Article

A Structured Nursing Intervention to Address Oral Chemotherapy Adherence in Patients With Non-Small Cell Lung Cancer

Jean E. Boucher

Joan Lucca

Catherine Hooper

Lillian Pedulla

Donna L. Berry

lung cancer, oral chemotherapy, adherence, knowledge, oncology nursing
ONF 2015, 42(4), 383-389. DOI: 10.1188/15.ONF.383-389

Purpose/Objectives: To evaluate a nurse-led intervention to enhance medication knowledge and adherence using the Multinational Association for Supportive Care in Cancer Oral Agent Teaching Tool (MOATT).

Design: Longitudinal, descriptive feasibility study.

Setting: An ambulatory thoracic oncology disease center located at the Dana-Farber Cancer Institute in Boston, MA.

Sample: 30 adult patients with lung cancer who received the oral agent erlotinib.

Methods: Structured, nurse-led education sessions using the MOATT were provided, with a 72-hour follow-up telephone contact. Participants completed a Knowledge Rating Scale (KRS) and adapted Morisky Medication Adherence Scale–8 (MMAS-8) at the end of the first cycle of oral chemotherapy.

Main Research Variables: Knowledge and adherence; feasibility.

Findings: Twenty-seven participants completed the study outcome measures reporting high knowledge levels and MMAS-8 scores. Structured, nurse-led education and follow-up monitoring sessions ranged from 14–30 minutes. Several participants also initiated contact for assistance with prescription procurement and symptom management. Participants reported a median of two side effects.

Conclusions: The structured, nurse-led teaching, using the MOATT tool, and follow-up nurse contacts were feasible as integrated into the thoracic oncology setting. Adherence and knowledge outcomes were encouraging. Additional studies should include objective adherence measures and strategies for delivering supportive care to patients at home.

Implications for Nursing: Structured teaching with patients is important to enhance proper oral anticancer medication knowledge and adherence, including follow-up monitoring of administration and side effects at 72 hours.

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    With the use of oral chemotherapies rapidly expanding in oncology practice (Halfdanarson & Jatoi, 2010), an increasingly significant concern involves patient medication adherence when these oral agents are self-administeredat home (Given, 2009; Moore, 2007, World Health Organization, 2003). One challenge of oral chemotherapy is the rate of medication adherence to oral anticancer regimens, which varies widely from 16%–100% in adults (Ruddy, Mayer, & Partridge, 2009). Common patient problems related to oral chemotherapy adherence include improper administration, inadequate monitoring, and adverse side effects (Banning, 2009; Decker et al., 2009; Given, Spoelstra, & Grant, 2011; Goodin, 2007; Halfdanarson & Jatoi, 2010; Hartigan, 2003; Haynes, Ackloo, Sahota, McDonald, & Yao, 2008; Moore, 2007; Ruddy et al., 2009). Suboptimal or improper self-administration reduces treatment efficacy and increases toxicity (Hartigan, 2003; Maloney & Kagan, 2011; Partridge, Avorn, Wang, & Winer, 2002; Ruddy et al., 2009; Wood, 2012) and leads to treatment delays, changes in treatment, and premature death (Given et al., 2011). Patient self-administration of oral chemotherapy also increases the risk of errors and changes the way patients are monitored (Goodin, Aisner, Bartel, & Viele, 2007; Goodin et al., 2011). Older adults with cancer have additional adherence and safety risks because of age-related physical changes, comorbid conditions, polypharmacy, and drug interactions (Maloney & Kagan, 2011).

    As reported by Weingart et al. (2008), significant patient safety concerns exist related to medication adherence, including safe handling (Goodin et al., 2011) and how patients manage missed doses and adverse events. To address these concerns, guidelines were published by the American Society of Clinical Oncology and the Oncology Nursing Society (Neuss et al., 2013; Weingart et al., 2012) to standardize the approach to oral chemotherapy administration by educating healthcare providers. Patients require similar education and support, including monitoring of medication procurement (e.g., prior approval needs, associated costs) (Moore, 2007, 2010; Winkeljohn, 2010); knowledge of interactions with drugs (Goodin et al., 2007, 2011; Maloney & Kagan, 2011; Simchowitz et al., 2010), including nutritional supplements and herbs (Goodin, 2007); and monitoring and reporting of symptoms (Moore, 2010; Weingart et al., 2007, 2012; Wood, 2012). Symptomatology (e.g., fatigue, nausea/vomiting, diarrhea, dermatologic changes) associated with side effects in taking newer oral targeted therapies also affects a patient’s adherence to a prescribed regimen. Several weeks may elapse between patient visits, when the appearance of toxicities most likely occurs, placing the responsibility of self-report of adverse effects on the patient, who may require dose modifications or interruptions (Goodin et al., 2007).

    Studies of patient-oriented strategies to promote medication adherence (Banning, 2009; Decker et al., 2009; Haynes, Ackloo, Sahota, McDonald, & Yao, 2008) have used automated voice response systems (Decker et al., 2009), pill boxes (Haynes et al., 2008; Williams, Manias, & Walker, 2008), medication event monitoring system caps (Ruddy et al., 2009), and pill counts (Haynes et al., 2008). These strategies present problems and challenges, including accuracy, cost, and ease of use (Hartigan, 2003; Haynes et al., 2008; Partridge et al., 2002). Telephone follow-up is a strategy that has demonstrated improved patient satisfaction and knowledge of medication regimens (Berry et al., 2014; Courtney et al., 2009), functioning also as a reminder that supports adherence (Molassiotis, Lopez-Nahas, Chung, & Lam, 2003; Osterberg & Blaschke, 2005).

    Systematic reviews of interventional studies for medication adherence support a standardized multimethod approach to medication management that involves tailored cognitive-educational approaches (Haynes et al., 2008) with psychosocial support strategies (Wens et al., 2008; Williams et al., 2008). Additional use of feedback (Demonceau et al., 2013) and monitoring by nurses (Haynes, McDonald, Garg, & Montague, 2002; McCauley, Bixby, & Naylor, 2006), including management of side effects (Kav et al., 2008) and use of a daily self-report diary (Oakley, Johnson, & Ream, 2010) and written information (Nicolson, Knapp, Raynor, & Spoor, 2009), can provide educational reinforcement. Other studies underscore similar needs for structured educational tools for systematic patient education (Given, 2009; Goodin et al., 2011; Maloney & Kagan, 2011; Simchowitz et al., 2010; Weingart et al., 2007, 2012; Wood, 2012) in the promotion of safety, optimal dosing, adherence, and detection and management of adverse events (Balkrishnan, 2005; Winkeljohn, 2007).

    In response to the need for a standardized structured educational tool, a panel of oncology nurse experts created the Multinational Association of Supportive Care in Cancer (MASCC) Oral Agent Teaching Tool (MOATT) to help educate and monitor patients and caregivers. MOATT is a structured four-part systematic approach for oral cancer agent education involving key assessment questions, generic education discussion points, drug-specific education (e.g., frequency, storage, safety), and evaluation questions. In 2009, MASCC published the MOATT (Kav et al., 2010) for use by nurses with patients receiving oral anticancer agents, addressing a needed strategy to promote medication adherence and symptom management, including the reporting of related adverse side effects.

    Minimal evidence exists for tested interventions to promote oral chemotherapy adherence. The need to implement new professional guidelines and improve clinical approach compelled the researchers to evaluate the implementation of a structured, nurse-led intervention using the MOATT to maximize patient knowledge and adherence related to self-administration of the oral agent erlotinib in patients with non-small cell lung cancer (NSCLC). No studies had yet evaluated the MOATT in clinical practice to promote medication adherence.

    Methods

    A descriptive feasibility study was conducted as an evidence-based practice (EBP) project at the Dana-Farber Cancer Institute (DFCI), a National Cancer Institute–designated ambulatory cancer center setting. The Dana-Farber/Harvard Cancer Center Institutional Review Board expedited and approved the study. The sample included eligible patients who were adults, English-speaking, diagnosed with NSCLC, and prescribed oral erlotinib (as monotherapy). The EBP project was developed by a collaborative team of DFCI nurses, including direct care nurses (DCNs), nurse practitioners, clinic and research nurses from the Thoracic Oncology Program, and DFCI nurse scientists.

    Intervention

    A description of the intervention schema, which includes four educational sessions, is illustrated in Figure 1. During session 1, when erlotinib was prescribed, the health practitioner provided initial oral and written education to the patient and discussed the option of participation in the current feasibility study. The DCN then met with the patient to discuss the study and obtain informed consent, provided an erlotinib drug log, and scheduled a 72-hour follow-up educational telephone encounter.

    Session 2 was the first follow-up encounter prior to starting erlotinib and was determined to be a key time point for the DCN to contact patients who may have difficulty with prescription procurement or financial concerns related to the drug therapy. The DCN administered parts 1–4 of the MOATT (see Table 1). This tool included key assessment questions, generic education guidelines, discussion points, drug-specific education, and evaluation questions to assess and provide medication knowledge to participants (Kav et al., 2010).

    Session 3, performed at an approximate 72-hour window after starting erlotinib, involved the DCN conducting the follow-up phone encounter to assess learning and identify any issues that the participant had related to erlotinib procurement or administration and possible side effects. Session 4 occurred at the participant’s first scheduled clinic visit (usually about 2–3 weeks after starting therapy) or by phone. The adapted Morisky Medication Adherence Scale–8 (MMAS-8) (Morisky, Ang, Krousel Wood, & Ward, 2008; Morisky, Green, & Levine, 1986; Sommers, Miller, & Berry, 2012) and a demographic information form were administered along with parts 3–4 of the MOATT. This final study encounter occurred at the 6- to 8-week period of therapy in which the DCN collected and reviewed the erlotinib drug log with the participant and an adherence rate was calculated.

    Sessions with the participant were documented in electronic nursing notes, according to standard nursing policies and procedures. Data regarding the feasibility (see Figure 2) of providing the DCN education, including the ability to contact or meet with the participant, time spent doing education, review of the diary, and symptoms and management, were recorded at each encounter. Unplanned patient-initiated contact by phone with the DCN was documented throughout the study.

    Measures

    The MMAS-8 was used as a self-report measure of medication-taking and adherence behavior. This measure originally was developed to collect data on self-reported adherence to antihypertensive medications (Morisky et al., 2008). The MMAS-8 consists of seven medication-taking behavior questions with “yes” or “no” responses. A point is given for each “no” answer, except for question 5, for which a “yes” response is given one point. Question 8 has a five-point Likert-type scale response about difficulty remembering to take medication from “never/rarely” (scored as 0) to “all the time” (scored as 5). The MMAS-8 version used in the current feasibility study previously was adapted, with permission for use with oral chemotherapy agents, by Sommers et al. (2012).

    The total MMAS-8 score is a sum of the scores, with a possible range of scores from 0–8. A score of 6–8 indicates high adherence. Previous studies reported a reliability coefficient for the MMAS-8 of 0.83 (Morisky et al., 2008), with testing for concurrent validity (point biserial = 0.43, p < 0.01) (Morisky et al., 1986) and predictive validity (r = 0.58, p < 0.01) (Morisky et al., 1986) in adherence conducted with antihypertensive patients and correlated with blood pressure control. The reliability coefficient was 0.75 for the adapted MMAS version, as previously reported by Sommers et al. (2012). Participants also self-rated their perception of knowledge about erlotinib using a previously created Knowledge Rating Scale (KRS) (Fonteyn, Spenser, & Gross, 2008). The one-item scale is scored from 0–10, with 0 indicating no knowledge and 10 indicating the highest knowledge.

    Findings

    Of the 33 eligible patients, 3 declined to participate because of personal issues. Of the remaining 30 participants enrolled in the pilot study, 1 became ineligible to start the medication because of medical reasons, resulting in a total of 29 eligible participants who began the structured, nurse-led education. Two participants were not able to complete the study because of disease complications, leaving 27 participants who completed the entire four sessions of the study. Twenty-two of the 29 participants were women, 22 were Caucasian, and 17 had at least some college education.

    Session 1 involved initial participant contact to review medication instructions, including the drug diary, prior to starting erlotinib. The average DCN time spent talking with the participant in session 1 was 25.21 minutes (SD = 7.72), with a range of 12–49 minutes. Additional help was noted for prescription procurement, including prior approval and co-pay assistance. For sessions 2–4, the average time spent on any one MOATT education session was 14.12 minutes (SD = 10.72). Times for individual sessions ranged from 3–50 minutes. Session 2 included MOATT parts 1–4, taking an average of 25 minutes (SD = 9.28), including part 4 MOATT evaluation questions about medication administration answered by all participants. Questions 1–6 revealed that all participants answered “yes” to items involving knowledge about and ability to take oral agents (i.e., swallowing by mouth), reading drug label information, and opening the medicine bottle or package. One participant answered “yes” to having a problem with a particular symptom that would affect ability to keep pills down. To reinforce education, parts 3 and 4 of the MOATT were administered again to participants in session 3, averaging 8.56 minutes (SD = 3.42) and in session 4, averaging 6.92 minutes (SD = 5.23). During the MOATT education sessions, noted challenges for the DCN that interfered with the ability to contact participants at preset appointment times by phone included having a busy clinic or frequent interruptions. During DCN contacts with some participants, side effects also were reported, including anxiety, gastrointestinal complaints (e.g., nausea, vomiting, diarrhea), and skin rash, warranting assessment and instruction for proper symptom management.

    Knowledge and Adherence Measures

    All 27 participants completing session 4 were seen in the clinic for the fourth and final educational session, completing the adapted MMAS-8 and KRS (see Table 2). Study reliability coefficient of the adapted MMAS-8 was 0.78. Eight participants completed the diary logs, eight did not keep the diary, two did not return the diary, and diary use was not documented for nine.

    Feasibility outcomes included the 72-hour nurse follow-up call at session 3, during which a majority (n = 21) were contacted by telephone; six participants were unavailable because of work schedules. Of note, 66 patient-initiated telephone calls to the DCN for prescription and symptom management issues were documented. Twenty-eight calls for prescription procurement issues included refilling medication (n = 12), insurance coverage (n = 9), and paying for the drug (n = 7). Symptom management issues involved reporting of side effects such as rash, nausea, and diarrhea and how to manage them using moisturizer agents, hydration, diet, and medications for antiemetic and antidiarrheal therapy. Participants reported a median of two side effects (range = 1–5).

    Discussion

    The feasibility of a structured, nurse-led intervention with patients on oral chemotherapy to enhance proper erlotinib knowledge and adherence was demonstrated during this EBP project. Of the original 30 enrolled participants, the majority completed the study. The 10% attrition rate was involuntary and occurred when one participant tested negative for epidermal growth factor receptor and did not start oral therapy and two participants were removed from oral therapy because of medical complications. Findings of high knowledge and adherence scores by the remaining participants (n = 27) supported the structured, nurse-led intervention. The MOATT, administered by DCNs to participants, also was feasible in regards to the time to administer educational sessions, which was lower than the previous estimation of 60 minutes by Kav et al. (2010). Similar to Weingart et al.’s (2011) findings on oral medication adherence, participants required assistance with drug handling, insurance coverage, prescription filling, paying for medication, and managing side effects.

    Prior publications (Kav et al., 2010; Rittenberg, 2012) have promoted the MOATT as standard-of-care education, but randomized trials have yet to be published regarding the tool’s efficacy. Additional testing of innovative multimethod strategies, including nurse-led instruction, medication prompting, and reinforcement, with monitoring of self-care behaviors and symptoms, has been recommended to increase medication adherence (Schneider, 2012; Schneider, Hess, & Gosselin, 2011; Weingart et al., 2012), improve management of symptoms (Moody & Jackowski, 2010), and optimize patient outcomes. A randomized trial by Schneider, Adams, and Goselin (2014) supports additional studies of a nurse-led, tailored standard education and coaching plan approach, which showed adherence benefits for some study participants.

    Different methods for operationalizing and assessing adherence require additional investigation of the barriers, convenience, and cost issues associated with present devices and measures. Only 8 of 27 participants used the self-report diary log. Although a self-report diary is a simple subjective measure for monitoring medication adherence, the researchers found it to be the least feasible component of their intervention and monitoring measures. The adapted MMAS–8 questionnaire was an easily completed, self-report adherence measure, but the participants’ responses may have had a recall bias. Objective, cost-effective measures of adherence, although out of scope for the current EBP project, are needed to enhance outcome evaluation.

    The researchers’ feasibility study findings cannot be generalized beyond similar samples or settings or to oral agents other than erlotinib. In addition, because of the single-arm design, the researchers cannot claim to have improved adherence with the intervention.

    Implications for Nursing

    Structured, nurse-led teaching for patients on oral chemotherapy is important for proper medication knowledge in self-administration and monitoring of side effects related to such therapies. Use of the MOATT in ambulatory cancer settings provides a valuable standardized educational tool for assessment, generic and specific medication education, and evaluation. Patient self-management of oral chemotherapy also requires nurses’ support, using follow-up evaluation by telephone or during clinic visits after initial therapy starts. Another implication includes the patients' need for assistance with insurance coverage and prescription filling, as reported in previous findings by Weingart et al. (2011). Because pharmacy plays a role in medication dispensing and dosing instruction, the nurse’s role includes reinforcement of education (particularly in the first 6–8 weeks) while monitoring for side effects that require support through symptom management using physiological and psychosocial interventions.

    Conclusions

    The current feasibility pilot study was one of the first oncology-based projects in an oncology ambulatory setting that implemented structured, nurse-led education using the MOATT with follow-up nurse monitoring and supportive care. A structured, nurse-led intervention resulted in high scores for patient knowledge and adherence, suggesting that nurse involvement, along with use of the MOATT, with follow-up monitoring was very beneficial to these patients. The participation time required for each educational session was reasonable and supported the feasibility of the current pilot project. The overall findings from the current pilot study support wider implementation and evaluation with other cancer diagnoses for which oral chemotherapy is prescribed.

    References

    Balkrishnan, R. (2005). The importance of medication adherence in improving chronic-disease related outcomes: What we know and what we need to further know. Medical Care, 43, 517–520.

    Banning, M. (2009). A review of interventions used to improve adherence to medication in older people. International Journal of Nursing Studies, 46, 1505–1515. doi:10.1016/j.ijnurstu.2009.03.011

    Berry, D.L., Cunningham, T., Eisenberg, S., Wickline, M., Hammer, M., & Berg, C. (2014). Improving patient knowledge of discharge medications in an oncology setting. Clinical Journal of Oncology Nursing, 18, 35–37. doi:10.1188/14.CJON.35-37

    Courtney, M., Edwards, H., Chang, A., Parker, A., Finlayson, K., & Hamilton, K. (2009). Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: A randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program. Journal of the American Geriatrics Society, 57, 395–402. doi:10.1111/j.1532-5415.2009.02138.x

    Decker, V., Spoelstra, S., Miezo, E., Bremer, R., You, M., Given, C., & Given, B. (2009). A pilot study of an automated voice response system and nursing intervention to monitor adherence to oral chemotherapy agents. Cancer Nursing, 32(6), E20–E29. doi:10.1097/NCC.0b013e3181b31114

    Demonceau, J., Ruppar, T., Kristanto, P., Hughes D.A., Fargher, E., Kardas, P., . . . Urquhart, J. (2013). Identification and assessment of adherence—Enhancing interventions in studies assessing medication adherence through electronically compiled drug dosing histories: A systematic literature review and meta-analysis. Drugs, 73, 545–562. doi:10.1007/s40265-013-0041-3

    Fonteyn, M., Spenser, L., & Gross, A. (2008). Assessment of the challenges of oral chemotherapy adherence in adult oncology patients. Paper presented at the Oncology Nursing Society 33rd Annual Congress, Boston, MA.

    Given, B.A. (2009). 2009–2013 Oncology Nursing Society research agenda: Why is it important? Oncology Nursing Forum, 36, 487–488. doi:10.1188/09.ONF.487-488

    Given, B.A., Spoelstra, S.L., & Grant, M. (2011). The challenges of oral agents as antineoplastic treatments. Seminars in Oncology Nursing, 27, 93–103. doi:10.1016/j.soncn.2011.02.003

    Goodin, S. (2007). Oral chemotherapeutic agents: Understanding mechanisms of action and drug interactions. American Journal of Health-System Pharmacy, 64(9, Suppl. 5), S15–S24.

    Goodin, S., Aisner, J., Bartel, S.B., & Viele, C.S. (2007). Advancing the safe and appropriate use of oral chemotherapy agents. American Journal of Health System Pharmacy, 64(9, Suppl. 5), S3.

    Goodin, S., Griffith, N., Chen, B., Chuk, K., Daouphars, M., Doreau, C., . . . Meier, K. (2011). Safe handling of oral chemotherapeutic agents in clinical practice: Recommendations from an international pharmacy panel. Journal of Oncology Practice, 7, 7–12. doi:10.1200/JOP.2010.000068

    Halfdanarson, T.R., & Jatoi, A. (2010). Oral cancer chemotherapy: The critical interplay between patient education and patient safety. Current Oncology Reports, 12, 247–252. doi:10.1007/s11912-010-0103-6

    Hartigan, K. (2003). Patient education: The cornerstone of successful oral chemotherapy treatment. Clinical Journal of Oncology Nursing, 7(6, Suppl.), 21–24. doi:10.1188/03.CJON.S6.21-24

    Haynes, R.B., Ackloo, E., Sahota, N., McDonald, H.P., & Yao, X. (2008). Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews, 2, CD000011.

    Haynes, R.B., McDonald, H., Garg, A.X., & Montague, P. (2002). Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews, 2, CD000011. doi: 10.1002/14651858.CD000011

    Kav, S., Johnson, J., Rittenberg, C., Fernadez-Ortega, P., Suominen, T., Olsen, P.R., . . . Clark-Snow, R. (2008). Role of the nurse in patient education and follow-up of people receiving oral chemotherapy treatment: An international survey. Supportive Care in Cancer, 16, 1075–1083. doi:10.1007/s00520-007-0377-x

    Kav, S., Schulmeister, L., Nirenberg, A., Barber, L., Johnson, J., & Rittenberg, C. (2010). Development of the MASCC teaching tool for patients receiving oral agents for cancer. Supportive Care in Cancer, 18, 583–590. doi:10.1007/s00520-009-0692-5

    Maloney, K.W., & Kagan, S.H. (2011). Adherence and oral agents with older patients. Seminars in Oncology Nursing, 27, 154–160. doi:10.1016/j.soncn.2011.02.007

    McCauley, K.M., Bixby, M.B., & Naylor, M.D. (2006). Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Disease Management, 9, 302–310. doi:10.1089/dis.2006.9.302

    Molassiotis, A., Lopez-Nahas, V., Chung, W.Y., & Lam, S.W. (2003). A pilot study of the effects of a behavioural intervention on treatment adherence in HIV-infected patients. AIDS Care, 15, 125–135. doi:10.1080/0954012021000039833

    Moody, M., & Jackowski, J. (2010). Are patients on oral chemotherapy in your practice setting safe? Clinical Journal of Oncology Nursing, 14, 339–346. doi:10.1188/10.CJON.339-346

    Moore, S. (2007). Facilitating oral chemotherapy treatment and compliance through patient/family-focused education. Cancer Nursing, 30, 112–122. doi:10.1097/01.NCC.0000265009.33053.2d

    Moore, S. (2010). Nonadherence in patients with breast cancer receiving oral therapies. Clinical Journal of Oncology Nursing, 14, 41–47. doi:10.1188/10.CJON.41-47

    Morisky, D.E., Ang, A., Krousel‐Wood, M., & Ward, H.J. (2008). Predictive validity of a medication adherence measure in an outpatient setting. Journal of Clinical Hypertension, 10, 348–354.

    Morisky, D.E., Green, L.W., & Levine, D.M. (1986). Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care, 24, 67–74.

    Neuss, M.N., Polovich, M., McNiff, K., Esper, P., Gilmore, T.R., LeFebvre, K.B., . . . Jacobsen, J.O. (2013). 2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy. Journal of Oncology Practice, 9, 5s–13s. doi:10.1200/JOP.2013.000874

    Nicolson, D.J., Knapp, P., Raynor, D.K., & Spoor, P. (2009). Written information about individual medicines for consumers. Cochrane Database of Systematic Reviews, 2, CD002104. doi:10.1002/14651858.CD002104.pub3

    Oakley, C., Johnson, J., & Ream, E. (2010). Developing an intervention for cancer patients prescribed oral chemotherapy: A generic patient diary. European Journal of Cancer Care, 19, 21–28.

    Osterberg, L., & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353, 487–497. doi:10.1056/NEJMra050100

    Partridge, A.H., Avorn, J., Wang, P.S., & Winer, E.P. (2002). Adherence to therapy with oral antineoplastic agents. Journal of the National Cancer Institute, 94, 652–661. doi:10.1093/jnci/94.9.652

    Rittenberg, C.N. (2012). Meeting educational needs and enhancing adherence of patients receiving oral cancer agents through use of the MASCC Oral Agent Teaching Tool©. European Oncology and Haematology, 8, 97–100.

    Ruddy, K., Mayer, E., & Partridge, A. (2009). Patient adherence and persistence with oral anticancer treatment. CA: A Cancer Journal for Clinicians, 59, 56–66. doi:10.3322/caac.20004

    Schneider, S. (2012). Tailored intervention protocol for oral chemotherapy adherence. Abstracts of the 2012 International MASCC/ISOO Symposium. Supportive Care in Cancer, 20(Suppl. 1), S177. doi:10.1007/s00520-012-1479-7

    Schneider, S.M., Adams,D.B., & Gosselin, T. (2014). A tailored nurse coaching intervention for oral chemotherapy adherence. Journal of Advanced Practice Oncology, 5, 163–172.

    Schneider, S.M., Hess, K., & Gosselin, T. (2011). Interventions to promote adherence with oral agents. Seminars in Oncology Nursing, 27, 133–141. doi:10.1016/j.soncn.2011.02.005

    Simchowitz, B., Shiman, L., Spencer, J., Brouillard, D., Gross, A., Connor, M., & Weingart, S.N. (2010). Perceptions and experiences of patients receiving oral chemotherapy. Clinical Journal of Oncology Nursing, 14, 447–453. doi:10.1188/10.CJON.447-453

    Sommers, R.M., Miller, K., & Berry, D.L. (2012). Feasibility pilot on medication adherence and knowledge in ambulatory patients with gastrointestinal cancer [Online exclusive]. Oncology Nursing Forum, 39, E373–E379. doi:10.1188/12.ONF.E373-E379

    Weingart, S.N., Bach, P.B., Johnson, S.A., Langbaum, T.S., Muller, R.J., O’Brien, S., . . . Walters, R.S. (2008). NCCN task force report: Oral chemotherapy. Retrieved from http://www.nccn.org/JNCCN/PDF/JNSU3_combined_Oral_Chemo_2008.pdf

    Weingart, S.N., Flug, J., Brouillard, D., Morway, L., Partridge, A., Bartel, S., . . . Connor, M. (2007). Oral chemotherapy safety practices at US cancer centres: Questionnaire survey. BMJ, 334, 407.

    Weingart, S.N., Li, J.W., Zhu, J., Morway, L., Stuver, S.O., Shulman, L.N., . . . Hassett, M.J. (2012). US cancer center implementation of ASCO/Oncology Nursing Society chemotherapy administration safety standards. Journal of Oncology Practice, 8, 7–12. doi:10.1200/JOP.2011.000379

    Weingart, S.N., Spencer, J., Buia, S., Duncombe, D., Singh, P., Gadkari, M., & Connor, M. (2011). Medication safety of five oral chemotherapies: A proactive risk assessment. Journal of Oncology Practice, 7, 2–6. doi:10.1200/JOP.2010.000064

    Wens, J., Vermeire, E., Hearnshaw, H., Lindenmeyer, A., Biot, Y., & Van Royen, P. (2008). Educational interventions aiming at improving adherence to treatment recommendations in type 2 diabetes: A sub-analysis of a systematic review of randomised controlled trials. Diabetes Research and Clinical Practice, 79, 377–388. doi:10.1016/j.diabres.2007.06.006

    Williams, A., Manias, E., & Walker, R. (2008). Interventions to improve medication adherence in people with multiple chronic conditions: A systematic review. Journal of Advanced Nursing, 63, 132–143. doi:10.1111/j.1365-2648.2008.04656.x

    Winkeljohn, D. (2010). Adherence to oral cancer therapies. Clinical Journal of Oncology Nursing, 14, 461–466. doi:10.1188/10.CJON.461-466

    Winkeljohn, D.L. (2007). Oral chemotherapy medications: The need for a nurse’s touch. Clinical Journal of Oncology Nursing, 11, 793–796. doi:10.1188/07.CJON.793-796

    Wood, L. (2012). A review on adherence management in patients on oral cancer therapies. European Journal of Oncology Nursing, 16, 432–438. doi:10.1016/j.ejon.2011.10.002

    World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Retrieved from http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf

    About the Author(s)

    Jean Boucher, PhD, RN, ANP, is a clinical inquiry specialist, nurse faculty, in the Phyllis F. Cantor Center at Dana-Farber Cancer Institute in Boston, MA, and an oncology nurse practitioner at the University of Massachusetts Worcester Graduate School of Nursing; Joan Lucca, RN, MSN, NP-C, AOCN®, is a clinical research nurse and Catherine Hooper, RN, BSN, OCN®, is a thoracic oncology nurse, both in the Lowe Center for Thoracic Oncology at Dana-Farber Cancer Institute; Lillian Pedulla, RN, BSN, MSN, NEA-BC, is the director of Nursing and Patient Care Services at Dana-Farber Cancer Institute; and Donna L. Berry, PhD, RN, AOCN®, FAAN, is the director of the Phyllis F. Cantor Center at Dana-Farber Cancer Institute. No financial relationships to disclose. Berry can be reached at donna_berry@dfci.harvard.edu, with copy to editor at ONFEditor@ons.org. (Submitted June 2014. Accepted for publication January 28, 2015.)

     

    References

    Balkrishnan, R. (2005). The importance of medication adherence in improving chronic-disease related outcomes: What we know and what we need to further know. Medical Care, 43, 517–520.
    Banning, M. (2009). A review of interventions used to improve adherence to medication in older people. International Journal of Nursing Studies, 46, 1505–1515. doi:10.1016/j.ijnurstu.2009.03.011
    Berry, D.L., Cunningham, T., Eisenberg, S., Wickline, M., Hammer, M., & Berg, C. (2014). Improving patient knowledge of discharge medications in an oncology setting. Clinical Journal of Oncology Nursing, 18, 35–37. doi:10.1188/14.CJON.35-37
    Courtney, M., Edwards, H., Chang, A., Parker, A., Finlayson, K., & Hamilton, K. (2009). Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: A randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program. Journal of the American Geriatrics Society, 57, 395–402. doi:10.1111/j.1532-5415.2009.02138.x
    Decker, V., Spoelstra, S., Miezo, E., Bremer, R., You, M., Given, C., & Given, B. (2009). A pilot study of an automated voice response system and nursing intervention to monitor adherence to oral chemotherapy agents. Cancer Nursing, 32(6), E20–E29. doi:10.1097/NCC.0b013e3181b31114
    Demonceau, J., Ruppar, T., Kristanto, P., Hughes D.A., Fargher, E., Kardas, P., . . . Urquhart, J. (2013). Identification and assessment of adherence—Enhancing interventions in studies assessing medication adherence through electronically compiled drug dosing histories: A systematic literature review and meta-analysis. Drugs, 73, 545–562. doi:10.1007/s40265-013-0041-3
    Fonteyn, M., Spenser, L., & Gross, A. (2008). Assessment of the challenges of oral chemotherapy adherence in adult oncology patients. Paper presented at the Oncology Nursing Society 33rd Annual Congress, Boston, MA.
    Given, B.A. (2009). 2009–2013 Oncology Nursing Society research agenda: Why is it important? Oncology Nursing Forum, 36, 487–488. doi:10.1188/09.ONF.487-488
    Given, B.A., Spoelstra, S.L., & Grant, M. (2011). The challenges of oral agents as antineoplastic treatments. Seminars in Oncology Nursing, 27, 93–103. doi:10.1016/j.soncn.2011.02.003
    Goodin, S. (2007). Oral chemotherapeutic agents: Understanding mechanisms of action and drug interactions. American Journal of Health-System Pharmacy, 64(9, Suppl. 5), S15–S24.
    Goodin, S., Aisner, J., Bartel, S.B., & Viele, C.S. (2007). Advancing the safe and appropriate use of oral chemotherapy agents. American Journal of Health System Pharmacy, 64(9, Suppl. 5), S3.
    Goodin, S., Griffith, N., Chen, B., Chuk, K., Daouphars, M., Doreau, C., . . . Meier, K. (2011). Safe handling of oral chemotherapeutic agents in clinical practice: Recommendations from an international pharmacy panel. Journal of Oncology Practice, 7, 7–12. doi:10.1200/JOP.2010.000068
    Halfdanarson, T.R., & Jatoi, A. (2010). Oral cancer chemotherapy: The critical interplay between patient education and patient safety. Current Oncology Reports, 12, 247–252. doi:10.1007/s11912-010-0103-6
    Hartigan, K. (2003). Patient education: The cornerstone of successful oral chemotherapy treatment. Clinical Journal of Oncology Nursing, 7(6, Suppl.), 21–24. doi:10.1188/03.CJON.S6.21-24
    Haynes, R.B., Ackloo, E., Sahota, N., McDonald, H.P., & Yao, X. (2008). Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews, 2, CD000011.
    Haynes, R.B., McDonald, H., Garg, A.X., & Montague, P. (2002). Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews, 2, CD000011. doi: 10.1002/14651858.CD000011
    Kav, S., Johnson, J., Rittenberg, C., Fernadez-Ortega, P., Suominen, T., Olsen, P.R., . . . Clark-Snow, R. (2008). Role of the nurse in patient education and follow-up of people receiving oral chemotherapy treatment: An international survey. Supportive Care in Cancer, 16, 1075–1083. doi:10.1007/s00520-007-0377-x
    Kav, S., Schulmeister, L., Nirenberg, A., Barber, L., Johnson, J., & Rittenberg, C. (2010). Development of the MASCC teaching tool for patients receiving oral agents for cancer. Supportive Care in Cancer, 18, 583–590. doi:10.1007/s00520-009-0692-5
    Maloney, K.W., & Kagan, S.H. (2011). Adherence and oral agents with older patients. Seminars in Oncology Nursing, 27, 154–160. doi:10.1016/j.soncn.2011.02.007
    McCauley, K.M., Bixby, M.B., & Naylor, M.D. (2006). Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Disease Management, 9, 302–310. doi:10.1089/dis.2006.9.302
    Molassiotis, A., Lopez-Nahas, V., Chung, W.Y., & Lam, S.W. (2003). A pilot study of the effects of a behavioural intervention on treatment adherence in HIV-infected patients. AIDS Care, 15, 125–135. doi:10.1080/0954012021000039833
    Moody, M., & Jackowski, J. (2010). Are patients on oral chemotherapy in your practice setting safe? Clinical Journal of Oncology Nursing, 14, 339–346. doi:10.1188/10.CJON.339-346
    Moore, S. (2007). Facilitating oral chemotherapy treatment and compliance through patient/family-focused education. Cancer Nursing, 30, 112–122. doi:10.1097/01.NCC.0000265009.33053.2d
    Moore, S. (2010). Nonadherence in patients with breast cancer receiving oral therapies. Clinical Journal of Oncology Nursing, 14, 41–47. doi:10.1188/10.CJON.41-47
    Morisky, D.E., Ang, A., Krousel‐Wood, M., & Ward, H.J. (2008). Predictive validity of a medication adherence measure in an outpatient setting. Journal of Clinical Hypertension, 10, 348–354.
    Morisky, D.E., Green, L.W., & Levine, D.M. (1986). Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care, 24, 67–74.
    Neuss, M.N., Polovich, M., McNiff, K., Esper, P., Gilmore, T.R., LeFebvre, K.B., . . . Jacobsen, J.O. (2013). 2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy. Journal of Oncology Practice, 9, 5s–13s. doi:10.1200/JOP.2013.000874
    Nicolson, D.J., Knapp, P., Raynor, D.K., & Spoor, P. (2009). Written information about individual medicines for consumers. Cochrane Database of Systematic Reviews, 2, CD002104. doi:10.1002/14651858.CD002104.pub3
    Oakley, C., Johnson, J., & Ream, E. (2010). Developing an intervention for cancer patients prescribed oral chemotherapy: A generic patient diary. European Journal of Cancer Care, 19, 21–28.
    Osterberg, L., & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353, 487–497. doi:10.1056/NEJMra050100
    Partridge, A.H., Avorn, J., Wang, P.S., & Winer, E.P. (2002). Adherence to therapy with oral antineoplastic agents. Journal of the National Cancer Institute, 94, 652–661. doi:10.1093/jnci/94.9.652
    Rittenberg, C.N. (2012). Meeting educational needs and enhancing adherence of patients receiving oral cancer agents through use of the MASCC Oral Agent Teaching Tool©. European Oncology and Haematology, 8, 97–100.
    Ruddy, K., Mayer, E., & Partridge, A. (2009). Patient adherence and persistence with oral anticancer treatment. CA: A Cancer Journal for Clinicians, 59, 56–66. doi:10.3322/caac.20004
    Schneider, S. (2012). Tailored intervention protocol for oral chemotherapy adherence. Abstracts of the 2012 International MASCC/ISOO Symposium. Supportive Care in Cancer, 20(Suppl. 1), S177. doi:10.1007/s00520-012-1479-7
    Schneider, S.M., Adams,D.B., & Gosselin, T. (2014). A tailored nurse coaching intervention for oral chemotherapy adherence. Journal of Advanced Practice Oncology, 5, 163–172.
    Schneider, S.M., Hess, K., & Gosselin, T. (2011). Interventions to promote adherence with oral agents. Seminars in Oncology Nursing, 27, 133–141. doi:10.1016/j.soncn.2011.02.005
    Simchowitz, B., Shiman, L., Spencer, J., Brouillard, D., Gross, A., Connor, M., & Weingart, S.N. (2010). Perceptions and experiences of patients receiving oral chemotherapy. Clinical Journal of Oncology Nursing, 14, 447–453. doi:10.1188/10.CJON.447-453
    Sommers, R.M., Miller, K., & Berry, D.L. (2012). Feasibility pilot on medication adherence and knowledge in ambulatory patients with gastrointestinal cancer [Online exclusive]. Oncology Nursing Forum, 39, E373–E379. doi:10.1188/12.ONF.E373-E379
    Weingart, S.N., Bach, P.B., Johnson, S.A., Langbaum, T.S., Muller, R.J., O’Brien, S., . . . Walters, R.S. (2008). NCCN task force report: Oral chemotherapy. Retrieved from http://www.nccn.org/JNCCN/PDF/JNSU3_combined_Oral_Chemo_2008.pdf
    Weingart, S.N., Flug, J., Brouillard, D., Morway, L., Partridge, A., Bartel, S., . . . Connor, M. (2007). Oral chemotherapy safety practices at US cancer centres: Questionnaire survey. BMJ, 334, 407.
    Weingart, S.N., Li, J.W., Zhu, J., Morway, L., Stuver, S.O., Shulman, L.N., . . . Hassett, M.J. (2012). US cancer center implementation of ASCO/Oncology Nursing Society chemotherapy administration safety standards. Journal of Oncology Practice, 8, 7–12. doi:10.1200/JOP.2011.000379
    Weingart, S.N., Spencer, J., Buia, S., Duncombe, D., Singh, P., Gadkari, M., & Connor, M. (2011). Medication safety of five oral chemotherapies: A proactive risk assessment. Journal of Oncology Practice, 7, 2–6. doi:10.1200/JOP.2010.000064
    Wens, J., Vermeire, E., Hearnshaw, H., Lindenmeyer, A., Biot, Y., & Van Royen, P. (2008). Educational interventions aiming at improving adherence to treatment recommendations in type 2 diabetes: A sub-analysis of a systematic review of randomised controlled trials. Diabetes Research and Clinical Practice, 79, 377–388. doi:10.1016/j.diabres.2007.06.006
    Williams, A., Manias, E., & Walker, R. (2008). Interventions to improve medication adherence in people with multiple chronic conditions: A systematic review. Journal of Advanced Nursing, 63, 132–143. doi:10.1111/j.1365-2648.2008.04656.x
    Winkeljohn, D. (2010). Adherence to oral cancer therapies. Clinical Journal of Oncology Nursing, 14, 461–466. doi:10.1188/10.CJON.461-466
    Winkeljohn, D.L. (2007). Oral chemotherapy medications: The need for a nurse’s touch. Clinical Journal of Oncology Nursing, 11, 793–796. doi:10.1188/07.CJON.793-796
    Wood, L. (2012). A review on adherence management in patients on oral cancer therapies. European Journal of Oncology Nursing, 16, 432–438. doi:10.1016/j.ejon.2011.10.002
    World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Retrieved from http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf