The Association Between Patient-Reported and Objective Oral Anticancer Medication Adherence Measures: A Systematic Review

Patient symptoms, self-management, and unscheduled healthcare use during the first 6 months of targeted oral anticancer agent therapy: protocol for a mixed-methods US study

INTRODUCTION

Targeted oral anticancer agents (OAAs) are increasingly used to treat cancer, including haematological malignancies and ovarian cancer, but they can cause serious symptomatic side effects such as arrhythmias, hypertension, and hyperglycaemia. Unaddressed OAA symptoms or inadequately managed symptoms may also lead to unnecessary and unscheduled healthcare use that decreases patient quality of life and financially burdens both patients and the healthcare system. Limited information is available about patient symptoms, self-management behaviours, and use of healthcare services over time while taking targeted OAAs, but is needed to ensure successful OAA therapy. The primary objective is to understand patient experiences and behaviours on initiating targeted OAA, and elicit cancer care clinicians' (ie, physicians, advanced practice practitioners, nurses, and pharmacists) perspectives on supporting patients during therapy. Study results will inform comprehensive and realistic interventions that minimise disruptions to therapy while maximising quality of life.

METHODS AND ANALYSIS

We will conduct a remote single-arm, convergent-parallel mixed-methods cohort study within a large academic medical centre. A minimum of 60 patients will be enrolled. Patients will complete several validated patient-reported outcome measures at six timepoints over 6 months. Mixed-effects logistic regression will be used to predict the primary binary outcome of unscheduled healthcare use by patient self-efficacy for symptom self-management. Semistructured interviews will be conducted with patients and clinicians and thematically analysed. Triangulated quantitative and qualitative results will be reported using cross-case comparison joint display.

ETHICS AND DISSEMINATION

This study protocol is approved by the Institutional Review Board of University of Michigan Medical School (IRBMED). Study results will be published in peer-reviewed journals, presented at conferences, and disseminated to study participants.

Exploring adherence in patients with advanced breast cancer: focus on CDK4/6 inhibitors

Treatment adherence is crucial for optimal outcomes in advanced breast cancer, but can be challenging due to various factors, i.e. patients' attitudes and behavior upon diagnosis, and complex therapies with high adverse effect rates. Our aim was to explore the adherence to oral anticancer medications (OAM) in women with advanced breast cancer, focusing on cyclin-dependent kinase 4 and 6 inhibitors (CDKI), and identify factors associated with the adherence. We conducted a cross-sectional study at the University Hospital Centre Zagreb, Croatia, involving women with stage IV advanced breast cancer receiving OAM. Data collection included a questionnaire assessing socio-demographic and clinical information, Beck Depression Inventory-II for depressive symptoms, Medication Adherence Report Scale (MARS-5) for adherence to OAM, and Beliefs about Medicines Questionnaire. Plasma concentrations of CDKI were confirmed by LC-MS/MS in three randomly selected participants. A total of 89 women were included. The most prescribed OAMs were anti-estrogen (71.3 %) and CDKI (60.9 %). MARS-5 scores (mean: 24.1 ± 1.6) correlated with CDKI plasma concentrations. Forgetfulness was the primary reason for non-adherence (25.9 %). Women receiving CDKI (p = 0.018), without depressive symptomatology (p = 0.043), and with more positive beliefs about medicines were more adherent (p < 0.05). This study enhances understanding of medication adherence in advanced breast cancer and identifies influential factors.

The RAS-24: Development and validation of an adherence-to-medication scale for severe mental illness patients

Introduction

Several studies have found that most patients with severe mental illness (SMI) and comorbid (physical) conditions are partially or wholly nonadherent to their medication regimens. Nonadherence to treatment is a serious concern, affecting the successful management of patients with SMIs. Psychiatric disorders tend to worsen and persist in nonadherent patients, worsening their overall health. The study described herein aimed to develop and validate a scale (the Ralat Adherence Scale) to measure nonadherence behaviors in a culturally sensitive way.

Materials and Methods

Guided by a previous study that explored the primary reasons for nonadherence in Puerto Rican patients, we developed a pool of 147 items linked to the concept of adherence. Nine experts reviewed the meaning, content, clarity, and relevance of the individual items, and a content validity ratio was calculated for each one. Forty items remained in the scale's first version. This version was administered to 160 patients (21-60 years old). All the participants had a diagnosis of bipolar disorder, major depressive disorder, or schizoaffective disorder. The STROBE checklist was used as the reporting guideline.

Results

The scale had very good internal consistency (Cronbach's alpha = 0.812). After a factor analysis, the scale was reduced to 24 items; the new scale had a Cronbach's alpha of 0.900.

Conclusions

This adherence scale is a self-administered instrument with very good psychometric properties; it has yielded important information about nonadherence behaviors. The scale can help health professionals and researchers to assess patient adherence or nonadherence to a medication regimen.

Nondifferential Treatment Misclassification Biases Toward the Null? Not a Safe Bet for Active Comparator Studies

Active comparator studies are increasingly common, particularly in pharmacoepidemiology. In such studies, the parameter of interest is a contrast (difference or ratio) in the outcome risks between the treatment of interest and the selected active comparator. While it may appear treatment is dichotomous, treatment is actually polytomous as there are at least 3 levels: no treatment, the treatment of interest, and the active comparator. Because misclassification may occur between any of these groups, independent nondifferential treatment misclassification may not be toward the null (as expected with a dichotomous treatment). In this work, we describe bias from independent nondifferential treatment misclassification in active comparator studies with a focus on misclassification that occurs between each active treatment and no treatment. We derive equations for bias in the estimated outcome risks, risk difference, and risk ratio, and we provide bias correction equations that produce unbiased estimates, in expectation. Using data obtained from US insurance claims data, we present a hypothetical comparative safety study of antibiotic treatment to illustrate factors that influence bias and provide an example probabilistic bias analysis using our derived bias correction equations.

Real-world outcomes for neoadjuvant capecitabine versus infusional 5-fluorouracil in the treatment of locally advanced rectal cancer

BACKGROUND

Neoadjuvant chemoradiation therapy is standard-of-care treatment for locally advanced rectal cancer (LARC). A pathological complete response (pCR) following chemoradiation therapy is an early indicator of treatment benefit and associated with excellent survival outcomes, with capecitabine largely replacing infusional 5-fluorouracil as the choice in routine care of LARC.

AIMS

To analyse the uptake of capecitabine usage over time, and on the back of clinical trial data demonstrating equivalence between fluoropyrimidines, confirm that efficacy is maintained in the real-world setting.

METHODS

We analysed data from a prospectively maintained colorectal cancer database at three Australian hospitals including patients diagnosed from January 2009 to December 2018. Pathological response was determined as either complete or incomplete and compared for patients receiving 5-FU or capecitabine.

RESULTS

A total of 657 patients was analysed, 498 receiving infusional 5-FU and 159 capecitabine. Capecitabine use has markedly increased from approval in 2014 in Australia, now being used in more than 80% of patients. Patient characteristics were similar by treatment, including age, tumour location and pre-treatment stage. pCR was reported in 22/159 (13.8%) of capecitabine-treated patients and 118/380 (23.7%) that received 5-FU (P ≤ 0.01). More capecitabine-treated patients received post-operative oxaliplatin (44.2% vs 6.3%, P < 0.01). Two-year progression-free survival was similar (84.9% vs 88.0%, P = 0.34).

CONCLUSIONS

Capecitabine is now the dominantly used neoadjuvant chemotherapy in LARC. Capecitabine use was associated with a lower rate of pCR versus infusional 5-FU, a difference not explained by examined patient or tumour characteristics. Poor treatment compliance with oral therapy in the real-world setting is one possible explanation.

Mobile Health Interventions: Examining Medication Adherence Outcomes Among Patients With Cancer

BACKGROUND

Treatment for cancer is trending toward oral therapies, which patients can self-manage from home. Proper adherence to oral therapy is vital to safe and optimal care in this setting. Mobile health interventions (i.e., text message reminders, mobile applications, and automated calls) are an evolving strategy aimed at improving medication adherence for patients on long-term oral therapies.

OBJECTIVES

This review aims to provide an overview of research outcomes for the use of mobile health interventions among patients with cancer.

METHODS

A comprehensive review of CINAHL®, MEDLINE®, and PubMed® was completed. Eleven articles were eligible for inclusion in this review.

FINDINGS

Mobile health interventions are an acceptable approach among patients with cancer and may improve adherence outcomes for those at highest risk for suboptimal adherence.

Optimizing Oral Targeted Anticancer Therapies Study for Patients With Solid Cancer: Protocol for a Randomized Controlled Medication Adherence Program Along With Systematic Collection and Modeling of Pharmacokinetic and Pharmacodynamic Data

Background

The strengthening or substitution of intravenous cytotoxic chemotherapy cycles by oral targeted anticancer therapies, such as protein kinase inhibitors (PKIs), has provided impressive clinical benefits and autonomy as well as a better quality of life for patients with cancer. Despite these advances, adverse event management at home and medication adherence remain challenging. In addition, PKI plasma concentrations vary significantly among patients with cancer receiving the same dosage, which could explain part of the observed variability in the therapeutic response.

Objective

The aim of this optimizing oral targeted anticancer therapies (OpTAT) study is to optimize and individualize targeted anticancer treatments to improve patient care and self-monitoring through an interprofessional medication adherence program (IMAP) combined with measurement PKI plasma concentrations.

Methods

The OpTAT study has two parts: (1) a 1:1 randomized medication adherence program, in which the intervention consists of regular motivational interviewing sessions between the patient and the pharmacist, along with the delivery of PKIs in electronic monitors, and (2) a systematic collection of blood samples and clinical and biological data for combined pharmacokinetic and pharmacodynamic analysis. On the basis of the electronic monitor data, medication adherence will be compared between groups following the three operational definitions: implementation of treatment during the persistent period, persistence with treatment and longitudinal adherence. The implementation will be described using generalized estimating equation models. The persistence of PKI use will be represented using a Kaplan-Meier survival curve. Longitudinal adherence is defined as the product of persistence and implementation. PKI pharmacokinetics will be studied using a population approach. The relationship between drug exposure and efficacy outcomes will be explored using Cox regression analysis of progression-free survival. The relationship between drug exposure and toxicity will be analyzed using a pharmacokinetic-pharmacodynamic model and by logistic regression analysis. Receiver operating characteristic analyses will be applied to evaluate the best exposure threshold associated with clinical benefits.

Results

The first patient was included in May 2015. As of June 2021, 262 patients had participated in at least one part of the study: 250 patients gave at least one blood sample, and 130 participated in the adherence study. Data collection is in process, and the final data analysis is planned to be performed in 2022.

Conclusions

The OpTAT study will inform us about the effectiveness of the IMAP program in patients with solid cancers treated with PKIs. It will also shed light on PKI pharmacokinetic and pharmacodynamic properties, with the aim of learning how to adapt the PKI dosage at the individual patient level to increase PKI clinical suitability. The IMAP program will enable interprofessional teams to learn about patients’ needs and to consider their concerns about their PKI self-management, considering the patient as an active partner.

Trial Registration

ClinicalTrials.gov NCT04484064; https://clinicaltrials.gov/ct2/show/NCT04484064.

International Registered Report Identifier (IRRID)

DERR1-10.2196/30090

Use of therapeutic outcomes monitoring method for performing of pharmaceutical care in oncology patients

This study aimed to implement pharmaceutical care using the therapeutic outcome monitoring (TOM) method for pharmacotherapeutic follow-up of oncological patients. This was a prospective longitudinal study involving patients undergoing oral chemotherapy. The study environment was an outpatient pharmacy at a tertiary-level oncology hospital. Ninety patients who received oral chemotherapy were evaluated, and 27 patients were followed up in accordance with the exclusion criteria and acceptability of participation in the study. The patients were predominantly diagnosed with gynecological tumors, with a mean age of 57.56 ± 13.06. The average consumption of drugs per patient was 4.63 ± 4.85, and more than 55% of patients had undergone oral antineoplastic therapy for more than a year. The main therapeutic groups used were drugs that acted on the gastrointestinal tract and metabolism (34%). All patients had at least one drug-related problem (DRP). In total, 133 DRP were identified. Approximately 33% of patients had DRPs related to antineoplastic therapy; non-adherence, incorrect administration, and the probability of adverse events were among the frequently reported DRPs. We identified 43 negative outcomes associated with medication (NOM), with untreated health problems (47%) and non-quantitative insecurity (30%) being the most frequently reported. 81 pharmaceutical interventions were performed, and 96% were accepted. The main errors avoided with the interventions were untreated health problems, misuse, and interruptions associated with medication administration. The TOM method effectively achieved the desired results of therapy, improving the use of medicines, and thus increasing patient safety.

Treatment Experiences with CDK4&6 Inhibitors Among Women with Metastatic Breast Cancer: A Qualitative Study

PURPOSE

To describe patients' perspectives on the use of and potential challenges and barriers with adherence/persistence to cyclin-dependent kinase 4 and 6 inhibitors (CDK4&6i's) to treat metastatic breast cancer (MBC).

METHODS

This qualitative study consisted of 60-minute semi-structured telephone interviews with patients with MBC in the US who were either current or recent CDK4&6i users, identified from administrative claims of survey-eligible commercial and Medicare Advantage patients in the HealthCore Integrated Research Database between November 1, 2018 and November 1, 2019. Patients were recruited by email and/or mailed letter. The 60-minute telephone interviews were conducted by a trained facilitator using a study-developed interview discussion guide that included topics impacting treatment choice and adherence/persistence. Interviews were audio-recorded, transcribed, and thematically analyzed.

RESULTS

All 462 eligible patients were sent a recruitment email and/or letter to which 36 patients responded, consented to participate, and met study inclusion criteria; 25 patients scheduled interviews, and 24 completed them. Study participants were predominately white, non-Hispanic (96%) with a mean age of 59.5 years. Participants reported a largely positive experience and mentioned very few adherence/persistence issues. They further reported appreciating the ease and convenience of oral oncolytics, coped with side effects, had strong medical and social support, and experienced few cost issues.

CONCLUSION

The few adherence/persistence issues reported by participants contrasts with other findings of suboptimal oral oncolytic use. Interview themes indicated several factors that likely contributed to the lack of adherence/persistence issues: trusted relationship with oncologist, belief in importance of medication, positive medication views, strong medical and social support, and minimal personal drug cost. Future research should focus on whether and how much these factors impact adherence/persistence in more diverse populations. If adherence/persistence issues are identified in these populations, then it would be appropriate to study the development of interventions that target factors associated with better adherence/persistence.

A Nationwide Cross-Sectional Study of Self-Reported Adherence and Factors Associated with Analgesic Treatment in People with Chronic Pain

This study aims to shed light on the frequency and associated factors of self-reported adherence to analgesic treatment among chronic pain (CP) patients in the Spanish population. A nationwide cross-sectional study was performed of 1066 Spanish adults, of whom 251 suffered from CP and 168 had been prescribed analgesic treatment. Adherence was assessed using a self-reported direct questionnaire and related factors were collected. Descriptive and bivariate analyses were conducted. Among the 23.5% (95% CI: 21.0–26.2%) of the sample with CP, 66.9% (95% CI: 60.7–72.7%) were taking analgesic treatment prescribed by a doctor, and 81.0% (95% CI: 74.2–86.6%) said they took the treatment as the doctor indicated. However, 17.6% forgot to take the medication, 11% overused them when in great pain, 46.3% stopped the treatment when feeling better and 33.3% when feeling worse, and 7.3% stopped taking them for financial reasons. Higher intensity of pain, polymedication, administration route (injection/patches) and some patient-related factors were associated with self-perceived adherence to treatment. Most Spanish people with CP consider that they are adherent to their analgesic treatment. However, their behavior presents contradictions. It would be advisable for professionals to inform patients about appropriate behavior regarding their therapy recommendations, and to explore potential factors related to non-adherence. This could contribute to improving pain control.

The SPUR Model: A Framework for Considering Patient Behavior

BACKGROUND

Medication nonadherence is a global problem that requires urgent attention. Roughly half of all drugs that are prescribed for chronic treatments are not taken by the patients in question. Initiatives designed to support patients and help them modify their behavior are enhanced by personalization, and a number of profiling tools exist to help customize such interventions. Most of these tools were originally designed as paper-based questionnaires, but the growth of digital adherence technologies (DATs) illuminate the need for the development of digital profiling systems that can interact with fully automated patient interfaces.

OBJECTIVE

The objective of this study was to examine existing frameworks from medicine, psychology, sociology, consumer behavior, and economics to elaborate a comprehensive, quantitative profiling approach that can be used to drive the customization of patient support initiatives.

RESULTS

Building primarily on Icek Ajzen's Theory of Planned Behavior (TPB), the Health Belief Model (HBM) was used to inform the beliefs about behavior posited in the TPB, while incorporating established factors regarding self-efficacy in the "control" elements of the TPB and selected social and psychological factors in the other constituents of the model. The resulting SPUR (Social, Psychological, Usage, Rational) framework represents a holistic, profiling tool with detailed, quantitative outputs that describe a patient's behavioral risks and the drivers of that risk.

CONCLUSION

An interactive, digital questionnaire built around SPUR represents a potentially useful tool for those desirous of building interactive digital support programs for patients with chronic diseases.

Clinician Report of Oral Oncolytic Symptoms and Adherence Obtained via a Patient-Reported Outcome Measure (PROM)

PURPOSE

Patient-reported outcome measures (PROMs) for symptom monitoring during cancer therapy have been shown to have a positive impact on outcomes. These findings have primarily been shown for patients receiving intravenous chemotherapy. In addition, there is known discordance between physician reporting of symptoms and patient self-report. This initiative sought to describe patient-reported symptom burden and medication adherence and to indicate the degree of PROM results being discussed with the provider as indicated by documentation in the medical record for patients taking oral oncolytic therapy.

METHODS

The Michigan Oncology Quality Consortium (MOQC) PROM, which included symptom ratings, medication adherence, and patient confidence in self-management, was completed during outpatient visits and compared with corresponding data documented in the electronic medical record (EMR).

RESULTS

There were 82 completed PROMs. Approximately half included at least one symptom rated as severe (46%). Sixty-five percent of reported severe symptoms were documented in the EMR. Patient-reported moderate-to-severe pain was most likely to be documented in the EMR (100%), whereas patient-reported moderate-to-severe depression and anxiety were least likely to be documented (21%). Of the total symptoms documented, grading of symptom severity matched that of the patients' own report for 11% of severe symptoms. Adherence to oral oncolytics was excellent for 63% of patients, and patient adherence was documented in 7% of provider notes.

CONCLUSION

Patients frequently reported moderate-to-severe symptoms, and approximately 40% of patients reported nonadherence. Clinician report (documented in the EMR) of the patient symptom burden, symptom severity, and adherence to oral oncolytic therapy was not consistent with the patients' self-report. Use of a PROM for patients taking oral oncolytics has the opportunity to improve symptom management and medication adherence.

Challenges to the design and testing supportive interventions for cancer patients treated with oral oncolytic agents

Conducting research into supportive care for patients as they initiate treatment with oral oncolytic agents poses numerous new challenges. Some of these medications have very complex dosing schedules and produce symptoms that patients need to manage at home with less reliance on oncology clinicians. We describe lessons learned from a multi-site trial designed to improve adherence to these medications and self-management of symptoms among patients newly prescribed oral oncolytic agents. Identifying these challenges can assist researchers to improve the integrity of their future supportive care trials.

Use of a Smartphone Application for Prompting Oral Medication Adherence Among Adolescents and Young Adults With Cancer

OBJECTIVES

To explore the feasibility and acceptability of use of a smartphone medication reminder application to promote adherence to oral medications among adolescents and young adults (AYAs) with cancer.
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SAMPLE & SETTING

23 AYAs with cancer from a Children's Oncology Group-affiliated children's hospital and a National Cancer Institute-designated comprehensive cancer center in Salt Lake City, UT.
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METHODS & VARIABLES

Participants were asked to use the application for eight weeks. Data on application usage were obtained from a cloud-based server hosted by the application developers. Weekly self-report questionnaires were completed. Feasibility was assessed through participants' usage and responses. Acceptability was assessed through participants' perceived ease of use and usefulness.
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RESULTS

Almost all participants used the application at least once. More than half reported that they took their medications immediately when they received reminders. Participants also reported that the application was easy to set up and use, and that it was useful for prompting medication taking.
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IMPLICATIONS FOR NURSING

Nurses could continue to test the efficacy of integrating e-health modalities, such as smartphone applications, into efforts to promote medication adherence.

An innovative and comprehensive technique to evaluate different measures of medication adherence: The network meta-analysis

BACKGROUND

Poor medication adherence is associated with adverse health outcomes and higher costs of care. However, inconsistencies in the assessment of adherence are found in the literature.

OBJECTIVE

To evaluate the effect of different measures of adherence in the comparative effectiveness of complex interventions to enhance patients' adherence to prescribed medications.

METHODS

A systematic review with network meta-analysis was performed. Electronic searches for relevant pairwise meta-analysis including trials of interventions that aimed to improve medication adherence were performed in PubMed. Data extraction was conducted with eligible trials evaluating short-period adherence follow-up (until 3 months) using any measure of adherence: self-report, pill count, or MEMS (medication event monitoring system). To standardize the results obtained with these different measures, an overall composite measure and an objective composite measure were also calculated. Network meta-analyses for each measure of adherence were built. Rank order and surface under the cumulative ranking curve analyses (SUCRA) were performed.

RESULTS

Ninety-one trials were included in the network meta-analyses. The five network meta-analyses demonstrated robustness and reliability. Results obtained for all measures of adherence were similar across them and to both composite measures. For both composite measures, interventions comprising economic + technical components were the best option (90% of probability in SUCRA analysis) with statistical superiority against almost all other interventions and against standard care (odds ratio with 95% credibility interval ranging from 0.09 to 0.25 [0.02, 0.98]).

CONCLUSION

The use of network meta-analysis was reliable to compare different measures of adherence of complex interventions in short-periods follow-up. Analyses with longer follow-up periods are needed to confirm these results. Different measures of adherence produced similar results. The use of composite measures revealed reliable alternatives to establish a broader and more detailed picture of adherence.

Impact of an integrated oral chemotherapy program on patient adherence

As the use of oral chemotherapy continues to rise, the issue of patient adherence is a concerning aspect of cancer treatment. In this concurrent prospective and retrospective study, we assessed oral chemotherapy adherence in patients receiving their prescriptions at an institutional specialty pharmacy, with an integrated oral chemotherapy program. The primary endpoint is medication possession ratio. Secondary endpoints include self-reported adherence comparing survey data before and after the introduction of the oral chemotherapy program to assess the impact of the comprehensive pharmacy services provided. Patients receiving their oral chemotherapy from the institutional specialty pharmacy have a mean medication possession ratio of 0.92, indicating excellent adherence rates. The oncology clinical pharmacist, in collaboration with the specialty pharmacy, has also decreased the rates of patient-reported non-adherence.