Making a Connection: Staying in Touch for Better Anticancer Drug Adherence

By staying in touch, nurses and pharmacists can help patients successfully adhere to oral anticancer treatments that they take at home.
MARILYN FENICHEL
PUBLISHED: NOVEMBER 16, 2016
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NURSES AS THE POINT PEOPLE FOR PATIENTS

Traditionally, nurses and nurse practitioners have served as the points of contact for patients during treatment, and many of these new models follow that approach. The thinking behind these interventions is that bringing back the human touch, either by phone or online, provides support that can change the behaviors of patients and their families.

Schneider conducted a small intervention for 45 patients new to oral anticancer drugs to determine if a personalized adherence plan made a difference. All patients received weekly phone calls from nurse practitioners during the first month of therapy, and then bimonthly calls for six months or until they had completed their medication. Patients in the intervention group were compared with those in the control, who strictly received standard chemotherapy education. The unique feature of the intervention was that it wasn’t one-size-fits-all; instead, the approach was tailored to the needs of the patient. “We had one patient who was having trouble remembering when to take her medication,” recalls Schneider. “So the nurse practitioner set up an alarm system on her cell phone, alerting her to when it was time to take her pill. Another woman told us that she was having trouble remembering to take her evening pill. It just so happened that the timing coincided with the 6 o’clock news, which she always watched. Putting the pill bottle by the television took care of the problem.” The study’s findings, published in 2014 in the Journal of the Advanced Practitioner in Oncology, showed that at two and four months, adherence rates were better for the intervention group than for the control. “The study illustrates the importance of having nurses available to help patients make the transition to taking oral medications,” notes Schneider. “We help them figure out how to incorporate taking medications into daily life.”

A small practice in Michigan, part of the Michigan Oncology Quality Consortium, also found that education and follow-up phone calls made a difference in adherence. “By providing education up front and following up with phone calls, we found that patients were more adherent,” says Tallat Mahmood, M.D., an oncologist in the practice. “We also had the medication delivered to our pharmacy, so we knew when the patient came to pick it up. These strategies have had some impact.”

REACHING OUT ONLINE AND THROUGH THE PHARMACY

Text messaging is not as personal as follow-up phone calls, but it has shown potential as an effective reminder tool. Spoelstra has conducted a couple of different studies testing the feasibility of using daily automated text messages, along with weekly messages asking about symptoms, to promote adherence among patients new to oral cancer medication. The larger of the two studies also tested whether recruiting patients from different venues affected outcomes. She and her team enrolled 121 patients from a large national specialty pharmacy, where patients purchase medication, and 128 from community cancer clinics. Interestingly, Spoelstra and her team found that they were able to recruit a higher percentage of African-Americans from the specialty pharmacy. In addition, drawing from two different types of sites resulted in a wide representation of cancer types: more than 20 different cancers, with 28 anticancer medications prescribed.

The study found a high interest in text message reminders, especially among patients recruited from the specialty pharmacy. The reason may be that more people in this group owned cell phones and used text messaging more frequently, so they were already comfortable with this mode of communication. The downside to this option, however, is cost. It may be difficult to determine who will pay for a text messaging platform, Spoelstra says, and who will be responsible for managing it on a daily basis. Another intervention has taken advantage of the expertise of pharmacists to deliver high-quality patient education and support. The Oncology Specialty Pharmacy Program, part of the University of California Davis Comprehensive Cancer Center, works closely with patients to inform them about their medications and answer questions about side effects. The program even takes on the responsibility of sending patients their medications so that they never have to worry about running out. In addition, a collaborative practice agreement with the Division of Hematology/Oncology is in place, allowing pharmacists to write prescriptions for medications to address side effects.

Lead pharmacist Iris Zhao, Pharm.D., B.C.P.S., runs the program, which started as a small pilot in 2013. She and two assistants work closely with their patients — now numbering 600 — beginning with an initial education session. Monthly follow-up calls give patients an opportunity to discuss side effects and to make sure they are current with their supplies of medications. “Many patients are afraid to call, especially to discuss side effects,” says Zhao. “We remove that obstacle by initiating the calls ourselves. Usually, we can come up with strategies to address their problems. For example, we found that freezing a marshmallow and cutting off small pieces to wrap around pills really helps with mouth sores.”

In the same vein, an ongoing phase 2 study has found that a steroid mouthwash can markedly reduce the rate of occurrence of mouth sores in patients who are being treated with Afinitor (everolimus). An investigator on the study says the mouthwash is ready to integrate into practice, but patients may not be aware that it exists, and may discontinue taking their medication without realizing that there is a probable solution. Through follow-up programs, medical professionals can make them aware of such strategies to reduce side effects.

The program at UC Davis also provides another much-needed service: finding payment sources to alleviate the financial burden of treatment. “Drugs can cost as much as $15,000 a month,” says Zhao. “We don’t want patients stressing about money, so we find grants or go directly to the manufacturer for assistance. Organizations like the Patient Access Network Foundation can offer between $4,000 and $15,000 a year.”
 

Talk about this article with other patients, caregivers, and advocates in the General Discussions CURE discussion group.
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