The Pledge of Adherence

By Lisa Harrison |

A practice-level guide to improving oral oncolytics adherence.

Oral oncolytics currently make up 25 to 30 percent of cancer drug therapies and their use is continually expanding. In fact, the FDA now approves one new oral oncolytic every four months. And while the demand for oral drug therapies is on the rise, patient adherence is low. Studies reveal rates of non-adherence ranges from 20 to 80 percent.1 This has many physician practices asking why, and more importantly, what can be done to improve it? The answers may lay in new ways to use current resources and new areas to grow the practice.

Unlike infused oncology regimens, oral drug therapies transfer the responsibility of medication administration from the doctor to the patient, reducing the frequency of patient-practice interaction. This gap and its consequential impact to patient drug adherence presents a need for the practice to reallocate time that would have been spent during face-to-face appointments to less traditional (and increasingly more critical) patient touch points. In addition to adopting a new clinical pathway to manage patients on oral oncolytics, practices should consider when to reach out and what circumstances might prevent the patient from adhering to their prescribed drug therapy.

In a self-reported survey of breast cancer patients, 33 percent reported their healthcare provider discussed the importance of adherence with them only once, and this occurred before treatment began. When asked to select factors that could have increased their adherence, 89 percent selected knowledge that their oral drug therapy might improve clinical outcomes and 60 percent cited improved side effect management.2 What this survey may reveal is not a lack in action on the practice side, but a lack of understanding of the patient mindset after a negative diagnosis.

Master Crisis Communications

No matter the severity of the diagnosis or the progress of treatment, the practitioner will find himself or herself trying to educate a patient in crisis. No matter the severity of the diagnosis or the progress of treatment, the practitioner will find himself or herself trying to educate a patient in crisis.  A heightened emotional state can compromise the patient's ability to absorb and retain all the critical information about the prescribed oral drug therapy. For this reason, providers should consider the following protocols during the initial patient education process:

  • Dedicate additional time for patient education. Best practices put this at 20 to 30 minutes performed a few days after diagnosis when emotions are less likely to cloud judgment or memory.
  • When possible, recommend the patient bring a second set of ears - a family member, friend, or spouse. This person serves as a potential caregiver and additional touch point for the practice.
  • Help the patient get an understanding of the drug and its benefits. Many patients think that because it's a pill it's not as effective. Oral therapy patients need to understand the importance of their therapy and how it impacts their disease outcome. 
  • Manage expectations around side effects. While practitioners know that side effects can signal that the drug is working, patients only see the potential compromise to their lifestyle. As a sign of commitment, the patient should agree to follow strategies that could minimize adverse side effects and not abandon therapy.
  • In addition to details around dosing, discuss if/then scenarios: What happens if the patient misses a dose, if they take it on an empty stomach and the prescribed therapy requires food. These rules not only establish a protocol for patients to follow, they reinforce the critical nature of adhering to the drug exactly as prescribed.
  • Reconcile and discuss all current and potential medications, even over-the-counter medications and supplements, as well as food and alcohol that might interfere with the oral drug therapy being prescribed.
  • Finally, provide a written summary of your discussion in an easy-to-digest format.
Subscribe To Patient Profiling

Considering all the medication-related information that need to be absorbed, retained and enacted into everyday life, it's worth conducting a pre-assessment to determine whether the patient is an ideal candidate for oral therapies simply based on their lifestyle, education and economic level. For instance:

  • Do they have good reading and communication skills or have responsible, committed family members that could communicate on their behalf?
  • Do they have the means to integrate their therapy into their daily routine?
  • Do they have the ability to swallow pills and/or liquids?
  • Will they be able to pay for the oral drug therapy prescribed?

The latter question is a common sticking point in non-adherence scenarios. While most traditional intravenous oncology medications are covered under a patient's medical benefits, oral oncolytics are almost always managed under the pharmacy benefit of a health plan. This can result in higher out-of-pocket costs for the patient, resulting in the patient under-adhering by taking the drug less frequently or halting adherence all together. One study showed that up to 10 percent of patients chose not to fill their initial prescriptions for oral cancer drugs because of prohibitive cost sharing.3 For this reason it's recommended that practices help determine the treatment cost to the patient and, if needed, direct them toward financial assistance resources.

After completing a proper evaluation to determine the likelihood of adherence and giving a thorough initial education, practices can then turn their focus to outpatient support. This process is made simpler and sounder with some upfront preparation:

  • Develop a written protocol for the most prescribed regimens so they're accessible to clinicians. In addition to benefits and other data from clinical trial, this template-style document should outline what side effects to expect and when. This ultimately provides a roadmap for the practitioner to flag key dates for follow up.
  • Provide adherence aids, such as pillboxes, access to reminder apps or printed calendars, and encourage the patient to keep a daily journal - whether recorded or written. Keep in mind the practicality of the tools to the patient. If they're not likely to maintain a journal or react to reminders, perhaps those should be handed off to the home caregiver.
  • In addition to labs, consider scheduling regular appointments to evaluate the response to therapy and identify adherence issues early.
  • Contact patients who miss or cancel appointments and schedule a follow-up visit to re-engage.
  • Have on-call resources for patients who may need clarification or advice.
Play Up Practice Strengths

While managing adherence to oral oncolytics is a daunting endeavor for some practices, the right role allocation can minimize costs while maximizing job capabilities and skill sets. Whether it's the oncologist or oncology-certified nurse doing the initial patient education, the nurse practitioner conducting follow-up phone calls, or the pharmacist or technician conducting a pill count with the patient, every member of the clinical staff can contribute to adherence support. Plus, if detailed, yet digestible protocols are established for each drug regimen, the clinical team becomes better educated and more empowered to address potential barriers with every oral drug therapy prescribed.

It's worth mentioning that as oral oncolytics become more common in the practice, there are additional opportunities to be considered - both of which target improving adherence rates while setting the practice up for growth.

Partner with specialty pharmacies.

Medication Therapy Management (MTM) is a practice where community pharmacies work closely with patients to ensure they understand their medication and therapy process. The high-touch program not only simplifies complex regimens for patients and adds a layer of support, it can help identify potentially harmful drug interactions. Patients are ensured the attention they need to remain adherent to their prescribed drug therapies, while practices can gain actionable information from the pharmacist relative to the patient's progress.

Consider becoming an in-practice dispenser.

There are a number of reasons why practices might become a dispenser. Among the leading incentives: Control. The practice prescribes the drug, doses it and gives it to the patient - in most cases the same day they're prescribed. Equally important, the direct interaction can help mitigate the issue of non-adherence. Having an in-house pharmacy can also lead to additional benefits, like fostering collaboration between staff, expediting reimbursement and improving the clinical review of medications (i.e., possible interactions).

The challenges surrounding oral oncolytics present unique opportunities for practices to promote and facilitate medication adherence. As the oncology landscape continues to evolve, the clinical team must work together with a patient-centric vision to optimize the patient experience and their clinical outcomes. That means developing a practice-level protocol that emphasizes upfront education and timely touch points, leveraging unique skill sets already within the practice and potentially exploring new partnerships and capabilities.

1. Roshan Rahnama, Aileen Soper, "Oral Oncolytics: New Reimbursement Opportunities in a Shifting Landscape," Oncologistics magazine, Fall 2014.
2. Kirk MC, Hudis CA. Insight into barriers against optimal adherence to oral hormonal therapy in women with breast cancer. Clin Breast Cancer. 2008;8(2):155-61.
3. Ibid.

About the Author

Lisa Harrison

Lisa Harrison

President and General Manager
Oncology Supply
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