Action plan aims to improve adherence to oral anticancer therapies
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Availability of oral anticancer medications has increased greatly during the past decade, offering patients the convenience of fewer appointments, less travel time and targeted treatment within the comfort of their homes.
However, these self-administered regimens may also have the unintended effect of compromising patient adherence to potentially lifesaving medications.
“Adherence to oral anticancer medicines is a significant concern,” R. Donald Harvey, PharmD, professor in the department of hematology and medical oncology at Emory University School of Medicine, said in an interview with Healio. “Studies have shown that adherence to agents like tyrosine kinase inhibitors for chronic myeloid leukemia tends to degrade over time in all patients because of the duration of therapy. The idea that because patients have cancer, they are going to take their medicine is not necessarily accurate.”
Harvey and colleagues wrote a paper, published in Journal of Clinical Oncology, calling for better methods of ensuring patient compliance to oral anticancer medications. He spoke with Healio about the barriers to adherence, implications of nonadherence, and ways to ensure adherence without placing undue burden on the patient.
Healio: What are some of the obstacles to oral anticancer medication adherence?
Harvey: We know adherence to tamoxifen, in addition to medications like tyrosine kinase inhibitors, wanes over time and patients with breast cancer might take it for up to 10 years. We don’t know as much about adherence rates for shorter-term therapies, and we don’t have as much data as we would like on difficulties taking oral medications because of adverse events. Adverse events directly affect a patient’s willingness to take a drug. So, in terms of side effect profiles that we focus on in cancer, we need to reset our prism for what is seen as an “acceptable” adverse effect.
Healio: These patients also often have to take multiple medications. Does this impact adherence?
Harvey: That is certainly a concern. Cancer is more common in older patients, and older patients have more comorbidities, which means more medicines. We are also asking them to take these medicines on somewhat strange schedules. Instead of once a day in the morning, it might be once a day for 2 weeks and take a week off, or it might be once a week for 3 weeks and then nothing on the fourth week. It’s a lot of complicated information for patients to remember.
Healio: How can patient-centered formulations help improve adherence to oral anticancer medications?
Harvey: Patient-centered formulations reflect the idea that we have many drugs coming to the market that are promising and helpful, but these often have formulations that are challenging and can be a significant pill burden. It may be that patients have to take a regimen of four or more large tablets once a day. We have formulations that mandate that a patient cannot be on antacids while taking them because that will reduce the absorption of the cancer drug. Some drugs need to be taken with food and some need to be taken on an empty stomach. These formulations make it difficult to schedule other medicines and schedule their eating habits.
There’s a little bit of tension in the way we develop drugs for cancer— there’s the push from the company to get the drug onto the market as quickly as possible. Sometimes that comes at the expense of optimizing formulations and knowledge about how the drug should be taken. Some companies and sponsors do this very well, and others have some work to do.
Healio: How can pharmacists play a more active role in supporting patient adherence?
Harvey: Pharmacists need to own drug management when it comes to patients with cancer. They need to be front and center when it comes to helping patients adhere to their medicines over the long term.
Healio: Your paper also states that these drugs should be more affordable. How can this be achieved?
Harvey: A great paper by Dusetzina and colleagues out of The University of North Carolina discusses copays, which are a detriment to patient adherence to medications. Anything above $30 has made it less likely that a patient with chronic myeloid leukemia would be persistent in their treatment over a long period. So, we need to make it as easy as possible for patients to get their medicines, and minimize out-of-pocket costs and the number of barriers to access to these drugs.
Healio: What is the impact of patients being nonadherent to anticancer regimens?
Harvey: One thing that is very challenging in this field is that we don’t necessarily know when a patient is nonadherent. We might not know that a patient’s cancer progressed because the patient was not able to adhere to their medication. We may never know whether the outcome might have been different if we had been able to help them be adherent. Another challenge is that, unfortunately, many of our therapies don’t work as well as we would like. So, when the cancer progresses, we are left with the basic assumption that the cancer has become resistant or there was another biological problem.
Healio: Is there anything else you’d like to mention on this topic?
Harvey: There needs to be a change in the way we assess the research around adherence to anticancer medications. A lot of our research right now is insurance claims data. We need a better understanding in real time of whether patients can adhere to their medicines. That could be done through things such as improved understanding of drug concentration within a patient. An increased focus on therapeutic monitoring is also important.
I also think we need more research around technology, so we can understand when patients take their medicine and how they take it. In psychiatry, for example, certain medications have a film coating on the tablets. This enables us to know that a patient has absorbed or ingested a medication. That might be useful in the cancer population, as well, as we move toward cancer as a chronic condition in more patients.
References:
Dusetzina SB, et al. J Clin Oncol. 2014;doi:10.1200/JCO.2013.52.9123.
Levit L, et al. J Clin Oncol. 2022. 2022;doi:10.1200/JCO.21.02529.
For more information:
R. Donald Harvey, PharmD, can be reached at Emory University, 1365 Clifton Road NE Building C, Atlanta, GA 30322; email: donald.harvey@emory.edu.
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