Effect of a structured, active, home-based cancer-treatment program for the management of patients on oral chemotherapy

CHEOPS trial: a GINECO group randomized phase II assessing addition of a non-steroidal aromatase inhibitor to oral vinorelbine in pre-treated metastatic breast cancer patients

BACKGROUND

The objective of the CHEOPS trial was to assess the benefit of adding aromatase inhibitor (AI) to metronomic chemotherapy, oral vinorelbine, 50 mg, three times a week for pre-treated, HR + /HER2- metastatic breast cancer patients.

METHODS

In this multicentric phase II study, patients had to have progressed on AI and one or two lines of chemotherapy. They were randomized between oral vinorelbine (Arm A) and oral vinorelbine with non-steroidal AI (Arm B).

RESULTS

121 patients were included, 61 patients in Arm A and 60 patients in Arm B. The median age was 68 years. 109 patients had visceral metastases. They all had previously received an AI. The study had been prematurely stopped following the third death due to febrile neutropenia. Median PFS trend was found to be different with 2.3 months and 3.7 months in Arm A and Arm B, respectively (HR 0.73, 95%CI 0.50-1.06, p value = 0.0929). No statistical difference was shown in OS and better tumor response. 56 serious adverse events corresponding to 25 patients (21%) were reported (respectively, 12 (20%) versus 13 (22%) for arms A and B) (NS).

CONCLUSION

The addition of AI to oral vinorelbine over oral vinorelbine alone in aromatase inhibitor-resistant metastatic breast cancer was associated with a non-significant improvement of PFS. Several unexpected serious adverse events were reported. Metronomic oral vinorelbine schedule, at 50 mg three times a week, requires close biological monitoring. The question of hormonal treatment and chemotherapy combination remains open.

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.

Domains of Structured Oral Anticancer Medication Programs: A Scoping Review

PROBLEM IDENTIFICATION

An interprofessional approach is necessary to support the multifactorial process of patient adherence to oral anticancer medications (OAMs). This scoping review aims to identify structured OAM programs in published literature, identify components within studies, and propose a framework for institutions developing or maintaining OAM programs.

LITERATURE SEARCH

Embase®, PubMed®, and CINAHL® databases were searched for studies published between January 2000 and April 2021.

DATA EVALUATION

Two reviewers screened studies and extracted data. Characteristics and specific domains of the OAM programs were captured. Key components of the programs were identified, and a framework was created to guide program development.

SYNTHESIS

Components identified among the 21 studies were education; counseling; follow-up; dedicated clinician contact; adverse event and toxicity monitoring; adherence monitoring; drug procurement, delivery, and supply; patient- and system-level cost reduction; information technology; and risk assessment.

IMPLICATIONS FOR RESEARCH

Based on the findings, a framework for building and evaluating OAM adherence programs is proposed. Future studies should evaluate the reliability and validity of this framework because further testing may lead to the development of additional components.

ONS Guidelines™ to Support Patient Adherence to Oral Anticancer Medications

PURPOSE

This evidence-based guideline intends to support patients, clinicians, and others regarding interventions and processes to support patient adherence to oral anticancer medications (OAMs).

METHODOLOGIC APPROACH

A panel of healthcare professionals and patient representatives developed a clinical practice guideline to support patients taking OAMs. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology and criteria for trustworthy guidelines were followed. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A quantitative or narrative synthesis of the evidence was completed. Certainty of the evidence was assessed using GRADE.

FINDINGS

The panel agreed on recommendations and suggested an adherence risk assessment, education addressing adherence, ongoing assessment, proactive follow-up, coaching, and motivational interviewing in addition to usual care. The panel suggested the implementation of a structured OAM program.

IMPLICATIONS FOR NURSING

As cancer treatment shifts from clinic to home settings, interventions and programs to support patients on OAMs are needed.

Proposal for a general framework for the administration of anticancer immunotherapy in a hospital-at-home care

INTRODUCTION

Immunotherapy has transformed the treatment paradigm of several cancers. Hospital-at-home (HAH) care is an innovative healthcare model in which treatments are delivered at home under the supervision of a hospital, which likely applies to cancer immunotherapy. For this home-care option, official treatment guidelines are still lacking. We therefore sought to create guidance and recommendations on how to administer immune response checkpoint inhibitor therapies and other monoclonal antibodies used in cancer treatment in the context of HAH setting.

METHODS

A multidisciplinary group of healthcare professionals with expertise in managing cancer patients and prescribing immunotherapy in HAH settings was set up.

RESULTS

Based on the survey results and working group discussions, six major components were identified: (1) existing HAH organization in France; (2) underlying framework; (3) flowchart; (4) patient pathway before, the day of, and after immunotherapy; (5) healthcare personnel training; (6) patient therapeutic education. The detailed specifications for each component are provided herein, along with an illustrative flowchart. The prerequisites for home administration of cancer immunotherapies are summarized in Table 1.

DISCUSSION

This paper seeks to facilitate the implementation of cancer immunotherapy within HAH settings for the healthcare professionals concerned.

Current management of adults receiving oral anti-cancer medications: A scoping review

PURPOSE

Oral anti-cancer medication (OAM) has revolutionised oncology care. Due to their potential toxicities and associated safety challenges ongoing assessment and monitoring is essential; currently generally performed in acute care settings. Internationally there exists a transformative vision to shift patient care from acute to primary care. A nurse-led integrated model of care could be developed for OAM patient management in primary care. The aim of this study was to examine international literature regarding current clinical management practices for assessment and monitoring of patients receiving OAM.

METHODS

Following PRISMA-ScR guidelines, databases MEDLINE, CINAHL and Web of Science were searched for English studies published between 2010 and 2020 using keywords: assessment, cancer, care, management, oral anticancer medications. Articles were screened and assessed for eligibility. From eligible studies, data were extracted to summarize, collate and make a narrative account of the findings.

RESULTS

2261 papers were reviewed, 14 met inclusion criteria. Three phases of management are reported: 1. Patient treatment plan development; 2. Patient education; 3. Patient monitoring. Within these phases seven specific stages of care were identified broadly representing the patient's journey: (1) treatment decision, (2) prescribing of OAM, (3) OAM dispensing and administration, (4) maximising patient safety (5) ongoing patient assessment (6) patient support (7) communication with other health-care professionals.

CONCLUSIONS

Despite a paucity of international literature, a dedicated OAM clinic was endorsed as a means to achieve improved care. Nurses and pharmacists were identified as being of particular importance especially in education and ongoing management of patients receiving OAMs.

Novel Tool to Monitor Adherence to Oral Oncolytics: A Pilot Study

PURPOSE

Nonadherence is a significant issue in cancer care, especially as more oral therapies become available. Measuring and optimizing adherence to such therapies is challenging. In this study, we tested a novel technology that records real-time medication-taking behavior from a smart prescription bottle and can communicate with patients via text message to intervene in cases of nonadherence.

METHODS

We conducted a 28-patient pilot study to assess the feasibility of this technology in measuring and improving adherence in patients taking capecitabine, an oral chemotherapy agent with a complex, cyclical regimen. The study had a preintervention stage, during which patients were monitored, and an intervention stage, during which the text messaging intervention was enabled.

RESULTS

During preintervention, patients had an average self-adherence of 89%, and during post intervention, they had an average adherence of 90%. We defined three categories of patients by change in adherence: category 1 (> 8%), category 2 (-8% to 8%), and category 3 (< -8%). Patients in category 1 tended to live in regions with lower average household income (mean = $58,937 in US dollars [USD]) than those in category 2 (mean = $77,482 USD) and category 3 (mean = $90,972 USD). Of poststudy survey respondents, most indicated that they would want to continue using this technology and that they would recommend it to others.

CONCLUSION

This novel technology is able to monitor, measure, and intervene for patients taking capecitabine in real time. Adherence overall was high, and some patients appeared to benefit more from text-message interventions. Future work should focus on patients deemed high risk for nonadherence.

Evolving Best Practice for Take-Home Cancer Drugs

PURPOSE

Take-home cancer drugs (THCDs) have become a standard treatment of many cancers. Robust guidelines have been developed for intravenous chemotherapy drugs, but few exist for THCDs with a focus on decentralized models. Hence, Ontario Health (Cancer Care Ontario) established the Oncology Pharmacy Task Force (OPTF) to develop consensus-based recommendations on best practices for THCDs to ensure that patients receive safe, consistent, high-quality care in the community once they leave the cancer center/practice with a prescription.

METHODS

The OPTF included 34 members with comprehensive representation. Guidance from leading authorities was extracted through literature review, thematically analyzed, and synthesized to develop 29 recommendations. The consensus process (> 70% agreement) included a three-step modified Delphi method followed by an extensive review process.

RESULTS

Sixteen recommendations were developed: training and education for providers (2), drug access (1), prescribing (4), patient and family/caregiver education (3), communication (1), dispensing (3), monitoring for patient adherence and adverse effects (1), and incident reporting (1).

CONCLUSION

Through a rigorous methodology, the OPTF derived a robust set of recommendations similar to the ASCO/Oncology Nursing Society and ASCO/National Community Oncology Dispensing Association guidelines, further validating and strengthening the applicability across multiple jurisdictions, including those with decentralized models. Unique aspects in a decentralized model include the need for two pharmacy professionals, with one doing cognitive verification of the script and the other dispensing the medication; moreover, they optimize interprofessional communication between community providers and the cancer center/practice health care team.

Prospective evaluation of an anti-cancer drugs management programme in a dedicated oral therapy center (DICTO programme)

Oral therapies have highly modified cancer patient management and changed hospital practises. We introduce a specific Oral Therapy Centre and retrospectively review information prospectively recorded by co-ordination nurses (CNs) (the DICTO programme). We describe the roles played by CNs in the management of oral cancer therapies at Limoges Dupuytren Hospital between May 2015 and June 2018. All cancers, irrespective of stage or whether oral general chemotherapy or targeted therapy was prescribed, are included. We followed up 287 patients of median age 67 years (range 26–89 years). Of these, 76% had metastases and 44% were on first-line therapy. The vast majority (88%) of their first CN contacts occurred just after physician consultation and lasted an average of 60 min. As part of follow-up, the CNs made 2719 calls (average 10 min) to patients to educate them and to verify compliance and drug tolerance. They also received 833 calls from patients (70%) or their relatives or health professionals (30%) seeking advice on management of side effects. In addition to the initial appointments, 1069 non-scheduled follow-up visits were made to assess side effects (49.2%). The CNs devoted 5 h to each patient over 3 months of treatment (i.e. 25 min/day) and, also organised scheduled hospitalisations in the department of oncology for 51% of patients. We show the interest and real-life work in a specific oral therapy centre within oncology department with the role of CNs to facilitate the global health care of the patients.

Homcology: home chemotherapy delivery in a simultaneous care project for frail advanced cancer patients

Homcology is a project that represents both an opportunity for patients who may benefit from chemotherapy so far, but present physical and social problems that prevent day-hospital access, and a model of "no-profit" contribution to the Public Health System. Our medical oncology department conducted the project from May 2014 to January 2019. We included frail patients (G-8 < 14), with advanced disease, treated with oral, subcutaneous, or parenteral biological agents, with limitations to day-hospital access, comorbidities, and at least 6-month life expectancy. A multidisciplinary team included three oncologists, four nurses, an anesthetist, a psychologist, and a physiotherapist. Satisfaction was evaluated with FAMCARE scale. A total of 188 patients (median age of 73 years, 38-87) were enrolled. Ninety percent of patients presented with metastatic disease and a median G-8 score of 8.8 (3-13.5). All of them received anticancer treatment and concomitant supportive care; 24 patients received two or more lines of treatment. The median duration of taking care was 175 days (7-1200). A median number of 254 (195-325) nursing and 164 (139-190) medical visits were performed a year, with an average of 1.9 and 1.2 visits a month per patient respectively. The median number of in-line patients was 20 (17-25). Hospitalization occurred in 18% of cases. One-third of them died at home. The others were referred to hospice. Our experience shows that the integration of home cancer treatment and supportive care is effective. Hospitalization rate is lower than data reported in the literature. Results need to be confirmed in prospective pharmacoeconomics studies.

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.

Putting patients first: an inventive service delivering cancer treatment at home

Aim: This study evaluated the patient experience of receiving subcutaneous chemotherapy at home via a unique 'Cancer Treatment at Home' outreach service adapted by the UK Clatterbridge Cancer Centre NHS Foundation Trust. Patients & methods: The service involved using highly trained nurses to deliver cancer treatments to patients in their own homes. Patient outcomes were monitored over 12 months via the Systemic Anti-Cancer Therapy at Home (SACT) survey using handheld electronic devices. Results: Of the 56 participating cancer patients, 53 provided responses. Patients received subcutaneous trastuzumab, denosumab, pembrolizumab, fulvestrant and goserelin. Overall, 96% of respondents were 'very satisfied' and 4% 'satisfied' with the service. All respondents would recommend the service to others. Conclusion: The 'Cancer Treatment at Home' service has improved the patient experience for cancer care and has been recognized nationally for its achievements.

Challenges of Caregivers of Cancer Patients who are on Oral Oncolytic Therapy

OBJECTIVE

To describe the major challenges faced by caregivers of patients receiving oral oncolytic therapy (OOT).

DATA SOURCES

Published literature, national clinical practice guidelines, standards of care.

CONCLUSION

Caregivers of patients receiving OOT have unmet needs. Caregivers need standardized OOT education and coping support to improve patient outcomes through enhanced drug safety practices, better management of complex treatment regimens and adherence, patient symptoms, treatment side effects, care decision-making, and financial assistance for costly OOT.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are well-positioned to take leadership roles in facilitating optimal utilization of multidisciplinary health care resources necessary to support caregivers and improve outcomes in patients receiving OOT.

Nurse-led follow-up to outpatients with cancer pain treated with opioids at home-telephone calls plus WeChat versus telephone calls only: a quasi-experimental study

Background: Recently, cancer pain management has come increasingly to be provided in outpatient settings, requiring health-care providers and outpatients to take on responsibilities. Pain is among the most distressing symptoms of cancer. Objectives: To compare the effectiveness of nurse-led telephone calls plus WeChat versus telephone calls only for the pain management of outpatients with cancer. Methods: 231 outpatients with cancer pain were classified into two groups (group 1, N=125; group 2, N=106). Group 1 was followed up with weekly telephone calls for eight weeks, and group 2 with weekly telephone calls combined with the booklets through WeChat for eight weeks. Differences between groups in pain level, side effects, medication adherence, and satisfaction with pain management were analyzed, and statistical differences were tested usingan independent-sample t-test and a chi-squared test. Results: Group 2 had a significantly lower rest pain (p<0.01), and lower move pain but there was no statistical difference between the two groups. Among patients in group 2, constipation, nausea and vomiting, and dizziness were less (p<0.01), while medication adherence (p<0.05) and pain management satisfaction were higher (p<0.01) than patients in group 1. Conclusion: Nurse-led follow-up telephone calls combined with WeChat significantly reduced opioid-related health problems, such as pain intensity, side effects and medication adherence.

Factors Associated with Adherence Rates for Oral and Intravenous Anticancer Therapy in Commercially Insured Patients with Metastatic Colon Cancer

BACKGROUND

Over the past decade, oncology therapies have trended toward orally administered regimens, and there has been growing attention on evaluation of factors that affect adherence. There has not been a rigorous investigation of factors associated with adherence to intravenous (i.v.) and oral anticancer drugs in the setting of metastatic colorectal cancer (mCRC).

OBJECTIVES

To (a) assess potential patient-specific factors related to adherence to mCRC chemotherapy regimens and (b) compare adherence with IV versus oral dosage forms.

METHODS

A retrospective analysis was performed using the Optum Oncology Management claims database. Patients aged 18 years and older diagnosed with mCRC between July 1, 2004, and December 31, 2010, who were insured by a commercial health plan were included in the study. Adherence to i.v. and oral chemotherapy regimens was assessed using the National Comprehensive Cancer Network (NCCN) guidelines as the standard for expected cycle/regimen duration. The most commonly prescribed chemotherapy regimens were assessed. Adherence was evaluated using the medication possession ratio (MPR), calculated as the number of days a patient was covered by their chemotherapy regimen, according to NCCN guidelines, divided by the number of days elapsed from the first to the last infusion of that regimen. For most analyses, the MPR was considered a continuous variable that could take on values between 0 and 1. In other analyses, a dichotomous categorical variable designated if the MPR was at least 0.8 versus less than 0.8. The Wilcoxon rank sum, Kruskal-Wallis, and Student's t-test were used to detect differences in continuous measures between patients receiving oral capecitabine therapy versus i.v. chemotherapy. The chi square test (X(2) test) or Fisher's exact test was used to assess differences in the dichotomous MPR variable. Generalized estimating equation (GEE) models were used for regimen-level analyses to account for correlated responses within individuals.

RESULTS

A total of 6,780 patients were included in the analysis, virtually all (98%) with commercial insurance coverage and the remaining (2%) with Medicare Advantage. Patients with mCRC received 17,095 regimens of chemotherapy, including 2,252 regimens of oral capecitabine. Of the 17,095 regimens, 6,780 (40%) were first-line regimens (i.e., the first time mCRC was treated for a given patient). The most common chemotherapy regimen, regardless of line of therapy, was FOLFOX (2,991 regimens, 17.5% of all regimens used). FOLFOX-based therapies with or without bevacizumab were the most common regimens for first- and second-line chemotherapy, while oral capecitabine treatment was the most commonly prescribed regimen for patients in third- or fourth-line therapy. Overall, medication adherence across all regimens was relatively high, with a mean MPR of 0.87 (SD = 0.17). Evaluation of the distribution of i.v. and oral capecitabine regimens revealed that 28% of all regimens were associated with an MPR of less than 0.8. The average MPR was clinically similar, but statistically higher for i.v. chemotherapy regimens (0.881) compared with oral capecitabine regimens (0.799; P < 0.0001). In the multivariable GEE model, lung or liver metastases were associated with a higher MPR, while lower Charlson Comorbidity Index and oral anticancer therapy were associated with lower MPR. Furthermore, as line of therapy increased, the difference in MPR between patients receiving oral capecitabine and i.v. chemotherapy increased.

CONCLUSIONS

This analysis determined that adherence with i.v. chemotherapy regimens was clinically similar, but statistically higher, compared to oral capecitabine therapy. The difference in adherence rates between the 2 routes of administration increased as the line of anticancer regimen increased. These results suggest that there should be an increased focus on improving adherence rates in patients receiving oral capecitabine.

Transition journey from hospital to home in patients with cancer and their caregivers: a qualitative study

BACKGROUND

The National Cancer Institute Singapore initiated the NUH2 Home program in January 2014, referred to as "Caring Across the Cancer Continuum," a nurse-led cancer transitional care service (CTCS) that provides home care to patients with cancer and their caregivers. The study aimed to explore the transition experiences of patients with cancer and their caregivers.

METHOD

Using a purposive sampling, 12 patients with cancer and 12 caregivers were recruited. Audiotape interviews were conducted until data saturation was achieved. Each interview was transcribed verbatim, and thematic analyses were performed to extract significant themes and subthemes.

RESULTS

Four themes emerged from the data including (1) ongoing concerns, (2) needing timely help, (3) resuming control and normality of life, and (4) appreciating the transition care. The transition journey of patients and caregivers provided them with an ability to regain control and normality in their lives, be reassured and confident in being able to care for themselves and manage the physiological and psychological strains associated with the multiple vicissitudes associated with having cancer and its treatment while at home.

CONCLUSION

Our study addressed the nature, patterns, conditions, and responses to transition care. Our findings provided relevant contextual knowledge to further improve the transition care service based on the recommendations of the patients with cancer and their caregivers who first experienced the new service.