Dr Hansen provides a thorough review of adherence in cancer therapy and the growing use of oral therapies. These agents may provide patient convenience, but they also present significant adherence issues. As Dr Hansen reported, it cannot be assumed that a patient will adhere to the prescribed medication doses and schedules simply because he or she is facing a potentially life-threatening illness. Even for seemingly adherent patients, education alone does not always improve adherence rates.1 In fact, some patients believe they are taking medications appropriately when they are not. Many reasons for nonadherence were cited by Dr Hansen, including financial, social, and cognitive/depressive issues.
Interventions such as providing written information, instituting follow-up telephone call reminders, and using patient calendars have been shown to improve short-term adherence to antibiotic therapy.2-4 These interventions may prompt the individual who desires to take his or her medication as prescribed yet fail to address groups of patients who do not wish to take their medications as prescribed.
Finances are often cited as a reason for nonadherence.5 Patients may stop taking medications because of the costs of drugs and travel to the clinic. Some patients are unable to cover the costs because they are living on a fixed income. Others may be underinsured. It is important to identify patients who are facing financial problems since copay assistance and financial support are often available through various organizations and programs. To assist these patients, clinicians and their staff may make referrals to copay programs, navigate paperwork, or arrange transportation for routine appointments when necessary.
Social barriers to adherence also exist. Clinicians should screen patients to determine the types of social support they currently have. As situations may change, social support should be reviewed on an ongoing basis. Is your cancer patient the main support for an ill spouse, parent, or child? Does the patient appear to be highly functioning and adherent to the medication regimen or stressed about a loved one? Inquiring about social status and responsibilities in the home is important. Asking about involvement in meal preparation, ability to go grocery shopping, and travel to and from the hospital or clinic will enhance targeted interventions such as eliciting community services for those who do not have social support readily available.
Finally, depression and cognitive impairment can impact patients’ ability to successfully manage their care.6 Approximately 6.7% of adults in the United States have depression; some patients may have been diagnosed with depression before they developed cancer while others develop depression after their cancer diagnosis.7 Individuals with or without depression may experience cognitive impairment due to concurrent medications such as opioid analgesics and corticosteroids. Other comorbidities such as heart failure, CNS disease, or cancer-related fatigue may also play a role.8 Therefore, clinicians should regularly screen patients for depression and cognitive impairment, initiating referrals as appropriate.
Cancer has transitioned into a chronic illness for many. The issue of adherence will continue as the trend toward oral administration grows. Interventions such as education, technological reminders, family therapy, and telephone follow-up have been used in several trials; however, no single trial has demonstrated superiority of one approach over another. Education alone is insufficient for patients to adhere to recommended treatment, but patients should understand the benefits and side effects of a therapy before treatment is initiated.9 Addressing barriers to effective adherence may improve adherence.
References
- Haynes RB, Yao X, Degani A, et al. Interventions for enhancing medication adherence. Cochrane Database of Syst Rev. 2005;(4):CD000011. doi:10.1002/ 14651858.CD000011.pub2.
- Al-Eidan FA, McElnay JC, Scott MG, et al. Management of Helicobacter pylori eradication—the influence of structured counseling and follow-up. Br J Clin Pharmacol. 2002;53:163-171.
- Stevens VJ, Shneidman RJ, Johnson RE, et al. Helicobacter pylori eradication in dyspeptic primary care patients: a randomized controlled trial of a pharmacy intervention. West J Med. 2002;176:92-96.
- Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288:462-467.
- Partridge AH, Wang PS, Winer EP, et al. Nonadherence to adjuvant tamoxifen therapy in women with primary breast cancer. J Clin Oncol. 2003;21:602-606.
- DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160:2101-2107.
- National Institute of Mental Health. Depression and cancer. www. nimh.nih.gov/health/publications/depression-and-cancer/depression-and-can cer.pdf. Revised 2011. Accessed February 27, 2012.
- Faiman B. Medication self-management: important concepts for advanced practitioners in oncology. J Adv Pract Oncol. 2011;2:26-34.
- Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005; 353:487-497.