Current practice patterns for oral chemotherapy: results of a national survey

Medication Adherence Barriers: Development and Retrospective Pilot Test of an Evidence-Based Screening Instrument

BACKGROUND

Adherence to a prescribed medication regimen is often critical to successful comorbid disease management and decreased risk for adverse outcomes. The barriers that result in nonadherence are often multilayered and complex, making them difficult to address in an outpatient clinic setting.

OBJECTIVES

The primary objective of this project was to develop an evidence-based observational screening instrument and determine its potential to identify barriers to medication adherence.

METHODS

Medication adherence barriers were divided into five categories. These barriers provided the foundation for the screening instrument. To pilot test the instrument, a retrospective, quasiexperimental, observational comparison study was designed. The pilot study evaluated retrospective data of the Oncology Care Model (OCM).

FINDINGS

Of 250 OCM patient records, 184 (74%) revealed potential medication adherence barriers for patients with uncontrolled comorbid illness or events.

Medication Experience and Adherence to Oral Chemotherapy: A Qualitative Study of Patients' and Health Professionals' Perspectives

Lack of adherence constitutes one of the most important challenges in patients undergoing treatment with oral antineoplastic drugs (ANEO). Understanding cancer patients’ experiences with respect to their medication is key for optimizing adherence and therapeutic results. We aimed to assess the medication experience (ME) in patients with cancer in treatment with ANEO, to describe the barriers and facilitators related to the disease and its treatment and to compare them with the healthcare professionals’ perspectives. We carried out an exploratory qualitative study in the University Hospital of San Juan de Alicante, Spain. Three focus groups and two nominal group discussions were conducted with 23 onco-hematological patients treated with ANEO and 18 health professionals, respectively. The data were analyzed using content analyses and were eventually triangulated. The most impactful aspects in patients’ ME were the presence of adverse effects; lack of information about treatment; beliefs, needs and expectations regarding medications; social and family support; and the relationship with the health professionals. Both patients and professionals agreed on considering the negative side effects and the information about treatment as the main barriers and facilitators of adherence, respectively, although the approaches differed between both profiles. The professionals offered a more technical vision while patients prioritized the emotional burden and motivation associated with the disease and medication. This study allowed us to understand the real-life experiences of patients being treated with ANEO and explore the factors which had an impact on adherence to treatment. This understanding enables professionals to have a positive influence on patients’ behavior and provide individualized care plans. Pharmacists’ assistance is relevant to support patients’ adherence and self-management.

Prevention and conduct against the Extravasation of antineoplastic chemotherapy: a scoping review

OBJECTIVES

to identify and synthesize scientific evidence on prevention and management of extravasation of antineoplastic agents in adult patients by nurses.

METHODS

scoping review, according to Joanna Briggs Institute and PRISMA-ScR. Research was conducted in five electronic databases, Cochrane Library and eight catalogs of theses and dissertations. Data collection occurred from April to July 2018, with no time limit. The extracted data were analyzed and synthesized in a narrative way.

RESULTS

a total of 3,110 records were retrieved and 18 studies were kept for review. Most publications (66.6%) had a qualitative approach and addressed both aspects, i.e., prevention and management of extravasation of chemotherapy in adult patients.

CONCLUSIONS

the implementation of protocols based on scientific evidence on prevention and management of extravasation of antineoplastic agents is paramount in order to provide patient safety and support to the nursing staff.

Formulating a single thioether-bridged oleate prodrug into a self-nanoemulsifying drug delivery system to facilitate oral absorption of docetaxel

Oral chemotherapy of docetaxel (DTX) is restricted by active P-glycoprotein (P-gp) efflux, hepatic first-pass metabolism and then poor oral absorption. Herein, a lipophilic thioether-bridged oleate prodrug (DTX-S-OA) and an ester-bond linked oleate prodrug of docetaxel (DTX-OA) were synthesized and efficiently incorporated into a self-nanoemulsifying drug delivery system (SNEDDS) using core-matching technology with a high drug-loading rate. DTX-S-OA SNEDDS produced a uniform droplet size of about 30 nm and a significantly high drug loading capability (60 mg mL-1), compared with DTX SNEDDS (20 mg mL-1). Additionally, DTX-S-OA SNEDDS exhibited a markedly slower drug release property and higher (>2-fold) drug solubilization in the aqueous phase after 60 min lipolysis compared with DTX SNEDDS. In situ single-pass intestinal perfusion and intestinal biodistribution studies demonstrated that the membrane permeability and intestinal bioadhesion of SNEDDS were significantly increased. Moreover, DTX-S-OA showed a comparable ability with verapamil in inhibiting P-gp efflux. Lymphatic transport studies confirmed that DTX-S-OA SNEDDS could significantly enhance intestinal lymphatic transport. Notably, the bioavailability of DTX-S-OA SNEDDS was 6.2-fold and 2.0-fold higher than that of the DTX solution and DTX SNEDDS, respectively. Furthermore, DTX-S-OA achieved a more rapid release of free DTX from the prodrug in systemic circulation than DTX-OA. Therefore, such a unique combination strategy of the single thioether-bridged DTX-oleate prodrug and SNEDDS is a promising platform to enable effective oral delivery of DTX.

PATIENT SAFETY IN THE ADMINISTRATION OF ANTINEOPLASTIC CHEMOTHERAPY AND OF IMMUNOTHERAPICS FOR ONCOLOGICAL TREATMENT: SCOPING REVIEW

ABSTRACT Objective: to identify and synthesize the scientific evidence on cancer patient safety in the administration of antineoplastic and immunotherapeutic chemotherapeutic agents. Method: a scoping review, according to the Joanna Briggs Institute and to the recommendations of the PRISMA-ScR international guide. The research was conducted in five electronic databases, the Cochrane Library and eight catalogs of theses and dissertations. The inclusion criteria were the following: studies related to patient safety in the administration of antineoplastic and immunotherapeutic chemotherapy by nurses in places where cancer care occurs, published entirely in Portuguese, Spanish and/or English, with no time limit. The extracted data were analyzed and synthesized in narrative form. Results: a total of 14,444 records were retrieved and 47 studies were kept for review. Most publications (44.7%) had a qualitative approach, while 40.4% were quantitative and 14.9%, mixed. When summarizing the findings, the following themes emerged: Safety standards in parenteral administration of antineoplastic chemotherapy; Good practices for patient safety using oral antineoplastic therapy; Administration and safe handling of immunotherapies; Prevention and management of errors related to the administration of antineoplastic and immunotherapeutic chemotherapeutic agents. Conclusion: patients safety with cancer in the administration of antineoplastic therapy occurs when there is implementation of evidence-based protocols, continuing education of nurses and implementation of safety standards and processes, as a strategy to prevent errors in drug administration.

Evaluation of the prescribing patterns, adverse effects, and drug interactions of oral chemotherapy agents in an outpatient cancer center

Purpose

Although oral chemotherapy offers advantages over intravenous chemotherapy, it creates a unique set of challenges. Potential barriers include treatment complexity, patient responsibility for medication adherence and monitoring, reduced healthcare contact, and increased financial burden. The purpose of this study is to estimate the prevalence of drug-related problems among a sample of patients treated with oral chemotherapy agents.

Methods

A single-center, retrospective chart review was conducted on patients prescribed oral chemotherapy at our institution between 1 January 2017 and 31 August 2017. The primary endpoint was the incidence of drug-related toxicities within 90 days of starting treatment. Secondary endpoints included incidence of drug–drug interactions, proportion of patients receiving medication education by a clinical pharmacist, and quantification of issues related to medication access.

Results

Charts of 100 patients were reviewed. Median time to oral chemotherapy receipt by the patient from the day the order was written was eight days. Prior to initiating therapy, 27% of patients received education by a clinical pharmacist. Toxicity checks were conducted by the provider at 30, 60, and 90 days for 80%, 65%, and 48% of patients, respectively. Treatment-related toxicities secondary to oral chemotherapy were reported by 79% of patients, with 55% classified as severe. Potential drug interactions were in 55% of the patients.

Conclusion

Data from this study have highlighted avenues for pharmacists to make an impact on patients newly started on oral chemotherapy. Opportunities exist to increase patient education, ensure appropriate follow-up, and assess adherence while preventing and managing treatment-related toxicities.

Oral Agents: Challenges With Self-Administered Medication Adherence in Clinical Trials

BACKGROUND

In oral agent clinical trials, patients may not be adherent to self-administration of study medication; this nonadherence can affect validity and reliability. Many factors contribute to nonadherence to protocol requirements, and managing patients with fidelity issues is the responsibility of the research team.

OBJECTIVES

The aim is to identify which group (patients, physicians/principal investigators, nurses, or other personnel) research nurses report as most responsible for protocol nonadherence and to characterize the most observed causes and contributors to nonadherence within each group.

METHODS

Sixty-seven protocol nurses completed a nine-question survey developed from pilot data. Descriptive statistics and ordinal regressions addressed the objectives of the study.

FINDINGS

More than half of the nurses observed clinical trial nonadherence in their practices. Nurses identified challenges regarding physician, patient, and nurse factors. The most frequently identified causes included patients' forgetfulness, refusal to undergo study procedures, inadequate family or caregiver support to complete study activities, ineffective communication, and collaboration within the research team.

Administration of the Tablet Formulation of Olaparib in Patients with Ovarian Cancer: Practical Guidance and Expectations

Olaparib is a poly(ADP-ribose) polymerase enzyme inhibitor that is approved for use in patients with advanced ovarian cancer (OC) and genetic BRCA1/2 mutations who have received three or more prior lines of chemotherapy for maintenance treatment of recurrent OC that is in response to platinum-based chemotherapy regardless of BRCA mutation status and for human epidermal growth receptor factor 2-negative metastatic breast cancer with deleterious or suspected deleterious germline BRCA mutations who have previously been treated with chemotherapy in the neoadjuvant, adjuvant, or metastatic setting. Because olaparib is poorly soluble and requires advanced drug delivery techniques to ensure bioavailability, the originally approved 400 mg dose is taken as eight 50 mg capsules twice daily. An alternative melt-extrusion tablet formulation was developed to improve the pharmacokinetic and pharmacodynamic profile of olaparib and reduce the pill burden for patients. The recommended tablet dose is 300 mg twice daily (two 150 mg tablets). Phase III studies with the tablet formulation are ongoing for multiple tumor types. Two studies conducted with the olaparib tablet formulation have reported results: one in platinum-sensitive, BRCA-mutated recurrent OC (SOLO-2) and one that included patients with germline BRCA-mutated metastatic breast cancer (OlympiAD). The tablet is the approved formulation based on the SOLO-2 trial results. Because the capsule and tablet formulations have different bioavailability, physicians must strictly adhere to the dosing instructions provided in the prescribing information. The tablet offers greater convenience for most patients, especially when using olaparib for maintenance therapy. This review discusses the differences between the two formulations, dose determination, and guidance for use of olaparib tablets by patients with OC. Prior to implementing any changes in therapy, health care providers should engage their patients in discussion to support an informed transition between the formulations.

IMPLICATIONS FOR PRACTICE

Olaparib has recently been approved for maintenance treatment of recurrent ovarian cancer (OC) that is in response to platinum-based chemotherapy. The originally approved capsule formulation was dosed as 400 mg twice daily (eight 50 mg capsules). The recommended olaparib tablet dose is 300 mg twice daily (two 150 mg tablets). The tablet is the new approved formulation based on the SOLO-2 trial results. Because the capsule and tablet formulations have different bioavailability, physicians must strictly adhere to the dosing instructions provided in the prescribing information. The tablet offers greater convenience for most patients, especially when using olaparib for maintenance therapy. This review discusses the differences between the two formulations, dose determination, and guidance for use of olaparib tablets by patients with OC.

Nursing Application of Oral Chemotherapy Safety Standards:An Informal Survey

As the use of oral chemotherapy continues to rise, new approaches are needed to ensure patient safety. To help address this issue, the American Society of Clinical Oncology/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards were expanded in 2013 to include additional measures addressing oral anticancer drugs (OACs). Because minimal data assessing the application of these standards exist, ONS conducted an independent survey of oncology nurses to evaluate the application of these standards in practice as they relate to several areas of OAC use: assessment, consent, patient education, drug verification, and monitoring. The data revealed that, although the standards are followed in many settings, a large number of settings do not have processes in place to support safety standards and ensure patient safety when administering OACs. Information gained in this informal survey can be used to guide additional research and educational initiatives.

Oral agents for cancer: safety challenges and recommendations

BACKGROUND

The lack of knowledge and standardization of safety practices related to prescribing, dispensing, administering, and monitoring oral agents for cancer (OACs) has created significant safety challenges for patients and healthcare providers. Problems identified with the use of OACs include possible medication errors, increased potential for toxicity, unintentional exposure of hazardous medications to healthcare providers and informal caregivers, and possible pollution of the environment.

OBJECTIVES

The purpose of this review is to provide information about the current state of knowledge and recommendations in the literature regarding safety concerns with OACs and strategies for risk reduction.

METHODS

Articles published from 2003-2014 were retrieved using PubMed, CINAHL®, and the Cochrane Library.

FINDINGS

As the number of OACs continues to increase, existing standards related to medication errors and safety will require ongoing revision to lessen the risks and hazards for patients, caregivers, and healthcare providers.

Supporting adherence to oral anticancer agents: clinical practice and clues to improve care provided by physicians, nurse practitioners, nurses and pharmacists

Background

Healthcare provider (HCP) activities and attitudes towards patients strongly influence medication adherence. The aim of this study was to assess current clinical practices to support patients in adhering to treatment with oral anticancer agents (OACA) and to explore clues to improve the management of medication adherence.

Methods

A cross-sectional, observational study among HCPs in (haemato-)oncology settings in Belgium and the Netherlands was conducted in 2014 using a composite questionnaire. A total of 47 care activities were listed and categorised into eight domains. HCPs were also asked about their perceptions of adherence management on the items: insight into adherence, patients’ communication, capability to influence, knowledge of consequences and insight into causes. Validated questionnaires were used to assess beliefs about medication (BMQ) and shared decision making (SDM-Q-doc).

Results

In total, 208 HCPs (29% male) participated; 107 from 51 Dutch and 101 from 26 Belgian hospitals. Though a wide range of activities were reported, certain domains concerning medication adherence management received less attention. Activities related to patient knowledge and adverse event management were reported most frequently, whereas activities aimed at patient’s self-efficacy and medication adherence during ongoing use were frequently missed. The care provided differed between professions and by country. Belgian physicians reported more activities than Dutch physicians, whereas Dutch nurses and pharmacists reported more activities than Belgian colleagues. The perceptions of medication adherence management were related to the level of care provided by HCPs. SDM and BMQ outcomes were not related to the care provided.

Conclusions

Enhancing the awareness and perceptions of medication adherence management of HCPs is likely to have a positive effect on care quality. Care can be improved by addressing medication adherence more directly e.g., by questioning patients about (expected) barriers and discussing strategies to overcome them, by asking for missed doses and offering (electronic) reminders to support long-term medication adherence. A multidisciplinary approach is recommended in which the role of the pharmacist could be expanded.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3110-2) contains supplementary material, which is available to authorized users.

Enhancing Nurses' Oral Therapy Practice in 4 Latin American Countries: A Collaborative and Participatory Approach

BACKGROUND

Oral therapy (OT) use for cancer is increasing globally. Yet, nurses in 4 Latin American countries lacked knowledge and educational opportunities to safely care for people receiving OTs. Global partnerships to contextualize education and create local capacity may enhance nursing practice.

OBJECTIVE

Within 4 Latin American countries, this study aims to (1) develop, deliver, and evaluate an OT cancer nursing education program and (2) evaluate the feasibility and efficacy of using an integrated knowledge translation (iKT) framework to develop the program and foster nurses' capacity for OT care.

METHODS

Using the iKT framework, a "train the trainer" model was used to develop, contextualize, pilot test, implement, and evaluate the OT education program. An online survey evaluated nurses' perceived benefits, ease of use, barriers, facilitators, and recommendations for improvement. Nurses' self-reported OT practices were evaluated 9 months after the final workshop.

RESULTS

One hundred nineteen nurses across 4 countries participated in a pilot and/or final OT educational workshop, facilitated by 6 local nurse champions. The nurse champions found the program easy to use and modify. Participants reported using the curriculum to teach other nurses and patients and networking opportunities for problem solving. Barriers included nurses' role clarity and time for education.

CONCLUSIONS

The iKT approach was an effective method to develop the OT curriculum and build OT capacity among nurses and leaders within the 4 countries.

IMPLICATIONS FOR PRACTICE

The iKT approach may be useful in low- or middle-income countries to enhance nursing education and practice. Future OT education projects should strengthen strategies for ongoing support after education intervention.

Enabling Oral SN38-Based Chemotherapy with a Combined Lipophilic Prodrug and Self-Microemulsifying Drug Delivery System

Oral chemotherapy with SN38 is restricted by its poor solubility in gastrointestinal (GI) fluids and low permeability. Here we report the oral delivery of SN38 by a combined lipophilic prodrug and lipid-based formulation strategy. A lead lipophilic prodrug of SN38, SN38-undecanoate (SN38-unde20), was incorporated into a self-microemulsifying drug delivery system (SMEDDS) for improved in vitro and in vivo performance. The formulation was purposefully designed and optimized with long chain lipids and lipid-based nonionic surfactants to maximize drug solubilization in GI conditions, facilitate trans-membrane permeation, and hence improve oral absorption. SN38-unde20-SMEDDS significantly increased (>7 fold) drug solubilization in the aqueous phase compared to unformulated drug during in vitro lipolysis and drug solubilization studies. In an orally dosed in vivo pharmacokinetics study in a Dark Agouti rat model, the SN38-unde20-SMEDDS formulation confirmed oral absorption of SN38-unde20 and subsequent reconversion to SN38. Importantly, the overall plasma exposure of SN38 (AUC_0→∞) was equivalent for orally dosed SN38-unde20-SMEDDS in comparison with a parenteral dose of SN38-unde20-SMEDDS and SN38 at an identical dose (10 mg/kg). The combination of lipophilic prodrug along with an optimal delivery carrier is demonstrated to enable effective oral delivery of challenging chemotherapeutic compounds that are conventionally dosed by injection.

Safe handling of oral antineoplastic medications: Focus on targeted therapeutics in the home setting

Introduction With the growing number of oral targeted therapies being approved for use in cancer therapy, the potential for long-term administration of these drugs to cancer patients is expanding. The use of these drugs in the home setting has the potential to expose family members and caregivers to them either through direct contact with the drugs or indirectly by exposure to the parent compounds and/or their active metabolites in contaminated patients' waste. Methods A systematic literature review was performed and the known adverse health effect of 32 oral targeted therapeutics is summarized. In particular, the carcinogenicity, genotoxicity, and embryo-fetal toxicity, along with the route of excretion were evaluated. Results Carcinogenicity testing has not been performed on most of the oral targeted therapeutics and the genotoxicity data are mixed. However, the majority of these drugs exhibit adverse reproductive effects, some of which are severe. Currently, available data does not permit the possibility of a health hazard from inappropriate handling of drugs and contaminated patients waste to be ignored, especially in a long-term home setting. Further research is needed to understand these issues. Conclusions With the expanding use of targeted therapies in the home setting, family members and caregivers, especially those of reproductive risk age, are, potentially at risk. Overall basic education and related precautions should be taken to protect family members and caregivers from indirect or direct exposure from these drugs. Further investigations and discussion on this subject are warranted.

Inner conflict in patients receiving oral anticancer agents: a qualitative study

OBJECTIVES

To explore the experiences of patients receiving oral anticancer agents.

DESIGN

A qualitative study using semistructured interviews with a grounded theory approach.

SETTING

A university hospital in Japan.

PARTICIPANTS

14 patients with gastric cancer who managed their cancer with oral anticancer agents.

RESULTS

Patients with cancer experienced inner conflict between rational belief and emotional resistance to taking medication due to confrontation with cancer, doubt regarding efficacy and concerns over potential harm attached to use of the agent. Although they perceived themselves as being adherent to medication, they reported partial non-adherent behaviours. The patients reassessed their lives through the experience of inner conflict and, ultimately, they recognised their role in medication therapy.

CONCLUSIONS

Patients with cancer experienced inner conflict, in which considerable emotional resistance to taking their medication affected their occasional non-adherent behaviours. In patient-centred care, it is imperative that healthcare providers understand patients' inner conflict and inconsistency between their subjective view and behaviour to support patient adherence.

Administration of Oral Chemotherapy: Results From Three Rounds of the Quality Oncology Practice Initiative

The collection of oral chemotherapy test measure data is feasible, and improvement opportunities exist for patients who are prescribed oral chemotherapy.

Current nursing practice for patients on oral chemotherapy: a multicenter survey in Japan

BACKGROUND

With a paradigm shift toward a chronic care model in cancer, the issue of adherence is becoming increasingly important in oncology.

METHODS

We mailed two self-reported surveys on current nursing practices for patients on oral chemotherapy to all 309 designated cancer centers and 141 large general hospitals in Japan. The first survey was based on a nurse-based questionnaire containing 40 items concerning nurse's characteristics, nurse staffing at workplace, general nursing care for new patients on oral chemotherapy and those with refilled prescriptions, follow-up, and system-based approach. The second survey was based on a patient-based questionnaire containing 10 items about patient characteristics and adherence-related nursing practice for 249 patients taking oral chemotherapy of 903 systematically sampled. We used multivariate logistic regression to identify factors that were associated with adherence-related nursing practices.

RESULTS

A total of 62 nurses (mean age: 41.5 years) from 62 hospitals who consented participated in the both nurse-based survey and patient-based survey about 249 patients. The results of nurse-based survey indicated that practices varied, but nurses were less likely to ask adherence-related questions of patients with refilled prescriptions than of new patients. The results of patient-based survey found that questions on side effects, discussions about barriers to achieving balance between treatment and daily life activities, and medication management were all significantly related to the question about unused medicines. Logistic regression revealed that adherence-related nursing practices were associated with the nurse's background, type of treatment, and healthcare system-related factors. Patient orientation on oral chemotherapy, interdisciplinary learning, and having a system-based approach for detecting prescription errors were identified as healthcare system-related factors.

CONCLUSIONS

A more systematic approach must be developed to ensure patients receive safe and effective oral chemotherapy, while nurses should play significant roles in patient education and monitoring.