Impact of an Oral Anticancer Medication Program on Patient Adherence

Marjorie Adams Curry, PharmD, BCOP
Hematology/Oncology Clinical Pharmacist Specialist
Grady Health System
Atlanta, GA

Administration of oral anticancer medications (OAMs) associated with improved clinical outcomes and quality of life, often decrease the burden of cancer care. However, OAMs present unique challenges with regard to safety, toxicity management, and adherence to treat­ment.1 Adherence, a widespread obstacle in patient care, is a dynamic process governed by both patient and socioeconomic factors.^2,3,4 The number of OAMs in clinical practice has increased significantly, but strategies for toxicity monitoring and adherence tracking remain limited. Ambulatory oncology clinical pharmacists are uniquely posi­tioned to play a key role in the provision of care.^{1, 5-8}

The Georgia Cancer Center for Excellence (GCCE) at Grady Health System in Atlanta, Georgia, treats a patient population that is economically underserved and which has low health literacy. In collaboration with the American Society of Clinical Oncology’s (ASCO) Quality Training Program (QTP), the GCCE initiated a qual­ity improvement project to increase adherence to oral anticancer medications. A team consisting of a physician, clinical pharmacist, nurse and two cancer center administrators was created. Adherence barriers were identified through cause and effect analysis and patient and provider surveys. Potential adherence interventions were categorized using a priority/pay-off matrix.

First, a Baseline Adherence Rate was Established
A retrospective chart review was then performed to establish a baseline adherence rate. The GCCE has an onsite pharmacy with access to specialty OAMs that is utilized by the majority of patients with cancer, allowing for easy tracking of prescriptions and refill history. Randomly selected patients (n=54) who filled an OAM prescription at least three times in the Cancer Center Pharmacy were included in the analysis. Adherence was calculated using the medication possession ratio (total days of medication supplied/ total days in all cycles evaluated) on the basis of prescription refill history and was defined as having drug available ≥80% to <120% of days evaluated. Overall, twenty patients had a medication posses­sion ratio ≥80% to <120% of days evaluated, resulting in a baseline adherence rate of 37% (20/54).⁹

Program Aims to Increase Adherence
An ambulatory OAM adherence program was developed and im­plemented with the goal of increasing adherence by 30 percentage points within six months. The primary outcome was the change in adherence rate before and after the program implementation. The adherence program was led by a board-certified oncology clinical pharmacist. The main study focus was to improve adherence using low-cost adherence tools (pillbox and calendar), patient education, and toxicity monitoring. The pharmacist counseled patients, pro­vided a treatment calendar, and prepared color-coded pillboxes to align with days of treatment. For three cycles, a mid-cycle follow-up pharmacy visit was scheduled for toxicity monitoring and support­ive care management.

The adherence program intervention period ranged from October 2016 to November 2017, during which 52 patients were prescribed a new OAM. The most common OAMs were similar pre-and post-intervention and included immunomodulatory agents, tyrosine kinase inhibitors, antiandrogens, and antimetabolites. At the end of the 13-month study, 85% of patients (n=44/52) met the definition of adherence, exceeding the study goal of a 30-percent­age point increase compared to the historical data (85% vs. 37%, P<0.0001). The clinical pharmacist collected data on 204 patient encounters, including dedicated clinic visits and informal encoun­ters. Interventions were most commonly related to treatment counseling, drug acquisition, supportive care management, and filling pillboxes. Overall, 655 adherence-based (n=331; counseling, pillbox, treatment plan) and/or treatment-based (n=324; drug acquisition, supportive care, coordination of care) interventions were documented.

As part of the OAM clinic development plan, surveys were distributed to both patient (n=24) and healthcare professional (n=23) focus groups to identify barriers to adherence. Respondents were asked to rank the importance of various barriers. The two groups had contradictory results. Healthcare professionals ranked patient-related issues, financial support, and medication access as the main barriers affecting adherence. In contrast, patients’ top bar­riers included medication adverse events (AEs), lack of support, and challenges with transportation. Surprisingly, patients reported less emphasis on medication access. This could be explained in part by access to manufacturer medication assistance and state-sponsored programs for uninsured and underinsured patients with cancer. Such programs aim to alleviate obstacles and curtail the economic barriers to OAM access in the GCCE patient population.

Our pharmacist-led OAM adherence program targeted individual patient needs to improve adherence using low-cost adherence tools. Adherence improved by more than 48 percentage points during the study period and positively impacted clinical care. As previously demonstrated, low-cost tools do not improve patient adherence independently, thus highlighting the role of patient education and monitoring for these high-risk medications.⁷ Education has become more pertinent in light of studies indicating underreporting of AEs by patients which can lead to early medication discontinuation and nonadherence.^10,11 In this study, OAM counseling and toxicity monitoring delineated AEs warranting an Emergency Department visit versus outpatient toxicity management. Because of the established relationship and pharmacist accessibility, patients often felt comfortable communicating toxicity concerns throughout the treatment cycle. The specialized role of clinical pharmacists in the overall provision of oncology care continues to demonstrate the impact of collaboration, personalized education and close monitor­ing on adherence to anticancer treatment.^1,8

Study Strengths & Limitations
Strengths of this study included open access to a clinical phar­macist during clinic hours, limiting serious AEs in multiple cases. Additionally, nurses triaged telephone calls regarding toxicity and supportive care and directed them to the pharmacist as appropri­ate, a service that was not previously available. Furthermore, the cancer center pharmacy is onsite, allowing the pharmacist to easily follow up on insurance authorizations and communicate with out­side specialty pharmacies.

Limitations of the study include that prescription refill history is an indirect measure of adherence and it does not account for outside factors, including insurance delays or doses held due to toxicity. Patient interactions outside of clinic encounters were not always captured in pharmacist notes, possibly underestimating interventions, treatment delays, and AEs.

Conclusion
In conclusion, this clinical pharmacist-led adherence program combined with low-cost adherence measures exceeded the goal of this initiative, suggesting that a multidisciplinary collaborative approach to OAM adherence can have a significant impact on out­comes. To sustain this improved OAM adherence, a full-time clin­ical pharmacist was hired to assist with treatment initiation and follow up. The pharmacist leads the adherence clinic and continues to expand the program.

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