1. Nursing Interventions for Improved
Oral Chemotherapy Adherence
Alicia Vautour
Susan D. Flynn Oncology Fellow
August 27, 2015
2. Objectives
• Background on Oral Chemotherapy
• Describe the Problem
• Present Nursing Interventions for
Standardizing Oral Chemotherapy: Research
• Describe Oral Chemo Resources at DFCI
• Provide Recommendations for Improvement
2
3. Background
• Chemotherapy
– Infusion vs Pills
• What is Oral Chemotherapy?
– Cancer-fighting drug
– PO tablet, capsule, liquid form
• Why Oral Chemotherapy?
– Taken at home
• Can Improve Quality of Life
– Less frequent visits to hospital/clinic
Dana-Farber.org
3
4. Safety of Oral Chemo
• Education
– How to take the drug
– Storage
– Disposal
– Safe Handling of body waste
– Laundry
– Side Effects
– When to call/come in to Hospital
Dana-Farber.org
4
5. Why This Topic
• Witnessed Pt in clinic with multiple bottles of
chemo pills that were full
• Preliminary Research
– Non-Adherence: Pt Barriers
– National problem with pt adherence
• ASCO initiated project to develop standards for safe chemo
administration
– Many trials underway to standardize the education
– prescribing of oral chemo and production of new
oral chemo
5
6. Barriers to Adherence
• Socioeconomic
• Healthcare System
• Disease
• Treatment Regimen
• Patient Related
University of Pennsylvania Medicine, 2015
9/14/2015 6
7. Barriers: Managing Side Effects
• Common Side Effects of Oral Chemotherapy
– Varies from drug to drug
– Targeted Therapies
• Skin
– Acne-Like Rash (face, neck, chest, back)
– Dry Skin
– Itching
• Hair
– Alopecia/thinning
– Growing (i.e. face)
• Nail
– Painful swelling & redness
– Infected nailbeds (require antibiotics)
• Follow up with pts to manage and treat side effects
MASCC
9/14/2015 7
9. Research- National Survey
• Objective:
– Describe current nursing practice in US regarding care and safety of pts
taking oral chemo
– Study
• National Online Survey
– Emailed to 5000 members of Oncology Nursing Society
• 577 oncology nurses in outpatient settings
• Variables: pt care practices, nursing resources, and barriers to medication
adherence
• Results:
– 51% worked in practices that had developed specific policies,
procedures and resources for pts on oral chemo
– Barriers: Cost (81%) and Side Effects (72%)
Roop & Wu 2014
9
10. Research-Loma Linda University
• Objective:
– Improved outcomes in adherence by an oral chemotherapy management clinic
– Study
• Loma Linda University Cancer Center
• Retrospective Cohort Study: 30 pts evaluated
• Oncology pharmacists developed a comprehensive oral chemotherapy management
clinic (face-to-face initial and 3 month visits w/ RN, MD, & Pharmacists, telephone follow-
ups at 3-5 days and 7-10 days, and unscheduled visits prn)
• Results:
– Prevented moderate to severe drug interaction
– Improved symptom management
– Decreased cost of patient care
– No missed doses for 21 of the 30 pts
Wong, Bounthavong, Nguyen, Bechtoldt, & Hernandez, 2014
10
11. Research-Literature Review
• Objective:
– Describe the development of an oral chemotherapy nursing position
– Improve medication safety and adherence
– Article
• 112 pts at one time
• Initial teaching to 163 pts
• Nursing assessments and interventions provided for 1,710 pts before
their next cycle of chemo
• Telephone Triage to 2,410 pt calls
• Results:
– In the 2 yrs following the program, 3 of 1710 pts were known to have
varied from their prescribed regimens
– Oral chemotherapy nurse obtained excellent adherence outcomes
Moody & Jackowski, 2014
9/14/2015 11
12. Donna Berry, Phd, RN
• https://www.youtube.com/watch?v=OSUp6xT
ksLg
9/14/2015 12
13. DFCI Study
• Objective:
– Evaluate a nurse-led intervention to enhance medication knowledge &
adherence using MOATT
– Study
• 30 adult pts with lung cancer receiving oral Erlotinib at DFCI
• Nurse-led education sessions using MOATT, 72- hour follow-up telephone contact, pts
completed KRS and MMAS-8
• Variables: knowledge & adherence; feasibility
• Results:
– 27 pts completed study reporting high knowledge levels and MMAS-8 scores
– Pts also initiated contact for assistance with prescription procurement &
symptom management
– Feasible
– Adherence & knowledge outcomes were encouraging
Boucher, Lucca, Hooper, Pedulla, & Berry, 2015
9/14/2015 13
16. Drug Diary
One Oral Chemotherapy Once a Day
DRUG NAME:
Start Date:___________
How
much:_________
How often:___________ When:___________
Your MD: ____________ Phone:____________
Your RN: ____________ Phone:____________
Special Instructions:
Day Date Time Dose Symptoms
Example 1/2/2011 9:30 AM 1 tablet upset stomach hour later
1 : AM/PM
2 : AM/PM
3 : AM/PM
4 : AM/PM
5 : AM/PM
9/14/2015 16
17. Oral Chemo Videos
• https://www.youtube.com/watch?v=vzVDafn3
iHA
– 4-part, web based oral chemo animated video
series
– Available in English, Spanish, Portuguese,
Mandarin, Russian, and Arabic
9/14/2015 17
18. Conversation with Kitty Hooper
• What is going on at DFCI now?
– Initial phone call
• MOATT
• Pharmacy directed
• Calls documented in EPIC
– 72 hour adherence phone call
• Program nurse
• Go over side effects
• Avg call 10-15 mins
– 2 week follow-up visit with provider
• 2 week peak drug toxicity
• Review drug diaries
– Every 2 months
• May 2015: 80% of oral chemo pts had teaching
Kitty Hooper, personal communication, August 11, 2015
9/14/2015 18
19. Ongoing Issues at DFCI
• Phone call based
– No in person teaching
• Initial education no longer done by nursing
• Difficult to see if a patient is on oral
chemotherapy
• Lack of nursing knowledge
• Inconsistencies in Research Nursing
Kitty Hooper, August 2015
9/14/2015 19
20. Suggestions for Improvement
• Bring the education back to the nurses
– Program nurse in each disease center
– Oral Chemo Nurse position
• Continue standardized documentation forms for telephone calls
that include administration instructions, precautions, monitoring
and managing SE, etc
– Standardize Research oral chemo as well
• Scheduling pt for 2 education appts w/RN prior to prescribing oral
chemo
• RN maintaining weekly call list for each patient on oral chemo
• Routine follow-up phone calls or one week follow-up office visits
• Improve view of oral chemo within EPIC
• Providing classes for nurses & adding oral chemo as an annual
competency (? Healthstream)
9/14/2015 20
22. References
Boucher, J., Lucca, J., Hooper, D., Pedulla, L., & Berry, D. (2015). A structured nursing intervention to address oral
chemotherapy adherence in patients with non-small cell lung cancer. Oncology Nursing Forum, 42(4),
383-389. doi: 10.1188/15.ONF.383-389
Dana Farber Cancer Institute. (2015). Chemotherapy. Retrieved from http://www.dana-farber.org/Adult-
Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/Chemotherapy.aspx
Moody, M., & Jackowski, J. (2014). 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
Nuess, M., Polovich, M., McNiff, K., Esper, P., Gilmore, T., LeFebvre, K., Schulmeister, L., & Jacobson, J. (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.
Oncology Nursing Forum, 40(3), 225-233. doi:10.1188/13.ONF.40-03AP2
Penn Medicine. (2013). Patient adherence to oral cancer therapies: A nursing resource guide. OncoLink, 1-8.
Retrieved from www.oncolink.org
Rittenberg, C., Johnson, J., Kav, S., Barber, L., & Lemonde, M. (2010). MASCC oral agent teaching tool (MOATT).
MASCC, 1-28.
Roop, Janna & Wi, Horng-Shiuann. (2014). Current practice patterns for oral chemotherapy: Results of a national
survey. Oncology Nursing Forum, 41(2), 185-194. doi:10.1188/14.ONF.41-02AP
Wong, S., Bounthavong, M., Nguyen, C., Bechtoldt, K., & Hernandez, E. (2014). Implementation and preliminary
outcomes of a comprehensive oral chemotherapy management clinic. American Journal of Health-System
Pharmacy, 71(11) 960-965. doi: 10.2146/ajhp130278
9/14/2015 22
The most common ways to receive chemotherapy are through infusions or through pills you can take at home (oral chemotherapy)
Oral chemotherapy is a cancer-fighting drug given by mouth in tablet, capsule, or liquid form. Just like any other form of chemotherapy, oral chemotherapy has the same benefits and risks.
Today, many cancer patients receive oral chemotherapy as a treatment for their cancer. This method is sometimes easier than getting chemo by infusion at the hospital/clinic, because the medicine can be taken at home. Some patients report an increase in quality of life because of the less frequent hospital visits and because they feel they have control and management over their disease by taking it at home. However, it is important for patients to understand that these pills can be just as strong as the intravenous form of chemotherapy.
How to take
Swallow each tablet whole. Do not break/crush/chew
Prepare drug away from food/food prep area
If missed dose, tae as soon a possible. Almost time for next dose, skip missed dose and go back to regular dosing schedule
DO NOT DOUBLE DOSE
Clinical Trial– special instructions on how to take
Informing healthcare team if you are unable to swallow pills
If vomit up medication, call physician for special instructions
Wash hands after taking med.
Storage
Most at tooom temperature, away from excess hear and moisture.
Keep in original container, safe place away from other family medications.
Away from reach of children and pets
Disposal
Unused chemo pills– return to pharmacy where prescription was filled. Don’t flush down toilet, dump in sink, throw in trash
Body wastes
Chemo stays in body for hours or even days and can be found in vomit, stool, urine, and sweat. Special care for accdiental contact with patient/ caregiver
Use toilet as usual.
Wash hands well with soap and water after using toilet. If body waste gets on body, wash with soap and water. Always wear gloves when cleaning equipment or disposing waste from urinal or commode
Pregnant caregivers should not handle patient body waste
Laundry
Wear disposable gloves when handling sheets/clothes that have been soiled with bodily waste
Wash these items separately from other laundry
Education on side effects should be given to patient for the specific chemotherapy they are receiving
A patients quality of life can be drastically decreased with increased side effects/poor management of side effects
They should be educated and understand when to call the doctor if they notice any side effects and when it is necessary to come into the hospital to receive immediate care for potential side effects.
Found out Pt was not correctly taking his medication and was missing doses
Pt had been having side effects for weeks (skin changes) that the Pt had not informed any physician/nurse about. Thus was not treating side effects
American Society of Clinical Oncology
Socioeconomic
Low language literacy
Lack of family or social support
Homelessness
Lack of health insurance/medication
Limited access to a pharmacy
Busy work or social lifestyle
Healthcare System
Poor provider communication skills
Poor patient-provider relationship
Lack of knowledge on adherence
Lack of reinforcement from healthcare provider
Patient info materials written at a high literacy level
Disease
Asymptomatic
Severity of symptoms
Treatment Regimen
Complex regimen
Lack of quick benefit
Side Effects
Requires Significant behavioral chages
Patient Related
Physical factors
Knowledge Deficit
Attitiude, confidence, motivation
Psychological/behavioral/developmental factors
Perceived benefit of treatment
Fear of possible adverse effects
Stress/anxiety/anger
Alcohol or Substance Abuse
Side Effects are the most common reason that a patient would stop taking their oral chemotherapy. It is very important to educate the patient on the side effects of the medication and educate them on when to call the doctor. It is also important to follow up with the patients and ask them if they are having any side effects in order to manage and treat them early on.
Targeted therapies– epidermal growth factor receptor inhibitors such as Erlotinib
The most common body part affected by these drugs is the the skin. These include: an acne-like rash, drug skin, itching, nail changes, and hair changes. Although side effects are often mild or moderate, on occasion, they can be severe. When side effects are severe, the doctor may need to stop treatment either for a short time or permanently. So, it is important to know about preventing and treating the skin side effects.
MASCC provides an educational sheet caled Caring for Your Skin Hair and Nails when on “Targeted Therapies”
It provides education for the patients on what they should do to prevent or manage the side effects
Example: Nail Changes
Swelling/redness– wear soft shoes and avoid extreme heat or cold or bumping them
MD might prescribe silver nitrate
Pain/redness– soak fingers/toes in solution of white vinegar mixed in equal amount of tap water
MD may prescribe antibiotic if an infection
One Program Nurse, Kitty Hooper, emails her patients this educational sheet if they are on these specific targeted therapies
The administration of chemotherapy drugs has shifted dramatically in the past 15 years from parenteral to oral administration
Along with this change has come increased responsibility for pt self-management
Thus the families bear the burden for the 5 rights of medication administrtion :pt, drug, dose, time, and route
Family educationa nd follow-up are critical to treatment success with oral chemo
Systematic reliable policies and procedures for pt education, documentation, and interdisciplinary communication are urgently needed
reported less confidence in their ability to provide safe care because of their own knowledge deficits
Respondents reinforced concerns that were uncovered in phase 1 of the study, stating that caring for patients taking oral chemotherapy is a “huge problem.” They noted that the support in place for IV chemotherapy is missing for patients on oral chemotherapy, and that no policies or systematic methods are available for providing teaching, routine follow-up, and regular assessment of their patients on oral chemotherapy
Fragmentation of care and lack of consistent communication among healthcare providers
Nursing Implication: nurses should provide education and repeated teaching to improve pt safety, adherence to the medication, and self-monitoring for adverse effects
The American Society of Clinical Oncology and ONS have published and updated standards for chemotherapy administration safety. The 2013 standards were expanded to include oral chemotherapy. All editions of the standards assert that patients and families must receive extensive education about their chemotherapy before treatment begins
Follow up Care- After the initial clinic visit, pts received follow-up care
An OCM clinic with comprehensive medication therapy management services was effective in delivering early interventions, resulting in decreased adverse effects, non-adherence, drug interactions, and medication errors over time
Objective
Describe the development of an oral chemotherapy nursing position as well as role implementation in an ambulatory medical oncology setting
Improve medication safety and adherence for patients taking oral chemo medications
The oral chemo nursing role was initiated in August 2008. Since that time, she has cared for as many as 112 patients at one time. Initial teaching was provided for 163 patients. Nursing assessment and intervention were provided for 1710 patient visits prior to the start of the next cycle of chemo. Telephone triage was provided for 2410 patient calls. Since August 2008, three patients have altered from their prescribed doses of oral chemo during one cycle. Of those three cases, two were taught while oral chemo nurse was on vacation. With a nurse following pts taking oral chemo, pt safety has improved because pts understand how and when to take their chemo meds, when to report side effects, and comply with appts and meds. Pt documentation of side effects also has improved.
Moody, M., & Jackowski, J. (2014). 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
Donna Berry, Director of the Phyllis F. Cantor Center for Nursing Research
She has another video further explaining this compliance issue and how it is so important that we educate these patients
However it is hard to have the time because we used to have plenty of education time while we were hanging the chemotherapy. Now we don’t have as much time because these patients are just getting prescriptions. Thus it is so important that we have a systemized education system
Multinational Association for Supportive Care in Cancer Oral Agent Teaching Tool (MOATT)
Structured, nurse-led education sessions using the MAOTT were provided, with a 72-hour follow up telephone contact. Participants complete a Knowledge Rating Scale and adapted Morisky Medication Adherence Scale-8 at the end of the firsst cycle f oral chemotherapy
Initial education provided oral and written materials
Structured, nurse-led education and follow-up sessions ranged from 14-30 mins
Scheduled clinic visit (2-3 weeks after starting therapy) or by phone
6-8 weeks reviewed the pts drug log
Unplanned patient-initiated contact by phone was documented throughout the study
The structure, nurse-led teaching, using the MOATT tool, and follow-up nurse contacts were feasible as integrated intot he thoracic oncolgy setting.
The MOATT was feasible in regards to the time to adminiter educational session, which was lower than previous estimation of 60mmins from another study.
Use of the MOATT in ambulatory cancer settings provides a valuable standardized education tool for assessemnt, generic and specifc medication education, and evaluation
Patient self-management of oral chemotherapy also requires nurses’ support, using follow-up evaluation by telephone or during clinic visists after initial therapy starts
Nurses role includes reinforcement of education (particularly in first 6-8 weeks) while monitoring for side effects that require support through symptom management using psyiological and psychosocial interventions.
A drug diary can help patients to record daily medication use, keep track of special instructions and document side effects
This tool can aide patients in taking their medications and keeping track of their side effects
This also gives the patients a resource to use when following up with nurses & doctors
DFCI is committed to educating pts and their families about the benefits and risks of oral chemo
Since same safegaurds apply to oral chemo as do for infusions, DFCI created 4-part, web based oral chemo animated video series
Includes:
What is oral chemo
Handling oral chemo safely at home
Remembering to take oral chemo
Managing symptoms and side effects of oral chemo
Phone call based
Patients aren’t physically seen until 2 weeks into treatment. From that point on, they are only seen every 2 months. It is very easy for side effects to go undetected and/or not treated
This makes it easy for the pt to stop taking their chemo due to the side effects
Pts could also be dealing with very dangerous side effects that are not being controlled because they did not call into the nurse/doctor to tell them
It is easier to document and treat side effects with infusion chemotherapy as nurses get to spend the infusion time assessing the patient
Different disease groups were having trouble finding someone to do the initial teaching phone call. Some departments had program nurses making the calls, but others weren’t able to do that. They now changed the policy so that pharmacists make the initial education phone call
There is concern in this
Pharmacy is very drug based where nursing is patient based. A huge part of nursing is educating and advocating for our patients, and by having pharmacy perform the initial teaching, the standard of education may not be the same as if it were done by a nurse.
For patients that do come in for other treatments, such as concurrent chemo by infusion, it is hard for nurses to see that the patient is on oral chemo within Epic
The fact that they are on oral chemo is often overlooked
This could have been a perfect opportunity for reinforcement education, however, the nurse was not aware that the patient was on oral chemo
There is an overall lack in nursing knowledge on the subject of oral chemotherapy. Many nurses do not have to give paitents oral chemotherapy, but when they do have to, many express that they have a lack of knowledge and need further education themselves to educate their patients
Many nurses do not even know the educational resources on oral chemo that are available
Asked 3 new nurses, none know about online resources/videos
Research nurses have their own education protocols and educational information for their patients that is not the same as the standard education
I believe that this information should be more standardized, and then further education regarding the research drug can be added on
Supposed to be shown these resources at their new nurses orientation
Education, assessment, and symptom management are all components of nursing and theses are all the crucial components that are needed for the safety and adherence of oral chemotherapy. Thus these components should be handled by nurses, not by the pharmacy
This could either be done by having program nurses take on the responsibility or by creating a new oral chemo nurse position like the one in the research literature review
Like I said previously, the base of oral chemo education should be standardized regardless if it is a research drug or not. Research nurses can then add their teaching and include the specific education that the protocol calls for
Scheduling a pt for 2 education appts prior to prescribing the chemo allows for the pt to understand all of the content better and allows them more time to ask questions and receive clarification. In my own life, I am a very visual learner and would rather receive education in person rather than over the phone. I also like have the educational materials in front of me so that I can read along. The in person appts also gives the nurse the opportunity to show the pts the available online resources (videos, handouts, drug diaries)
Weekly call list as well as routine phone calls or one week follow ups office visits, would make sure that no pts fall through the cracks and so that we are keeping track of how the pts treatment is going, documenting se, reinforcing educaiton, and treating any se
Providing classes for nurses and adding an oral chemo competency would ensure that nurses are educated on oral chemo, are more competent in administering oral chemo, and are more confident in educating pts
I owe a huge thank you to Mr. Flynn for allowing me the opportunity to take part in such an amazing experience here at Dana Farber. I have learned so many things in the last 8 weeks that will travel with me into my nursing career. So thank you Mr. Flynn.
