Section 3. Unique Considerations With Oral Therapies

Adherence to an oral cancer therapy regimen can be a challenging commitment for patients and their caregivers. Highly motivated patients who take an active role in their care are well suited to manage home oral administration of chemotherapy, but this does not mean that, with good teaching and support, less motivated patients would be unsuccessful. The challenges for oncology nurses include identifying motivated patients, increasing motivation in others, and addressing barriers that stand in the way of optimal adherence. Challenges for patients include complexity of the medication regimen and scheduling issues, interactions with other drugs and foods, adverse effects, and access to medications.

3.1. Complexity of Oral Therapies in Oncology

The more complex the regimen, the higher the risk of error and nonadherence. This is true for all oral medication regimens, not just those treating cancer. Medication regimens that require multiple daily doses or complicated administration instructions specific to timing, dietary restrictions, or other factors often result in lower adherence (Haynes, McDonald, & Garg, 2002; Partridge et al., 2002).

3.2. Drug-Drug and Food-Drug Interactions

Oral chemotherapy, targeted agents, and chemoprevention agents have drug-drug and drug-food interactions that may or may not mirror their IV counterparts (if any exist.) While some classes of agents, such as the tyrosine kinase inhibitors, share similarities in regard to drug-drug interactions, there is enough variation that the practitioner should not rely on the class of drug to determine these interactions. It is prudent to address each agent individually, relying on published information and experts in the field to determine the type and extent of the interactions and the recommendations for how to deal with them.

Oral cancer therapies can interact with other medicines or food. Some are taken with food or immediately after eating; others must be taken on an empty stomach (up to one hour before or two hours after eating). A regimen may include more than one drug, with each drug having different eating guidelines. An example is the capecitabine-lapatinib combination for metastatic breast cancer. Capecitabine is taken within 30 minutes after eating; lapatinib is taken on an empty stomach. Tool 1 includes a list of currently available oral therapies, including drug-drug interactions and instructions on timing with meals.

3.3. Adverse Effects

This Toolkit is not designed to provide comprehensive information on the particular adverse effects for each drug. A better resource for that information is the prescribing information for each drug, available from the pharmacy, online at the drug manufacturer’s Web site, or via established drug information databases such as MicroMedex^®, Lexi-Comp^®, or Epocrates®. Patients’ anticipation of side effects often is enough to negatively affect their decisions about treatment and can negatively affect adherence as well. Comprehensive patient education at the beginning of therapy will help patients plan for side effects and give them information on what side effects they can safely manage at home or when they need to contact the nurse or doctor for help. Prompt management of side effects as they occur will reassure patients that side effects are manageable and will be addressed by nurses and physicians. Tool 2 lists common side effects of oral cancer therapies, listed by drug classification. Full side effect profiles for the drugs listed here, as well as additional drugs not listed, can be found in each drug’s prescribing information.

3.4. Cost, Insurance, and Access to Medications

A challenge for patients that has a significant impact on adherence is the cost of oral therapies, which can run to more than $10,000 per month. Depending on many variables, insurance plans may or may not cover the drug, and even if they do, sometimes the copay is untenable. The ability to obtain the medication (access) may be a deterrent to adherence, as some pharmacies will choose not to stock the agents because of the cost, and some agents are limited to certain pharmacies by regulatory agencies.

Many drug companies offer patient assistance programs to help with the cost and/or copays, yet these programs can be difficult and confusing to maneuver and monitor. Nurses, pharmacists, or social workers can be invaluable in assisting patients through these issues. Tool 3 includes information about reimbursement and general resources for patients who may have difficulty paying for their oral therapies for cancer.

What the nurse can do to help the patient navigate a retail pharmacy:

1. Encourage the patient to always utilize one pharmacy. This will help ensure that a current medication profile is maintained and that drug-drug interactions are monitored.
2. Discuss with the patient the importance of disclosing all therapy to all HCPs. Studies show that while up to two-thirds of patients getting treatment for cancer take complementary or alternative medications, only about 10% of those people share that information with the doctor, nurse, or pharmacist (Werneke et al., 2004).
3. Be an advocate for the patient. Ask whether he or she is having any issues accessing the medication from the pharmacy. If so, call and speak with the pharmacist about the importance of the therapy, and determine what barriers exist for successful treatment of the patient.