Examining adherence to oral anticancer medications through a human factors engineering framework: Protocol for a scoping review

BACKGROUND

The number of oral anticancer medications has increased over the past few decades, opening new possibilities in cancer care and improving convenience for patients and caregivers. However, adherence levels continue to be suboptimal, potentially jeopardizing therapeutic benefits. Poor adherence levels may indicate gaps in current strategies and interventions aimed at enhancing medication adherence and the extent to which they address the complex and multi-faceted medication management needs of patients and their caregivers. Beyond commonly understood barriers (e.g., forgetting to take medications), adherence interventions must address systemic barriers that may not be fully appreciated by members of the healthcare system. This scoping review aims to apply a systems framework (human factors engineering framework) to examine system elements targeted by adherence enhancing interventions.

METHODS

Studies published in English, reporting adherence interventions for oral anticancer medications with adherence and/or persistence as primary outcome measures will be included in this review. We will search the following electronic databases with no limits on dates: Ovid MEDLINE, Cochrane Library, Web of Science Core Collection, Embase, CINAHL Complete, PsycInfo, and Scopus. Two reviewers will independently screen study titles and abstracts for inclusion with a third reviewer adjudicating conflicts. Full text of included articles will be used to extract information on systemic barriers targeted by adherence interventions as well as information about intervention type, outcomes, and study characteristics. Extracted information will be synthesized to generate a summary of work system factors targeted by adherence interventions.

DISCUSSION

Through application of a systems-based approach, this scoping review is expected to shed light on the complex and multifaceted nature of factors influencing adherence to oral anticancer agents. The review may also identify areas that are ripe for further research.

A Pilot Nurse-Led Tele-Counseling Intervention to Parents of Children With Cerebral Visual Impairment on Adherence to Eye Activities During COVID-19 Pandemic: A Pre-experimental Study

Aim

To assess the impact of a culturally appropriate and theoretically driven nurse-led tele-counseling intervention to parents of children with cerebral visual impairment (CVI) on the adherence to visual therapy advised by the ophthalmologists.

Design

A pre-experimental design was used.

Methods

Parents of children with CVI aged 2–9 years were enroled telephonically during the coronavirus disease 2019 (COVID-19) pandemic through the Pediatric Ophthalmology Clinic of a tertiary eye care center. Pre-assessment of participants was done telephonically as per the interview schedule. As per the protocol, the trained nurse-delivered tele-counseling intervention two times weekly for the first 2 weeks and weekly for the next 2 weeks via audio and video two-way tele-interaction with parents. A CVI information booklet was shared with parents via WhatsApp interface and individualized visual therapy was reinforced in accordance with the advice of the treating ophthalmologist. It was based on a thorough review of clinical records of the child, such as a detailed CVI questionnaire, history, and findings of clinical examination and neuro-visual behavior of a child. In addition, parents were encouraged to maintain a diary of the daily sessions of visual therapy and share recorded videos of their training exercises which were then evaluated and discussed with the ophthalmologist for any deviation. Outcome measures included adherence to eye activities for 7–8 sessions per day. Data were analyzed by using SPSS statistics for windows, version 20.

Results

Overall, improvement of adherence to visual therapy was observed among children with CVI (p < 0.0001). Nearly half (47.6%) of participants adhered to 3–4 sessions/day and only 28.6% were adherent to the recommended 7–8 sessions/day.

Conclusion

The pilot study demonstrated the potential of the nurse-led tele-counseling intervention to supplement the ongoing health treatment of patients in improving the adherence to eye activities among parents of children with CVI.

A smartphone program to support adherence to oral chemotherapy in people with cancer: Proof-of-concept trial

AIM

Nonadherence to oral chemotherapy (OC) can lead to health complications, including premature death. Mobile phones are increasingly used to deliver medication adherence interventions. However, there is limited evidence about mobile phone-based interventions to increase adherence to OC, specifically. This study explores the proof-of-concept of a smartphone program to support adherence to OC in people with cancer.

METHODS

This was a 10-week, nonrandomized, multisite trial. The outcomes assessed were acceptability, satisfaction with the intervention, adherence to OC, knowledge about OC, and side-effects presence and severity. The program consisted of short message service (SMS) reminders to take OC, as well as information about OC, including the management of side-effects.

RESULTS

Twenty-two participants (17-74 y/o, median age 60 y/o) were recruited at six hospitals. The sample included 10 different cancer diagnoses (predominance of breast cancer) and 11 OC medications. Acceptability of the intervention was high, with 95% of the enrolled participants completing postintervention measures, and 81% reporting high satisfaction with the program. The intervention was found to have no effect on supporting adherence to OC (assessed by self-report and medication event monitoring system) in this sample. An increase in knowledge about OC was observed at postintervention (p = 0.010).

CONCLUSIONS

This study demonstrated proof-of-concept of the smartphone program and highlighted the need for intervention and trial design-related refinements. Future work should evaluate the effect of the program on adherence to OC with nonadherent patients.

Assessment of Oral Chemotherapy Nonadherence in Chronic Myeloid Leukemia Patients Using Brief Measures in Community Cancer Clinics: A Pilot Study

The purpose of this pilot study was to assess Chronic Myeloid Leukemia (CML) patients’ adherence to, beliefs about, and barriers to oral anticancer agents (OAC) using brief self-report measures in community-based cancer clinics. Patients completed a structured interview including a health literacy assessment, a Brief Medication Questionnaire, two single-item self-report adherence questions, and the Medications Adherence Reasons Scale. Of the 86 participants, 88.4% were white; 55.8% male; mean age, 58.7 years; and 22.1% had limited health literacy. Nonadherence (missing at least one dose in the last week) was reported by 18.6% of participants and associated (p < 0.003) with less-than-excellent perceived ability to take CML medications (16.3%). Black participants reported more difficulty taking CML medications than white participants (28.6% vs. 8.3%, p = 0.053). Among all participants, 43.0% reported their CML medicine was ineffective and 24.4% that taking CML pills was somewhat to very hard. The most common reasons for missing a dose were simply missed it (24.4%) and side effects (18.6%). Most patients perceived their ability to take CML medication was good to excellent, yet nearly one in five reported missing at least one dose in the last week. Brief, no-cost self-report assessments to screen CML patients’ OAC adherence, barriers, and beliefs could facilitate counseling in busy community cancer clinics.

Influence of the implementation of a multidisciplinary consultation program on adherence to the first ever course of oral antineoplastic treatment in patients with cancer

PURPOSE

To evaluate adherence (as measured by the medication possession ratio) to the first ever course of oral antineoplasic treatment in cancer patients before and after the implementation of a multidisciplinary consultation program (involving an oncologist, a pharmacist, and a nurse) and to investigate the program's impact on adverse events and drug-related problems.

PATIENTS AND METHODS

In a retrospective single-center study, we compared the medication possession ratio 2 months after treatment initiation in a control group (before multidisciplinary consultation program implementation) versus an interventional group (after multidisciplinary consultation program implementation).

RESULTS

Two months after oral antineoplasic treatment initiation, the mean ± standard deviation medication possession ratio did not differ significantly when comparing the interventional (multidisciplinary consultation program) group (n = 33; 0.99 ± 0.06) with the control group (n = 64; 0.94 ± 0.16) (p = 0.062). Patients in the multidisciplinary consultation program group had fewer adverse events in general (41, vs 109 in the control group; p = 0.048) and digestive adverse events in particular (6 vs 29, respectively; p = 0.007). A total of 53 and 40 drug-related problems were identified in the control and multidisciplinary consultation program groups, respectively (p = 0.074).

CONCLUSIONS

Implementation of an multidisciplinary consultation program was not associated with a significant difference in drug adherence (as assessed by the medication possession ratio), which was good before and after implementation. The multidisciplinary consultation program was associated with a lower incidence of adverse events.

Interventions to Improve Adherence to Tyrosine Kinase Inhibitors in Chronic Myeloid Leukemia: A Systematic Review

BACKGROUND

Lack of adherence to tyrosine kinase inhibitors (TKIs) is a significant problem resulting in incomplete cytogenetic response and increased mortality in patients with chronic myeloid leukemia (CML). Few studies have been conducted on interventions to improve adherence. The authors conducted a systematic review to explore studies that examined the impact of strategies to improve TKI adherence among individuals with CML.

METHODS

The first 2 authors completed a systematic literature review according to the guidelines in Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Studies (n=2633) conducted between 1980 and 2019 were identified through 3 databases and examined for inclusion/exclusion criteria.

RESULTS

Fourteen studies were identified which met the eligibility criteria. The studies only examined adherence to imatinib, dasatinib, or nilotinib. Ten of the 14 used large data sets (commercial health insurance plans or Surveillance Epidemiology and End Results [SEER] data) for analysis. The majority of the studies used a cohort design. Adherence was defined and measured in a variety of ways with most studies using 80% or higher as adequate adherence. Strategies not focused on health care costs used a multidisciplinary team approach.

CONCLUSION

Development of evidence to improve treatment adherence to TKIs for CML have relied on large data sets rather than prospective trials. Current studies lack patient focused interventions.

Monitoring and Improving Adherence to Tyrosine Kinase Inhibitors in Patients with Chronic Myeloid Leukemia: A Systematic Review

PURPOSE

Suboptimal adherence to tyrosine kinase inhibitors (TKIs) is a widely recognized issue compromising the disease control and survival of patients with chronic myeloid leukemia (CML). A recently published review by Heiney et al reported inconclusive findings on the effects of a broad range of adherence enhancing interventions. The current systematic review aimed to identify studies that evaluated adherence-enhancing interventions implemented by healthcare professionals and determine their effect on CML patients' medication adherence and clinical outcomes.

METHODS

A systematic literature search was performed in 5 databases for articles published between 2002 and 2021. Studies that compared adherence enhancing interventions implemented by healthcare professionals with a comparison group were included. Relevant data on study characteristics were extracted. Medication adherence and clinical outcomes between intervention and control arms were compared.

RESULTS

Nine studies were included in two randomised controlled trials, four cohort studies, and three before-and-after comparison studies. All the included studies incorporated complex interventions, including intensive education or consultation with pharmacists, nurses or multidisciplinary team, in combination with one or more other strategies such as structured follow-up, written materials or video, psychotherapy, medication reminder or treatment diary, with the overall goal of monitoring and improving TKI adherence. Most (7 out of 9) studies demonstrated significantly better adherence to TKIs in the intervention group than the comparison group. The relative proportion of participants who adhered to TKIs ranged from 1.22 to 2.42. The improvement in the rate of TKI doses taken/received ranged from 1.5% to 7.1%. Only one study showed a significant association between intervention and clinical outcomes, with a 22.6% higher major molecular response rate and improvement in 6 out of 20 subscales of health-related quality-of-life.

CONCLUSION

Complex interventions delivered by healthcare professionals showed improvement in adherence to TKIs in CML patients. Further studies are required to clarify the cost-effectiveness of adherence-enhancing interventions.

Adherence to and effectiveness of lenalidomide after 1 year of treatment in a real world setting

BACKGROUND

In combination with dexamethasone, lenalidomide is prescribed in the oral treatment of Multiple Myeloma for patients who have received at least one previous therapy.

OBJECTIVE

The objective of this study is to evaluate medication adherence to lenalidomide of Multiple Myeloma patients, as well as Progression Free Survival and Overall Survival one year from the beginning of the treatment.

SETTING

The study was carried out in Pescara Hospital, in Italy. All Multiple Myeloma patients who began lenalidomide therapy between January 1, 2012 and June 30, 2016 were included in our study.

METHODS

Adherence to treatment was calculated by using the ratio between the Received Daily Dose and the Prescribed Daily Dose. Effectiveness in real world has been evaluated as Progression Free Survival and Overall Survival one year from the beginning of the treatment.Main outcomes measure: We assessed medication adherence and effectiveness of lenalidomide in the treatment of Multiple Myeloma.

RESULTS

Adherence to the overall mean treatment was 0.73 ± 0.15, relative to 81 patients evaluated in our study. 32% of patients achieved an adherence equal to or greater than 80%. Real-life effectiveness in terms of Progression Free Survival and Overall Survival showed values of ​​53.75% and 88%, respectively, one year from the beginning of treatment.

CONCLUSION

The analysis of adherence in Multiple Myeloma patients treated with lenalidomide one year from the beginning of therapy reveal a concerning lack of adherence. Moreover, the lack of correlation of the levels of adherence with patient-related variables shows that, in the case of Multiple Myeloma, adherence is not related to personal, social and environmental characteristics that may determine each patient's correct treatment implementation, but is directly influenced by disease evolution.

Response and Adherence to Nilotinib in Daily practice (RAND study): an in-depth observational study of chronic myeloid leukemia patients treated with nilotinib

Introduction

This comprehensive observational study aimed to gain insight into adherence to nilotinib and the effect of (non)adherence on exposure (C_min) and treatment outcomes.

Methods

Chronic myeloid leukemia (CML) patients using nilotinib were followed for 12 months. Adherence was measured by Medication Event Monitoring System (MEMS), pill count, and Medication Adherence Report Scale (MARS-5). Nilotinib C_min and patient-reported outcomes (i.e., quality of life, side effects, beliefs, satisfaction) were measured at baseline, 3, 6, and 12 months.

Results

Sixty-eight patients (57.5 ± 15.0 years, 49% female) participated. Median adherence to nilotinib (MEMS and pill count) was ≥ 99% and adherence < 90% was rare. Self-reported nonadherence (MARS-5) increased in the first year of treatment to a third of patients. In line with the strong beliefs in the necessity of taking nilotinib, forgetting to take a dose was more prevalent than intentionally adjusting/skipping doses. Nilotinib C_min were generally above the therapeutic target in 95% of patients. Patients reported a variety of side effects, of which fatigue was most frequent. The mean C_min was higher in patients who reported severe itching and fatigue. The overall 1-year MMR rate ranged from 47 to 71%.

Conclusion

Substantial nonadherence (< 90%) to nilotinib was rare and nilotinib C_min were generally above the therapeutic target. Lack of response in our group of patients was not related to nonadherence or inadequate C_min. Nevertheless, a considerable number of patients experienced difficulties in adhering to the twice daily fasted dosing regimen, emphasizing the importance of continuous support of medication adherence in CML.

Clinical trial registration

NTR3992 (Netherlands Trial Register, www.trialregister.nl)

Electronic supplementary material

The online version of this article (10.1007/s00228-020-02910-3) contains supplementary material, which is available to authorized users.

Interventions to Enhance Adherence to Oral Antineoplastic Agents: A Scoping Review

BACKGROUND

As new targeted oral antineoplastic therapies have emerged in recent years, the development of effective strategies that promote optimal adherence to cancer medication regimens has become an important priority.

METHODS

We conducted a scoping literature review to search for English language articles published through July 15, 2019, to identify studies that reported the testing and/or evaluation of interventions to improve adherence to oral antineoplastic agents.

RESULTS

A total of 56 articles were selected for review. Of the studies evaluated, 14 were randomized trials. All interventions except two targeted adult patients. Thirty-three studies enrolled fewer than 100 patients. Most interventions were education- and counseling-based and centered on provision of information about the drug and strategies to manage side effects. Only eight studies used an mHealth tool and/or text messages to target nonadherence. Among studies with a comparison sample, fewer than one-half (44.7%) reported statistically significant improvements in adherence or persistence associated with the intervention; however, some pharmacist-directed programs, particularly those that integrated monitoring or routine follow-up with a provider, did demonstrate efficacy.

CONCLUSION

Although the development of adherence-promoting interventions for oral antineoplastic therapies has increased recently, few have been rigorously tested. The nascent literature suggests those that are pharmacist directed and use regular monitoring show promise, though additional prospective studies are needed. Study methodology, population selection, and potential challenges that may be encountered in the implementation and dissemination phases should be considered when developing new interventions to address nonadherence to oral antineoplastic treatment.

Front-line use of tyrosine kinase inhibitors in chronic phase chronic myeloid leukemia: Practice considerations

The development of BCR-ABL-targeting tyrosine kinase inhibitors has transformed chronic phase chronic myeloid leukemia (CP CML) from a disease with a terminal prognosis to a treatable chronic illness. Long-term treatment with tyrosine kinase inhibitors means that patients have to be clinically managed and monitored over extended periods of time, thus a patient-centered, medically integrated, and multidisciplinary oncology healthcare team is required to support patients through their journey. Pharmacists work with patients, physicians, and the wider support team to select the optimum therapy plan for a given patient. These decisions are based on risk factors, comorbidities, concomitant medications, and personal circumstances and pharmacists advise on the efficacy and safety of different treatment options. Additionally, pharmacists are a key point-of-contact and resource for monitoring patient response to treatment, identifying and managing adverse events and drug-drug interactions, any subsequent therapy plan modifications, and, potentially, treatment-free remission. Pharmacists also assist with patient education, medication adherence, and financial discussions with patients throughout the long course of the disease. This review provides an overview of BCR-ABL tyrosine kinase inhibitors, discusses the role of the medically integrated pharmacy team, and suggests strategies that pharmacists can use in patient management and clinical decision-making to optimize the treatment of CP CML.