2. Osborne R. Management programs for oral oncolytics drive adherence and brand loyalty. United BioSource Corporation. www.ubc.com/blog/management-programs-oral-oncolytics-drive-adherence-and-brand-loyalty. Published August 7, 2012. Accessed October 31, 2015.
3. McGann E. Promoting adherence to oral chemotherapy. Medscape Medical News. www.medscape.com/viewarticle/ 744303. Published June 9, 2011. Accessed October 31, 2015.