Considerations when choosing oral chemotherapy: identifying and responding to patient need

Assessment of patient perceptions of counselling on oral antineoplastic agents by a dedicated cancer services pharmacist in an outpatient cancer clinic

BACKGROUND

Oral antineoplastic agents have caused a paradigm shift in cancer treatment, however, they produce many unique challenges. Although oral antineoplastics can have complex administration regimes, low adherence rates and high possibilities of drug-drug interactions, they are administered unsupervised at home. Cancer services pharmacists have the required skillsets to improve patient outcomes associated with oral antineoplastic treatment by increasing patient health literacy, improving concordance and optimising administration protocols.

AIM

To evaluate patients' perceptions, experiences and overall satisfaction with dedicated clinical pharmacist consultations in patients treated with oral antineoplastic agents at a major public hospital.

METHOD

In this retrospective cross-sectional study at a quaternary hospital in Western Australia, data were collected by a paper questionnaire (mailed in March 2022) to a random sample of 191 patients initiated on oral antineoplastic drugs between January 2021 and February 2022. Demographics, prescribed antineoplastic drug/s, cancer type data were collected including using 5-point Likert scale questions assess patients' overall satisfaction with the clinical pharmacist consultations.

RESULTS

The questionnaire response rate was 27.7% (52/188) (mean age 63.2 years; 57.5% female). Most patients (42/52; 80.8%) were satisfied with pharmacist consultations, trusted the pharmacist's advice (45/52; 86.5%), considered that the pharmacist improved their understanding of how to manage side effects (43/52; 82.7%) and they provided an important service in outpatient care (45/52; 86.5%).

CONCLUSION

Overall, patients reported positive perceptions, experiences, and satisfaction with the cancer services pharmacist counselling services during their oral antineoplastic treatment.

Effect and mechanism of actionin vitroof cyclodextrin derivative nanoparticles loaded with tyroserleutide on hepatoma

In this study, a cyclodextrin derivative (R6RGD-CMβCD) nanoparticle with tumor targeting and cell penetration ability was successfully synthesized and loaded with tyroserleutide (YSL) to obtain YSL-loaded nanoparticles (YSL/R6RGD-CMβCD NPs). The characterization of these NPs revealed a smooth surfaces and an average diameter of approximately 170 nm. YSL/R6RGD-CMβCD NPs increased the NP uptake in Caco-2 cells. As regard the mechanism of action, the cell uptake was related to endocytosis mediated by reticulin and megacytosis. In addition, YSL/R6RGD-CMβCD NPs induced significantly higher cytotoxicity on tumor cells and better tumor targeting compared with the effect of CMβCD NPs. Most importantly, the good anti-cancer effect of YSL/R6RGD-CMβCD NPs might be due to the interference with the function of mitochondria. On the other hand, YSL/R6RGD-CMβCD NPs were not toxic for normal cells. Taken together, our results indicated that R6RGD-CMβCD could be considered as a nanopharmaceutical material with good tumor targeting abilities, and their combination with YSL could represent an effective anti-cancer system.

The Effect of Structured Education to Patients Receiving Oral Agents for Cancer Treatment on Medication Adherence and Self-efficacy

OBJECTIVE

This study was conducted to examine the effect of structured education on medication adherence and self-efficacy through the use of the MASCC Oral Agent Teaching Tool (MOATT) for patients receiving oral agents for cancer treatment.

METHODS

This quasi-experimental study has been conducted at two hospitals; 41 patients were included in the study. Data were obtained using a questionnaire, medication adherence self-efficacy scale (MASES), memorial symptom assessment scale, and a follow-up form (diary). Patients were educated through the use of the MOATT at a scheduled time; drug-specific information was provided along with a treatment scheme and follow-up diary. Phone interviews were completed 1 and 2 weeks after the educational session. At the next treatment cycle, the patients completed the same questionnaires.

RESULTS

Majority of the patients were receiving capecitabine (90.2%; n = 37) as an oral agent for breast (51.2%; n = 21) and stomach cancer (24.6%; n = 10) treatment. About 90.2% of patients (n = 37) stated that they did not forget to take their medication and experienced medication-related side effects (78%; n = 32). The total score of MASES was increased after the education (66.39 vs. 71.04, P < 0.05).

CONCLUSIONS

It was shown that individual education with the MOATT and follow-up for patients receiving oral agents for cancer treatment increased patient medication adherence self-efficacy.

Factors Influencing Adherence in Cancer Patients Taking Oral Tyrosine Kinase Inhibitors: A Qualitative Study

BACKGROUND

Nonadherence in cancer patients taking oral anticancer drugs is common. Reasons for nonadherence are still not really understood as influencing factors are often complex, dynamic, and interrelated.

OBJECTIVE

A qualitative study was conducted to gain insight into (non-)adherence behavior in patients taking oral tyrosine kinase inhibitors by exploring (1) processes and factors influencing (non-)adherence and (2) their interrelatedness.

METHODS

Semistructured interviews were held with 30 patients of different ages and with different types of cancer. A grounded theory approach was used.

RESULTS

Three foci were found when dealing with oral tyrosine kinase inhibitors: (1) a focus on survival, (2) a focus on quality of life, and (3) a balance between survival and quality of life. The process of adherence was determined by a set of complex and interrelated influencing factors: treatment-related side effects, hope, anxiety, trust, and feedback mechanisms.

CONCLUSIONS

This qualitative study gives insight into processes and factors influencing (non-)adherence behavior in patients taking oral tyrosine kinase inhibitors. The results of this study can help healthcare professionals understand why patients taking oral tyrosine kinase inhibitors do not always adhere to their therapy.

IMPLICATIONS FOR PRACTICE

Conditions should be created by which patients get maximum opportunity to establish a balance between survival and quality of life. An open climate and a trust-based relationship should be established in which patients feel comfortable to openly discuss their therapy and the difficulties they experience.

2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy

In 2009, ASCO and the Oncology Nursing Society (ONS) published standards for the safe use of parenteral chemotherapy in the outpatient setting, including issues of practitioner orders, preparation, and administration of medication. In 2011, these were updated to include inpatient facilities. In December 2011, a multistakeholder workgroup met to address the issues associated with orally administered antineoplastics, under the leadership of ASCO and ONS. The workgroup participants developed recommended standards, which were presented for public comment. Public comments informed final edits, and the final standards were reviewed and approved by the ASCO and ONS Boards of Directors. Significant newly identified recommendations include those associated with drug prescription and the necessity of ascertaining that prescriptions are filled. In addition, the importance of patient and family education regarding administration schedules, exception procedures, disposal of unused oral medication, and aspects of continuity of care across settings were identified. This article presents the newly developed standards.

Pharmacokinetics and antitumor efficacy of paclitaxel-cyclodextrin complexes loaded in mucus-penetrating nanoparticles for oral administration

AIM

The authors report a novel approach for enhancing the oral absorption of paclitaxel (PTX) by encapsulation in poly(anhydride) nanoparticles (NPs) containing cyclodextrins and poly(ethylene glycol).

MATERIALS & METHODS

Formulations were prepared using the solvent displacement method. Subsequently, pharmacokinetics and organ distribution assays were evaluated after oral administration into C57BL/6J mice. In addition, antitumor efficacy studies were performed in a subcutaneous tumor model of Lewis lung carcinoma.

RESULTS

PTX-loaded NPs displayed sizes between 190-300 nm. Oral NPs achieved drug plasma levels for at least 24 h, with an oral bioavailability of 55-80%. Organ distribution studies revealed that PTX, orally administered in NPs, underwent a similar distribution to intravenous Taxol(®) (Bristol-Myers Squibb, NJ, USA). For in vivo antitumor assays, oral strategy maintained a slower tumor growth than intravenous Taxol.

CONCLUSION

PTX orally administered in poly(anhydride) NPs, combined with cyclodextrins and poly(ethylene glycol), displayed sustained plasma levels and significant antitumor effect in a syngenic tumor model of carcinoma in mice.

2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy

In 2009, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) published standards for the safe use of parenteral chemotherapy in the outpatient setting, including issues of practitioner orders, preparation, and administration of medication. In 2011, these were updated to include inpatient facilities. In December 2011, a multistakeholder workgroup met to address the issues associated with orally administered antineoplastics, under the leadership of ASCO and ONS. The workgroup participants developed recommended standards, which were presented for public comment. Public comments informed final edits, and the final standards were reviewed and approved by the ASCO and ONS Boards of Directors. Significant newly identified recommendations include those associated with drug prescription and the necessity of ascertaining that prescriptions are filled. In addition, the importance of patient and family education regarding administration schedules, exception procedures, disposal of unused oral medication, and aspects of continuity of care across settings were identified. This article presents the newly developed standards.

pH-responsive hydrogels with dispersed hydrophobic nanoparticles for the oral delivery of chemotherapeutics

Amphiphilic polymer carriers were formed by polymerizing a hydrophilic, pH-responsive hydrogel composed of poly(methacrylic-grafted-ethylene glycol) (P(MAA-g-EG)) in the presence of hydrophobic PMMA nanoparticles. These polymer carriers were varied in PMMA nanoparticle content to elicit a variety of physiochemical properties which would preferentially load doxorubicin, a hydrophobic chemotherapeutic, and release doxorubicin locally in the colon for the treatment of colon cancers. Loading levels ranged from 49% to 64% and increased with increasing nanoparticle content. Doxorubicin loaded polymers were released in a physiological model where low pH was used to simulate the stomach and then stepped to more neutral conditions to simulate the upper small intestine. P(MAA-g-EG) containing nanoparticles were less mucoadhesive as determined using a tensile tester, polymer samples, and fresh porcine small intestine. The cytocompatibility of the polymer materials were assessed using cell lines representing the GI tract and colon cancer and were noncytotoxic at varying concentrations and exposure times.

pH-responsive hydrogels containing PMMA nanoparticles: an analysis of controlled release of a chemotherapeutic conjugate and transport properties

Biopolymers composed of a pH-responsive, hydrophilic poly(methacrylic acid-grafted-ethylene glycol) network polymerized in the presence of poly(methyl methacrylate) nanoparticles were designed for the oral delivery of chemotherapeutics for the treatment of colon cancer. An inulin-doxorubicin conjugate, designed to target the colon and improve doxorubicin efficacy, was loaded into these polymer carriers at an efficiency of 54%. Release studies indicated these polymer carriers minimized conjugate release in low pH conditions and released the conjugate at neutral pH conditions using a two-step pH experiment modeling the stomach and the small intestine. At lower concentration levels, the presence of the polymer carriers did not disrupt tight junctions as determined by transepithelial electrical resistance studies using Caco-2 and HT29-MTX cell lines which are an accurate model of the GI tract epithelia. Permeability values of unmodified doxorubicin and the inulin-doxorubicin conjugate in the presence of the polymer carriers were also determined using the same cell models and ranged from 1.87 to 3.80 × 10 (-6) cm/s.

pH-Responsive Hydrogels with Dispersed Hydrophobic Nanoparticles for the Delivery of Hydrophobic Therapeutic Agents

To investigate the delivery of hydrophobic therapeutic agents, a new class of polymer carriers was synthesized. These carriers are composed of two components: (i) a pH-responsive hydrogel composed of methacrylic acid grafted with poly(ethylene glycol) tethers, P(MAA-g-EG), and (ii) hydrophobic poly(methyl methacrylate) (PMMA) nanoparticles. Before the P(MAA-g-EG) hydrogel was crosslinked, PMMA nanoparticles were added to the solution and upon exposure to UV light they were photoencapsulated throughout the P(MAA-g-EG) hydrogel structure. The pH-responsive behavior of P(MAA-g-EG) is capable of triggered release of a loaded therapeutic agent, such as a low molecular weight drug or protein, when it passes from the stomach (low pH) to upper small intestine (neutral pH). The introduction of PMMA nanoparticles into the hydrogel structure affected the swelling behavior, therapeutic agent loading efficiency, and solute release profiles. In equilibrium swelling conditions the swelling ratio of nanoparticle-containing hydrogels decreased with increasing nanoparticle content. Loading efficiencies of the model therapeutic agent fluorescein ranged from 38 - 51 % and increased with increasing hydrophobic content. Release studies from neat P(MAA-g-EG) and the ensuing P(MAA-g-EG) hydrogels containing nanoparticles indicated that the transition from low pH (2.0) to neutral pH (7.0) triggered fluorescein release. Maximum fluorescein release depended on the structure and hydrophobicity of the carriers used in these studies.

Molecular buckets: cyclodextrins for oral cancer therapy

The oral route is preferred by patients for drug administration due to its convenience, resulting in improved compliance. Unfortunately, for a number of drugs (e.g., anticancer drugs), this route of administration remains a challenge. Oral chemotherapy may be an attractive option and especially appropriate for chronic treatment of cancer. However, this route of administration is particularly complicated for the administration of anticancer drugs ascribed to Class IV of the Biopharmaceutical Classification System. This group of compounds is characterized by low aqueous solubility and low intestinal permeability. This review focuses on the use of cyclodextrins alone or in combination with bioadhesive nanoparticles for oral delivery of drugs. The state-of-the-art technology and challenges in this area is also discussed.

Amphiphilic Interpenetrating Networks for the Delivery of Hydrophobic, Low Molecular Weight Therapeutic Agents

To investigate the delivery of hydrophobic therapeutic agents, a novel class of interpenetrating networks (IPNs) were synthesized and composed of two networks: methacrylic acid grafted with poly(ethylene glycol) tethers, P(MAA-g-EG), and poly(n-butyl acrylate) (PBA). The hydrophilic P(MAA-g-EG) networks are pH-responsive hydrogels capable of triggered release of an encapsulated therapeutic agent, such as a low molecular weight drug or a protein, when it passes from the stomach (low pH) to upper small intestine (neutral pH). PBA is a hydrophobic homopolymer that can affect the IPN swelling behavior, the therapeutic agent loading efficiencies in IPNs, and solute release profiles from IPNs. In dynamic swelling conditions, IPNs had greater swelling ratios than P(MAA-g-EG), but in equilibrium swelling conditions the IPN swelling ratio decreased with increasing PBA content. Loading efficiencies of the model therapeutic agent fluorescein ranged from 21 - 44%. Release studies from neat P(MAA-g-EG) and the ensuing IPNs indicated that the transition from low pH (2.0) to neutral pH (7.0) triggered fluorescein release. Maximum fluorescein release depended on the structure and hydrophilicity of the carriers used in these studies.

Adherence and oral agents with older patients

OBJECTIVE

Oral antineoplastic agents offer multiple advantages in cancer therapies. Thus, understanding issues of adherence to these agents for older adults becomes critical to successful comprehensive care of the older cancer patient.

DATA SOURCES

This analysis of adherence to oral agents among older cancer patients draws on interdisciplinary geriatric and oncologic research reports and clinical reviews.

CONCLUSION

Older adults are at increased risk for poor adherence to oral agents. Barriers to adherence are diverse. Problems emerge from age-related physical changes, comorbid conditions, polypharmacy, and drug interactions. Psychosocial barriers include limited insurance coverage and transportation problems to social isolation and inadequate social support.

IMPLICATION FOR NURSING PRACTICE

Nurses should lead interdisciplinary, individualized plans of care to mitigate barriers and support adherence to cancer therapy.