Oral Therapies for Multiple Myeloma Continuum

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Multiple Myeloma

Perception Is Patients’ Reality: How to Increase Oral Oncolytic Adherence

Yelak Biru, MSc 

From 2004 to 2013, 22 new oral anticancer medications were introduced in the United States, which is almost the same number (27) of oral anticancer medications that were introduced in the previous 50 years combined.1 Of the US Food and Drug Administration (FDA)-approved myeloma novel therapies, 5 are orally administered.2 With the FDA approval of ixazomib (Ninlaro; a first-in-class oral proteasome inhibitor) in November 2015, an all-oral treatment combination for patients with myeloma is now a reality with the combination of ixazomib, lenalidomide (Revlimid), and dexamethasone (Decadron).3

With the improved diagnosis and availability of treatment and care, some patients with myeloma are living longer; median survival for younger standard-risk patients is approaching >10 years.4 Oral myeloma drugs play a big part in continuing this trend, not only because they are preferred by patients, but also because there are more of them in the drug pipeline.5

Oral anticancer medications are preferred by most patients because of their ease of administration (ie, no searching for a vein, no starting an IV, no bruising from subcutaneous injection), and may even increase medication adherence, because patients can take them while traveling, during the holidays, or when their physician is not available. Taking medication orally also prevents time being wasted in the clinic waiting room, and can allow patients to gain back some of the level of control and empowerment they lost when they were diagnosed with cancer.5

Unfortunately, preference does not always result in adherence to the medication schedule. In addition to the operational complexity of acquiring anticancer oral medications, medication cost, treatment side effects, disease progression, complexity of instructions, and simply forgetting are some of the reasons patients with cancer do not take their medication as prescribed. For these reasons, patients can take medication at a lower dose than prescribed, less often than prescribed, or, in some cases, more than prescribed.5

There are telltale signs that indicate patients may not be taking their medications as prescribed, including a less frequent prescription refill rate, progressing disease, and not having the expected side effects—but the best way to find out is for the provider to ask the patient. Most patients are very open and frank if they are asked. Asking about adherence also shows the patient that the provider cares, which enhances the patient–provider relationship.

The reason patients are not adhering to the prescribed treatment regimen needs to be recognized. Patients’ perceptions around cost, side effects, and the effectiveness of the medication can lead to adherence or lack thereof. Patient education is not only the foundation for oral oncolytic adherence, but also overall survival in patients with myeloma. Providers need to have the heart of a teacher and cater to various levels of patient understanding and involvement. Because of myeloma’s clonal heterogeneity, patients need to be taught that myeloma is a sneaky cancer that they cannot be complacent with, even when they are feeling well.6 This education process certainly requires a 1-on-1 component, but also needs to have a community component. The whole myeloma community needs a better understanding that failing to take medication as prescribed can lead to disease progression or relapse, poor quality of life, and more aggressive disease.

Patients also need help navigating complex oral oncolytic medication administration regimens. This is especially true if the patient has comorbidities and conflicting regimens and administrations of oral medications. Some medications need to be taken in the morning, whereas others need to be taken at night, some need to be taken with food, others on an empty stomach, and some may need to be taken with other medications concurrently.

Not being able to afford medication is one reason patients self-adjust their dosing. Active engagement by providers, pharmaceutical companies, and third parties is critical to educate patients regarding the various direct and indirect means of getting financial help for their medications. Copay assistance foundations and drug assistance programs can sometimes help patients get their drugs at a price they can afford. Cost is not an individual patient, provider, pharmaceutical, payer, or political issue; it is an issue that affects all stakeholders, and needs to be addressed collaboratively.

Side effects that patients encounter or anticipate are also a main reason patients do not take medications as prescribed. The patient’s ability to report and get help for adverse effects between appointments is key for combating this issue. The provider’s willingness to acknowledge the issue and adjust the dose, find ways to reduce the side effects, and even change treatment protocols will go a long way in building trust between them and the patient. This, in turn, will go a long way in increasing adherence.

The average age of a patient with myeloma is 70 years, with just 2% of patients being <40 years at the time of diagnosis.7 Simply forgetting is another major reason why patients do not take their medications as prescribed. Can emerging technologies be used to remind patients it is time for them to take their medicine?8 Can microchipped smart pills be used to ensure the drug has entered the digestive track?9 Can widely adopted and related technologies, such as texting and mobile applications, be used to monitor and encourage patients’ adherence to their oral oncolytic drugs?

More oral oncolytics are becoming available for treatment of cancers, including myeloma. In most cases, they are preferred by the patient because of their ease of administration, but adherence can be lacking. Patient beliefs and realities need to be balanced, and barriers need to be acknowledged and removed by reducing costs, managing side effects, simplifying instructions and reorder processes, and improving patient–provider communication.


  1. Mancini R, Mcbride A, Kruczynski M. Oral oncolytics: part 1—financial, adherence, and management challenges. Cancer Network. www.cancernetwork.com/practice-policy/oral-oncolytics-part-1-financial-adherence-and-management-challenges#sthash.zMgtAgWd.dpuf. Published August 15, 2013. Accessed January 19, 2016.
  2. National Cancer Institute. Drugs approved for multiple myeloma and other plasma cell neoplasms. www.cancer.gov/about-cancer/treatment/drugs/multiple-myeloma. Updated December 10, 2015. Accessed January 19, 2016.
  3. US Food and Drug Administration. FDA approves Ninlaro, new oral medication to treat multiple myeloma. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm473771.htm. Updated November 24, 2015. Accessed January 19, 2016.
  4. Rajkumar VS. Maintenance therapy in multiple myeloma. The ASCO Post. www.ascopost.com/issues/may-1,-2014/maintenance-therapy-in-multiple-myeloma.aspx. Published May 1, 2014. Accessed January 19, 2016.
  5. O’Neill VJ, Twelves CJ. Oral cancer treatment: developments in chemotherapy and beyond. Br J Cancer. 2002;87:933-937.
  6. Bianchi G, Ghobrial IM. Biological and clinical implications of clonal heterogeneity and clonal evolution in multiple myeloma. Curr Cancer Ther Rev. 2014;10:70-79.
  7. Cancer.Net. Multiple myeloma: risk factors. www.cancer.net/cancer-types/multiple-myeloma/risk-factors. Published June 2015. Accessed January 19, 2016.
  8. Stern J. When does connecting our personal health products to our smartphones make sense? Wall Street Journal. www.wsj.com/articles/the-connected-medicine-cabinet-bluetooth-pregnancy-test-makes-debut-at-ces-2016-1452045541. Updated January 5, 2016. Accessed January 19, 2016.
  9. Cha AE. Smart pills’ with chips, cameras and robotic parts raise legal, ethical questions. Washington Post. www.washingtonpost.com/national/health-science/smart-pills-with-chips-cameras-and-robotic-parts-raise-legal-ethical-questions/2014/05/24/6f6d715e-dabb-11e3-b745-87d39690c5c0_story.html?tid=ss_tw. Published May 24, 2014. Accessed January 19, 2016.

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