Patient adherence to oral anticancer medications is an increasing concern, as more therapies are available in pill format that require self-management and training from patients, clinicians, and healthcare systems. While oral medications have advantages, including less travel and time required by patients and caregivers, they come at the risk of treatment initiation, dosing implementation, and discontinuation not occurring as intended. While non-adherence may simply be related to patient forgetfulness, deeper factors that impact adherence include financial burden related to cancer therapy, difficult medication administration schedules, and health system barriers.
The Oncology Nursing Society, as the premiere professional society for oncology nurses, recently published guidelines, based on the work of a team of researchers and clinicians. The first author, Sarah M. Belcher, PhD, RN, OCN®, an assistant professor at the University of Pittsburgh School of Nursing, led an interprofessional panel who reviewed literature, rated evidence, and developed a list of recommendations. The guidelines are intended to inform clinical practice, identify research gaps to be addressed in future work, and promote health policy and advocacy regarding oral anticancer medications.
The panel considered multiple factors when developing these guidelines. They first evaluated the level of evidence using a framework encompassing the quality of evidence, risk for bias, and inconsistency among other factors. Other considerations included benefits and harms, patients’ values, equity, and feasibility.
Overall, the panel reviewed eight clinical questions and provided both the level of strength of each recommendation and an assessment of the quality of evidence for that question. For seven of the eight questions, the strength of the commendation was “conditional,” meaning, it was not “strong,” having “no recommendation,” or being a “knowledge gap.” For seven of the eight questions, the quality of the evidence was “very low.” For one of the eight questions, no recommendation was given, and it was listed as a knowledge gap.
In addition to receiving standard care, the panel made the following recommendations:
- Patients starting a new oral anticancer medication should undergo an adherence risk assessment. No single assessment tool was used across settings, however, and the panel suggested that feasibility concerns be considered and integration into clinical flow to ensure equitable access and clinical follow-up.
- Patients taking oral anticancer medications should receive education regarding adherence to the treatment regimen. Such education could review patient knowledge of dosage frequency, management of missed doses, and dosage schedules. The panel suggested this education be received at each clinical encounter, though details about preferred mode of delivery and specifics are needed.
- Patients should receive ongoing assessment of patient adherence to oral anticancer medications. Since this is not currently done, the panel encouraged the development of a standard for ongoing assessment in terms of frequency and resources needed.
- Patients with additional risk-factors for non-adherence to oral anticancer medications should receive proactive follow-up care. This recommendation had few sources of evidence, though, and requires more specific inquiry.
- Patients should receive coaching to improve adherence to oral anticancer medication. Coaching involves goal setting, identifying values and strengths, and developing supportive adherence routines and behaviors. Several studies have tested coaching interventions, and while they varied, demonstrated consistent benefits.
- Patients should receive motivational interviewing to improve adherence to oral anticancer medication. This was the only recommendation with “low” rather than “very low” quality of evidence. Motivational interviewing is a patient-centered approach to building patient commitment to behavior change. This type of intervention could include additional intervention components and be delivered over time.
- The panel found a knowledge gap regarding the use of technological interventions to support adherence, and so made no recommendation on this topic. While the panel found 13 studies considering technology-based adherence interventions, they often delivered with other interventions (e.g., clinical follow-up). They recommend additional research to further clarify how technology can support adherence.
- Providers and healthcare systems should implement structured oral anticancer medication programs. Fourteen studies assessed home-, clinical-, and pharmacy-based programs. While the components and follow-up varied between studies, these programs can improve adherence and more downstream outcomes. Considerations regarding such programs include the significant amount of resource allocation, responsibility for starting and maintaining a program, and financing such a program.
The panel concludes their recommendations by encouraging clinicians to incorporate these findings into their processes and care for patients taking oral anticancer medications. They also point to specific areas of needed research, including how adherence is affected by patients’ financial burden. Building from these recommendations, oncology nurses can support both the clinical application of this work and the continued quality improvement and research necessary to continue to build the science around adherence to oral medications.