Adherence to Oral Medications During Maintenance Therapy Among Children and Adolescents With Acute Lymphoblastic Leukemia: A Medication Refill Analysis

Associations between Medicaid enrollment and diagnosis stage and survival among pediatric cancer patients

BACKGROUND

Medicaid-associated disparities in childhood and adolescent (pediatric) cancer diagnosis stage and survival have been reported. However, a key limitation of prior studies is the assessment of health insurance at a single time point. To evaluate Medicaid-associated disparities more robustly, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid linked data to examine diagnosis stage and survival disparities in those (i) Medicaid-enrolled and (ii) with discontinuous and continuous Medicaid enrollment.

METHODS

SEER-Medicaid linked data from 2006 to 2013 were obtained on cases diagnosed from 0 to 19 years. Medicaid enrollment was classified as enrolled versus not enrolled, with further classifications as continuous when enrolled 6 months before through 6 months after diagnosis, and discontinuous when not enrolled continuously for this period. We used multinomial logistic and Cox proportional hazards regression models to determine associations between enrollment measures, diagnosis stage, and cancer death adjusted for covariates.

RESULTS

Among 21,502 cases, a higher odds of distant stage diagnoses were observed in association with Medicaid enrollment (odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.48-1.65), with the highest odds for discontinuous enrollment (OR = 2.0, 95% CI: 1.86-2.15). Among 30,654 cases, any Medicaid enrollment, continuous enrollment, and discontinuous enrollment were associated with 1.68 (95% CI: 1.35-2.10), 1.66 (95% CI: 1.35-2.05), and 1.89 (95% CI: 1.54-2.33) times higher hazards of cancer death versus no enrollment, respectively.

CONCLUSIONS

Medicaid enrollment, particularly discontinuous enrollment, is associated with a higher  distant stage diagnosis odds and risk of death. This study supports the critical need for consistent health insurance coverage in children and adolescents.

Polypharmacy and medication fill nonadherence in a population-based sample of adolescent and young adult cancer survivors, 2008-2017

PURPOSE

We examined the association between polypharmacy-an established risk factor for nonadherence in the elderly-and medication fill nonadherence in a large national sample of adolescent and young adult cancer survivors (AYAs) in the USA.

METHODS

We pooled data (2008-2017) from the Medical Expenditure Panel Survey. We defined polypharmacy as ≥ 3 unique medications prescribed, based on self-report and pharmacy data, and medication fill nonadherence as self-reported delay or inability to obtain a necessary medication. We estimated prevalence of medication fill nonadherence among AYAs (age 18-39 years with a cancer history). We used logistic regression to estimate the association between (1) polypharmacy and medication fill nonadherence in AYAs, and (2) total number of medications prescribed and medication fill nonadherence, controlling for sex, number of chronic conditions, disability, and survey year.

RESULTS

AYAs (n = 598) were predominantly female (76.2%), age 30-39 years (64.9%), and non-Hispanic White (72.1%). Nearly half were poor (19.0%) or near-poor/low income (21.6%). One in ten AYAs reported medication fill nonadherence (9.75%). Of these, more than 70% cited cost-related barriers as the reason. AYAs with polypharmacy had 2.49 times higher odds of medication fill nonadherence (95%CI 1.11-5.59), compared to those without polypharmacy. Odds of medication fill nonadherence increased by 16% with each additional medication prescribed (AOR 1.16, 95% CI 1.07-1.25).

CONCLUSIONS

Polypharmacy may be an important risk factor for medication fill nonadherence in AYAs in the USA.

IMPLICATIONS FOR CANCER SURVIVORS

Improving AYAs' medication adherence requires eliminating cost-related barriers, particularly for those with polypharmacy.

Impact of Mercaptopurine Metabolites on Disease Outcome in the AIEOP-BFM ALL 2009 Protocol for Acute Lymphoblastic Leukemia

In the maintenance phase of Associazione Italiana di Ematologia e Oncologia Pediatrica (AIEOP)- Berlin-Frankfurt-Muenster (BFM) acute lymphoblastic leukemia (ALL) 2009 protocol, mercaptopurine (MP) is given at the planned dose of 50 mg/m2 /day; however, dose adjustments are routinely performed to target patients' white blood cells to the optimal range of 2,000-3,000 cells/μL. Pediatric patients with ALL (n = 290, age: median (1st-3rd quartile): 4.8 (3.0-8.1) years; boys: 56.9%) were enrolled mainly in 4 medium-large Italian pediatric hospitals; 14.1% of patients relapsed after a median (1st-3rd quartile) follow-up time of 4.43 (3.82-5.46) years from maintenance beginning. MP metabolites (thionucleotide (TGN) and methyl-derivatives (MMPN)) were measured in the erythrocytes of 387 blood samples of 200 patients by high performance liquid chromatography with ultraviolet detection. Single-nucleotide polymorphisms (SNPs; (rs1800462, rs1800460, and rs1142345 in TPMT gene, rs116855232 in NUDT15, rs1127354, rs7270101, rs6051702 in ITPA, and rs2413739 in PACSIN2) were characterized by Taqman SNP genotyping assays. Cox proportional hazard models did not show an impact of TGN levels and variability on relapse. In contrast, after multivariate analysis, relapse hazard ratio (HR) increased in children with ALL of the intermediate risk arm compared with those in standard risk arm (3.44, 95% confidence interval (CI), 1.31-9.05, P = 0.012), and in carriers of the PACSIN2 rs2413739 T allele compared with those with the CC genotype (heterozygotes CT: HR, 2.32, 95% CI, 0.90-5.97, P = 0.081; and homozygous TT: HR, 4.14, 95% CI, 1.54-11.11, P = 0.005). Future studies are needed to confirm the lack of impact of TGN levels and variability on relapse in the AIEOP-BFM ALL trials, and to clarify the mechanism of PACSIN2 rs2413739 on outcome.

The demands of caregivers of children with acute lymphoblastic leukaemia in different therapy stages and the exploration of possible interventions: A longitudinal investigation survey at a Tertiary Medical Institution

AIM

To describe the demands of family caregivers of children with ALL at different therapy stages and explore the possible interventions to address their care demands.

DESIGN

A longitudinal investigation study.

METHOD

A total of 157 family caregivers of children treated in the Haematological oncology ward of a tertiary medical hospital in China between March and December in 2020 were included in this study. The Comprehensive Needs of Caregivers of Cancer Patients and Families Taking Care of Children Scale was used to investigate the family caregivers of children with ALL. The family caregivers completed the questionnaire accompanied by a researcher within two weeks of each therapy stage, which included the induction, consolidation and continuation stages.

RESULTS

Family caregivers of children with ALL had many demands that varied based on the stage of therapy. Family caregivers in the induction therapy stage needed more information about their children's disease, having the highest score in information demands (35.60 ± 5.85). The family caregivers in the consolidation therapy stage needed more information on symptom management and socio-economic support, having the highest score in care and support demands (36.14 ± 5.12). The family caregivers in the continuation therapy stage (including interim and maintenance therapy stages) focused more on their own and the children's social adaptation, so they scored the highest for psychosocial demands (35.96 ± 5.69).

CONCLUSION

Family caregivers of children with ALL had different demands that varied based on the stage of therapy. Medical personnel should be aware of the primary needs of family caregivers at different therapy stages to provide early interventions and support based on their demands, ultimately improving the physical and mental condition of family caregivers and the quality of care.

Adherence to Oral Chemotherapy in Acute Lymphoblastic Leukemia during Maintenance Therapy in Children, Adolescents, and Young Adults: A Systematic Review

Acute lymphoblastic leukemia (ALL) is the most common malignancy in children and young adults. Treatment is long and involves 2-3 years of a prolonged maintenance phase composed of oral chemotherapies. Adherence to these medications is critical to achieving good outcomes. However, adherence is difficult to determine, as there is currently no consensus on measures of adherence or criteria to determine nonadherence. Furthermore, there have been few studies in pediatric B-ALL describing factors associated with nonadherence. Thus, we performed a systematic review of literature on oral chemotherapy adherence during maintenance therapy in ALL following PRISMA guidelines. Published studies demonstrated various objective and subjective methods of assessing adherence without generalizable definitions of nonadherence. However, the results of these studies suggested that nonadherence to oral maintenance chemotherapy was associated with increased risk of relapse. Future studies of B-ALL therapy should utilize a uniform assessment of adherence and definitions of nonadherence to better determine the impact of nonadherence on B-ALL outcomes and identify predictors of nonadherence that could yield targets for adherence improving interventions.

Adherence and Barriers to Inpatient Physical Therapy Among Adolescents and Young Adults with Hematologic Malignancies

This study described inpatient physical therapy (PT) adherence and barriers to inpatient PT among adolescents and young adults (AYAs) with hematologic malignancies receiving care at a Midwestern children's hospital. Forty-seven AYAs receiving care over a 2-year period were included. PT contact was established in 93% of hospitalizations. AYAs declined an average of 34% of PT visits, resulting in PT visits on 27% of hospitalized days, 1 day less than the goal of 3 days a week. The most frequent reasons for decline included: AYA sleeping (22%), AYA undergoing medical procedure (18%), and AYA not feeling well (12%).

Controversies in the Treatment of Adolescents and Young Adults with Philadelphia Chromosome-Negative B-Cell Acute Lymphoblastic Leukemia

PURPOSE OF THE REVIEW

The incidence of acute lymphoblastic leukemia (ALL) has been increasing steadily in the adolescent and young adult (AYA) population. In this review article focused on the management of AYAs with Philadelphia chromosome-negative (Ph-) B-ALL, we examine topics of clinical interest and identify areas of controversy in need of further investigation.

RECENT FINDINGS

We explore four areas of active investigation: pediatric-inspired front-line treatment regimens, the optimal time of measurable residual disease (MRD) assessment, the role of hematopoietic stem cell transplant and the optimal salvage therapy for relapsed/refractory B-ALL in AYAs. There has been rapid advancement in the management of ALL in the AYA patient population, which has resulted in improved outcomes. We must build on the successes by continuing to promote multi-center innovative clinical research with clinical trial populations reflecting the AYA ALL patient spectrum. The incorporation of novel targeted immunotherapy into front-line treatment will be transformative and redefine treatment paradigms in the coming years.

Understanding Adolescent and Young Adult 6-Mercaptopurine Adherence and mHealth Engagement During Cancer Treatment: Protocol for Ecological Momentary Assessment

BACKGROUND

Adolescents and young adults (AYAs) with cancer demonstrate suboptimal oral chemotherapy adherence, increasing their risk of cancer relapse. It is unclear how everyday time-varying contextual factors (eg, mood) affect their adherence, stalling the development of personalized mobile health (mHealth) interventions. Poor engagement is also a challenge across mHealth trials; an effective adherence intervention must be engaging to promote uptake.

OBJECTIVE

This protocol aims to determine the temporal associations between daily contextual factors and 6-mercaptopurine (6-MP) adherence and explore the proximal impact of various engagement strategies on ecological momentary assessment survey completion.

METHODS

At the Children's Hospital of Philadelphia, AYAs with acute lymphoblastic leukemia or lymphoma who are prescribed prolonged maintenance chemotherapy that includes daily oral 6-MP are eligible, along with their matched caregivers. Participants will use an ecological momentary assessment app called ADAPTS (Adherence Assessments and Personalized Timely Support)-a version of an open-source app that was modified for AYAs with cancer through a user-centered process-and complete surveys in bursts over 6 months. Theory-informed engagement strategies will be microrandomized to estimate the causal effects on proximal survey completion.

RESULTS

With funding from the National Cancer Institute and institutional review board approval, of the proposed 30 AYA-caregiver dyads, 60% (18/30) have been enrolled; of the 18 enrolled, 15 (83%) have completed the study so far.

CONCLUSIONS

This protocol represents an important first step toward prescreening tailoring variables and engagement components for a just-in-time adaptive intervention designed to promote both 6-MP adherence and mHealth engagement.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32789.

Metronomic Maintenance for High-Risk Pediatric Malignancies: One Size Will Not Fit All

Maintenance therapy sometimes relies on the use of metronomic chemotherapy (MC); that is, the continuous administration of low-dose chemotherapy. Maintenance therapy has been successfully used for decades in pediatric patients with acute lymphoblastic leukemia (ALL) and recent results have demonstrated improved outcomes in patients with pediatric high-risk rhabdomyosarcoma (RMS) on maintenance therapy. Here, we review the use of metronomic maintenance therapy in pediatric cancer and discuss its mechanisms of action on the tumor microenvironment and cancer cells. We also discuss its potential use as a chemotherapy alone or in combination with targeted therapies, immunotherapies, or agents for drug repurposing.

Promoting adherence in adolescents and young adults with cancer to optimize outcomes: A developmentally oriented narrative review

Adherence is a critical consideration in ongoing efforts to improve outcomes among adolescents and young adults (AYAs) with cancer. In this narrative review, we embed existing conceptualizations of adherence within a developmental context to provide a novel vantage point from which to examine this important issue. Applying this developmentally oriented framework, we summarize the most current literature on strategies to enhance adherence in the AYA population. A developmentally informed approach to working with AYAs can elucidate unique strengths and vulnerabilities of this population and offer a new perspective on opportunities to respond to biopsychosocial barriers to adherence in a strengths-based, collaborative manner.

A Systematic Review of Rates, Outcomes, and Predictors of Medication Non-Adherence Among Adolescents and Young Adults with Cancer

Nonadherence to medications in cancer treatment protocols may be a particular concern among adolescents and young adults (AYAs) with cancer and predictive of poor health outcomes, but data supporting this claim remain limited. The purpose of this article was to systematically review the rates, outcomes, and predictors of oral medication nonadherence among AYAs with cancer. PubMed (i.e., MEDLINE), CINAHL, and PsycINFO databases were searched in 2018 using terms related to medication adherence and cancer. A total of 37,884 records representing 34,006 unique articles were identified and reviewed. Thirteen articles representing 12 studies met inclusion criteria and examined medication adherence among AYAs with cancer. Results of these studies suggest that 21%-60% of AYAs are nonadherent to oral medications, likely placing them at increased risk for poor health outcomes (i.e., relapse, infection/fever, and death). Psychosocial factors (i.e., knowledge, beliefs about capabilities, beliefs about consequences, environmental context and resources, and emotion) were related to nonadherence and warrant future study. Of note, demographic, disease, and family composition variables did not predict nonadherence. Clinical implications as well as limitations and resulting future directions are discussed.