Achieve Gold Standard Oral Oncology Drug Adherence Through Collaboration

Oncology patients are historically among the most therapy-adherent patient populations. Recently, however, nonadherence has become an emerging challenge.1 Significant advancements in cancer treatment now give patients the opportunity to maintain their daily lifestyle with fewer adverse effects and better long-term disease management, but these same advancements have taken away some of the direct interaction among providers and patients that occurred when care was administered in the clinic. The greater freedom and independence that are among the advantages patients gain from oral therapies has ultimately led to lower adherence rates.

For example, oral oncolytics now comprise nearly 25% of cancer medication therapies,2 making treatment more convenient but also moving it from the clinical setting to a patient’s home. Fewer regular touchpoints between the patient and physician can cause increases in nonadherence. This type of nonadherence is referred to as primary nonadherence, in which providers write prescriptions but the medication is never filled or initiated by the patient.3 In fact, primary nonadherence is the leading cause of nonadherence among all patients.

Despite the attention and research invested in understanding adherence behaviors, there is no gold standard that exists when it comes to managing adherence among patients. Health care providers—including physicians, oncologists, and specialty pharmacists—must leverage their collective resources and expertise to work together to address adherence on a larger scale. Specialty pharmacies exist at the nexus of these providers, a unique position that allows them to not only support the care team, but also be an extension of it. This creates a clinically coordinated model of care in which the patient is supported on every side by professionals who can help address various barriers to adherence.

The following best practices can be employed by specialty pharmacies to ensure treatment adherence among oncology patients.

Communication

The single most important tool to combat nonadherence is communication. Consistent and coordinated messaging from oncologists and specialty pharmacists—health care professionals who have historically worked somewhat independently from each other—is vital to avoid exacerbating the confusion that surrounds complex dosing regimens. Communication enables providers to make calculated, real-time treatment decisions based on their knowledge of a patient’s medical profile and the available health data. A strong, coordinated conversation regarding patient care helps providers and pharmacists more easily identify when to intervene and implement strategies to combat nonadherence.

Developing an integrated approach to patient communication and education helps care providers monitor a patient’s treatment and seamlessly identify adherence barriers. Simple solutions, such as 24/7 on-call support, enable specialty pharmacies to identify whether there is a nonadherence risk and, if so, pass that information along to the provider. At US Bioservices, for example, we partnered with oncology practices that are members of the ION Solutions group purchasing organization—one of our sister companies within AmerisourceBergen—to establish nursing outreach programs that proactively manage patients at key milestones in their therapy.

However, communication is not just among providers and patients. It is important that providers and pharmacists also communicate with each other. As such, we are conducting comprehensive business reviews with our provider partners using data-driven insights. The result is that we are able to have detailed conversations with our provider partners to discuss challenges and data associated with patients who are in the care of their office and our pharmacy. Our goal is to be in lockstep with provider messaging about a patient’s treatment regimen while providing complementary high-touch, personalized specialty pharmacy care.


Patient Education

Studies show that patient education increases adherence rates.4 Consistent face-to-face interactions enable health care providers to emphasize the importance of medication adherence and make adjustments to dosage or therapy to prevent adverse effects from escalating into adverse events. Patients on oral oncolytics taking their medication at home and managing their disease long-term may not have the same opportunity for these conversations. Although programs exist to help health care providers monitor the status of patients who self-administer an oral therapy at home, approximately half of all patients report nonadherence and a quarter of these patients do not discuss it with their provider. Patients who start to feel better or worse may self-adjust their dosing regimen or stop treatment completely, which jeopardizes the success of the prescribed therapy and can lead to medication waste.

Specialty pharmacists—the last provider to speak with patients prior to taking their medication—are able to foster a relationship with their patients and provide education. For example, specialty pharmacists can answer questions regarding medications or can direct patients to seek care from their physician, if needed. In addition to the pharmacist, US Bioservices employs telephonic nurses and patient care coordinators who are trained to identify nonadherence risks and to intervene when necessary. These professionals know how to address dosage frequency and timing, as well as symptom management, on a personalized level. Ongoing education regarding new therapies, adverse effect management, and resources that create cost efficiencies are important to help oncology patients shift from a new diagnosis to a chronic disease management model with oral oncolytics to maintain long-term adherence.


Adverse Effect Management

Patients may comment to their pharmacists that they are feeling tired. The specialty pharmacist can work to identify whether the patient’s fatigue is a result of the psychological effects of cancer care, including stress or depression, or a result of a clinical issue such as anemia. By simply looking at the treatment a patient is prescribed, specialty pharmacists can identify whether it is a third- or fourth-line therapy that could be causing fatigue. Patients are optimally adherent if no doses are missed, no extra doses are taken, and no doses are taken in the wrong quantity or at the wrong time. Even an adverse effect as common as fatigue can result in a patient missing or incorrectly administering a dose.

To mitigate adverse effects, providers and specialty pharmacies should have an open, ongoing dialogue about patient response to treatment. For now, specialty pharmacies are able to obtain and review electronic medical records (EMRs), which helps us to act as an extension of the care team and support providers by offering more holistic care. In an optimal setting, both the provider and specialty pharmacy will be able to contribute to EMRs to ensure that patient feedback is coordinated and adverse effects are addressed quickly, before a patient decides to stop taking their medication.

Specialty pharmacies exist to give patients a sense of peace. Collectively, oncologists and pharmacists have the resources and expertise to drive improved adherence to oral oncolytics and help patients navigate the challenges they face throughout treatment. But it will take continued movement toward a multidisciplinary approach that makes an even greater impact on patient care to create improved outcomes. An integrated solution involves physicians along with the specialty pharmacists who provide patients with continuity of care from the initial dispense to completion of therapy. By collaborating with providers on communication, patient education, and adverse effect management, specialty pharmacies can help create a clinically coordinated care model that allows oncology patients to truly benefit from treatment and live longer lives. 

References
  1. David Marin, et al., “Adherence Is the Critical Factor for Achieving Molecular Responses in Patients with Chronic Myeloid Leukemia Who Achieve Complete Cytogenetic Responses on Imatinib” Journal of Clinical Oncology 28, no.14 (May 2010): 2381-2388.
  2. Ann H. Partridge, et al., “Nonadherence to Adjuvant Tamoxifen Therapy in Women with Primary Breast Cancer” Journal of Clinical Oncology 21 no.4 (February 2003): 602-606.
  3. C McCowan, et al.,“Cohort Study Examining Tamoxifen Adherence and its Relationship to Mortality in Women with Breast Cancer” British Journal of Cancer 99 (2008):  1763-1768.
  4. Cancer Experience Registry Index Report, 2017.  Washington, DC:  Cancer Support Community. https://www.cancersupportcommunity.org/sites/default/files/uploads/our-research/2017_Report/registry_report_final.pdf?v=1 (accessed March 8, 2018).
  5. Jacobsen, PB, Donovan KA, Trask PC, Fleishan SB, Zabora J, Baker F, Holland JC. Screening for Psychological distress in Ambulatory Cancer Patients. Cancer 2005 Apr 1;103(7):1494-502
  6. Bansal A, Ramsey SD, Feorenko Cr, et al. Journal of Clinical Oncology.  2015;34: ASCO Abstract 6509


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