Background: The use of oral antineoplastic agents has continued to increase as more cancer patients are prescribed these drugs as part of their treatment plan. This shift has created many new challenges for oncology nurses who take care of and manage patients taking these agents in their homes. Barriers to oral antineoplastic drugs can lead to decreased oral adherence, which can affect overall survival and lead to poorer patient outcomes.
Objective: To determine if a nurse-led telephone intervention leads to a high level of self-reported adherence in adult patients taking oral antineoplastic agents.
Methods: Ten adult cancer patients starting a new oral antineoplastic agent received 6 weekly phone calls from an oncology nurse beginning the first week they started their medication. Using a standardized telephone script, the nurse asked each patient to report how they were taking their medications each day, if they had missed any doses, and if they had, what the reasons were for the missed doses. The nurses provided symptom management, addressed any barriers, answered any questions and concerns, and developed an individualized plan with the patient.
Results: The patients who received the phone call intervention self-reported a high level of adherence to their antineoplastic agents during the interview with the clinic nurse. The nurse was able to provide timely symptom management, as well as additional education and support to several of the patients who verbalized barriers to taking their medications.
Conclusion: Nurses play an important role by decreasing barriers that may influence adherence for cancer patients taking oral antineoplastic agents. Nurse-led supportive telephone interventions are a simple and effective way to evaluate a patient’s adherence and provide strategies for patients to self-manage their care.
During the past 25 years, oral antineoplastic agents have increasingly become a primary form of treatment for many types of cancers, ranging from traditional cytotoxic therapies to targeted therapy for specific genetic mutations.1 The number of cancer patients taking oral antineoplastic drugs as part of their treatment regimen continues to increase. The shift has created many new challenges for oncology nurses who care for and manage patients taking oral antineoplastic drugs outside the traditional healthcare setting. Some of the challenges faced by these patients include financial and social barriers, lack of resources, ineffective side effect management, lack of patient education and comprehension, comorbidities, and lack of support.2 The World Health Organization defines adherence as the extent to which a person’s behavior corresponds with agreed recommendations from a healthcare provider.3 Nonadherence to oral antineoplastics can be either overadherence, in which a patient intentionally or unintentionally takes too much medication in a prescribed period, which can lead to increased toxicity, or underadherence, in which the patient takes an inadequate amount of prescribed medication. According to the Association of Community Cancer Centers, patients on long-term medications geared toward decreasing mortality, such as oral chemotherapy, have a low adherence rate.4 Decreased oral adherence can cause the treatment to be ineffective, leading to disease progression and poorer patient outcomes.5 Nurses play an important role by addressing multifactorial issues that may influence adherence to these drugs. Oral antineoplastics can be more convenient for patients because there is less disruption to daily routines, and the treatment is noninvasive and often results in better quality of life.5 Unfortunately, adherence and safety issues can become cumbersome if patients are not followed closely by the healthcare team.
Patients are active participants in their own care, and for effective clinical practice to occur, they must maintain communication with their healthcare team throughout their treatment plan. Good communication and trust between healthcare professionals and patients are important so that patients can openly disclose adverse effects of their treatment and any thoughts of nonadherence.4 One challenge with patients taking antineoplastic drugs can be the lack of follow-up and monitoring that are needed to ensure adherence and tolerability. Current practice includes a comprehensive education session by the oncologist or advanced practice provider followed by weekly office visits during the first cycle, and then according to provider preferences.
Unfortunately, these guidelines are not always consistent, leading to a fragmentation of care and poor communication between the healthcare team and patient. Other members of the healthcare team include the pharmacy technician, financial navigator, unlicensed assistive personnel, and occasionally, an infusion nurse, if the patient is on both oral and IV chemotherapy. Nursing care is inconsistent and identified as a gap in care for these patients. Patients can experience barriers, such as transportation issues leaving them without a way to come to their scheduled follow-up appointments. They may also forget to schedule their follow-up appointments before leaving the office, or have inadequate financial resources resulting in them not being able to afford their treatment. Patients may experience side effects and stop taking their medications and wait until their next appointment to tell the provider. Many factors can lead to nonadherence, leading to poorer outcomes.
A literature review has shown that nurse-led follow-up phone calls can improve patients’ tolerability and adherence.6 The Oncology Nursing Society’s Putting Evidence Into Practice initiative found that monitoring patients’ adherence to oral antineoplastics and incorporating multicomponent interventions could promote oral adherence.7 In addition, education as a single intervention is not enough to increase adherence to oral chemotherapy agents, but rather a multifaceted intervention has demonstrated better compliance.7 Calling patients weekly for the first 4 weeks, followed by biweekly calls has been found to positively impact patient-reported adherence rates.8,9
The study was designed to determine if a nurse-led telephone intervention leads to a high level of self-reported adherence in adult patients taking oral antineoplastic agents. Patient adherence to these drugs is necessary to optimize patient outcomes.
The evidence-based practice change took place in a private oncology group practice in New England. Over an 8-week period from April 2020 to June 2020, patients starting a new oral antineoplastic agent and filling their prescription in the in-office dispensary were included in the individualized nursing intervention. All patients received the standard of care for a new patient starting an oral antineoplastic, including a review of the treatment plan with the oncologist, followed by a separate comprehensive teaching session conducted by an advanced practice provider. During the session, the patients were provided verbal and written instructions on their treatment plan, medication regimen, supportive medications, side effect management, safe handling, food interactions, and what to do if they missed a dose. A calendar was given to the patient for the first cycle if the medication was not ordered to be taken daily. The prescription was sent to the pharmacy technician to ensure the patient had access to the drug, and financial barriers were minimized. When the medication was picked up from the pharmacy, the patient or family member was required to verbalize understanding of how the medication was to be taken. The pharmacy technician then alerted the care team to schedule the 4 weekly provider visits (Table 1).
Once the patient was prescribed a new oral antineoplastic agent, a nurse in the infusion clinic was assigned to the patient. Each infusion nurse received a series of educational sessions on certain topics related to oral adherence. The topics included reviewing national guidelines on safe handling, as well as maintaining best practices, which require the organization to maintain written policies and procedures to perform an assessment of the patient’s compliance to starting their oral chemotherapy regimen.10 The nurses also received tailored educational sessions specifically addressing the oral antineoplastic agent and regimen within the patient’s treatment plan. A telephone questionnaire was created by the interdisciplinary team to use as a prompt during the phone calls to ensure consistency. The questionnaire included the patient’s self-reported adherence, reasons for missed doses, side effects experienced, interventions discussed by the nurse and patient, as well as the treatment plan and necessary referrals for any identified barriers (Table 2). There is modest support for the validity of using self-report as an outcome measure for adherence.8 The patients were asked how they were taking their medication, whether they had missed any doses, what the reasons were for the missed doses, as well as any experienced side effects. The nurses used the same teaching material the patients received during their initial teaching to ensure consistency. Six weekly phone calls were completed, starting the week the patient picked up the prescription from the in-office dispensary, and on a different day than the planned provider visit. If the patient did not answer the phone call, 2 additional attempts were made over the next 2 days. A total of 10 patients were identified as new patients starting a new antineoplastic agent during this time frame. Seven of the patients completed the full 6-week nursing intervention and were included in the analysis.
All 7 patients self-reported 100% adherence to their new medication over the 6-week telephone intervention time frame. In addition, 6 patients reported side effects that required nursing education and interventions, and 4 patients identified barriers that were affecting their ability to remain adherent to their regimens, requiring additional support and referrals (Table 3). The 7 patients were all on different medications and regimens. Six of the 7 patients had metastatic or advanced disease. Cancer types were diverse, including breast, colon, lung, and prostate cancer and chronic lymphocytic leukemia.
Some of the challenges included relying on patients or a family member to recall if any doses were missed in the past week, as well as the possible patient desire to not disappoint the healthcare provider, thus leading to an overestimation of adherence. Metastatic patients are at risk for not reporting adverse events and for overadherence compared with patients on lifelong chemotherapy.11 Another challenge was the small sample size. Due to the COVID-19 pandemic, the number of patients starting new oral antineoplastic medications was decreased during this time frame. In addition, due to limitations with the electronic medical record system, there were no baseline data to know what the adherence levels for patients were prior to implementing the telephone intervention.
Weekly telephone calls to monitor adherence, address side effects in a timely manner, and identify possible barriers may positively impact oral adherence, which can lead to better patient outcomes. There is also a better awareness of how many side effects and barriers to optimal care are occurring that we as a healthcare team are missing when patients are not coming into the clinic. The addition of the weekly phone calls has led to improved monitoring and communication between the nurses and their patients. During the pandemic, some of these calls were able to address psychosocial barriers, anxiety, and depression due to isolation. The patients shared that they looked forward to the phone calls. The infusion nurses also verbalized that the phone calls were time-consuming and made it difficult to care for patients in the clinic, as well as to complete the phone calls to the patients taking oral antineoplastics at home. Even though the length of the calls was not captured as part of the project, each of the nurses in the clinic shared the concern that more resources were necessary to provide a high level of care to these patients.
Due to the positive outcomes of this project, a proposal was made for an oncology nurse navigator position to help care for the increasing needs of the oncology patients on oral antineoplastic drugs. The position encompasses identification of psychosocial barriers and completion of standardized distress screening tools, financial navigation to minimize financial impacts and delays of treatment, as well as coordination of care from diagnosis through survivorship. The nurse navigator position also serves as a liaison between the patient and the healthcare team to improve communication and ensure patient-centered care.
Implications for Practice
Despite the challenges of managing patients taking oral antineoplastic drugs, the use of these agents will likely continue to increase. Improved self-management of side effects, and a decrease in barriers can lead to optimized adherence and best patient outcomes. A dedicated nurse navigator position that assists with barriers and effective side effect management, addresses psychosocial issues, provides financial navigation, and reinforces education and safe handling, can positively impact patient adherence and quality of life. The nurse navigator can coordinate care to decrease fragmented care in the healthcare team, leading to improved communication. In addition, a nurse navigator can implement interventions to promote adherence for patients taking oral antineoplastics over the longer term. Encouraging patients to take an active role in their care and learning self-management strategies can empower patients. With the support of the nurse navigator, patients can be successful in safely and effectively managing their antineoplastics in the home setting.
No funding was used for this study.
- Greer JA, Amoyal N, Nisotel L, et al. A systematic review of adherence to oral antineoplastic therapies. Oncologist. 2016;21:354-376.
- Washburn DJ, Thompson K. Medication adherence barriers: development and retrospective pilot test of an evidence-based screening instrument. Clin J Oncol Nurs. 2020;24:E13-E20.
- World Health Organization. Adherence to Long-Term Therapies: Evidence for Action. www.who.int/chp/knowledge/publications/adherence_Section1.pdf. 2003.
- Bettencourt E. Oral chemotherapy—What Your Patients Need to Know. Association of Community Cancer Centers. www.accc-cancer.org/docs/documents/oncology-issues/articles/ND14/nd14-oral-chemotherapy-what-your-patients-need-to-know. 2014.
- Dowling M, Hunter A, Biesty L, et al. Driving and disabling factors of noncurative oral chemotherapy adherence: a qualitative evidence synthesis. Oncol Nurs Forum. 2019;46:16-28.
- Eldeib HK, Abbassi MM, Hussein MM, et al. The effect of telephone-based follow-up on adherence, efficacy, and toxicity of oral capecitabine-based chemotherapy. Telemed J E Health. 2019;25:462-470.
- Spoelstra SL, Sansoucie H. Putting evidence into practice: evidence-based interventions for oral agents for cancer. Clin J Oncol Nurs. 2015;19(suppl):60-72.
- Burhenn PS, Smudde J. Using tools and technology to promote education and adherence to oral agents for cancer. Clin J Oncol Nurs. 2015;19 (suppl):53-59.
- Schneider SM, Adams DB, Gosselin T. A tailored nurse coaching intervention for oral chemotherapy adherence. J Adv Pract Oncol. 2014;5:163-172.
- Neuss M, Gilmore T, Belderson K, et al. 2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, including standards for pediatric oncology. Oncol Nurs Forum. 2017;44:31-43.
- Spoelstra SL, Sikorskii A, Majumder A, et al. Oral anticancer agents: an intervention to promote medication adherence and symptom management. Clin J Oncol Nurs. 2017;21:157-160.