04 gustafsson

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04 gustafsson

  1. 1. Adherence - to oral drugs in Cancer Care Eva Gustafsson , Oncology department, Karolinska University Hospital 3rd EONS - ESO Master class in Oncology Nursing 21-26 March 2009 Portugal
  2. 2. <ul><li>Adherence can be defined as; </li></ul><ul><li>“ the extent to which a person ’ s behaviour coincides with medical or health advice ” </li></ul>E.Gustafssson 2008
  3. 3. <ul><li>Oral drugs have several advantages and improves quality of life : </li></ul><ul><li>self-administered </li></ul><ul><li>increases patients’ independence </li></ul><ul><li>reduces the number/length of hospital visits </li></ul><ul><li>eliminates the need for venous access </li></ul>E.Gustafssson 2008
  4. 4. Potential problems <ul><ul><li>patient compliance - adherence </li></ul></ul><ul><ul><li>variability of gastrointestinal absorption </li></ul></ul><ul><ul><li>control of side-effects </li></ul></ul><ul><ul><li>management of toxicity </li></ul></ul>E.Gustafssson 2008
  5. 5. <ul><li>The use of oral therapies is dependent on patient’s adherence to medication </li></ul>E.Gustafssson 2008
  6. 6. <ul><li>Adherence to medication cannot be assumed, even when faced with a potentially life-threatening disease such as cancer </li></ul>E.Gustafssson 2008
  7. 7. Non adherence <ul><li>chronic diseases </li></ul><ul><li>long-term treatments </li></ul><ul><li>may mislead physicians’ decisions </li></ul><ul><li>barrier to effective treatment </li></ul>E.Gustafssson 2008
  8. 8. <ul><li>Non-adherence to medication for patients with chronic conditions is a major public health issue </li></ul><ul><li>The level of non-adherence reported by studies is large, up to 50%, and many studies have shown worse clinical outcomes associated with low adherence </li></ul><ul><ul><ul><ul><ul><li>DiMatteo, 2004. </li></ul></ul></ul></ul></ul>E.Gustafssson 2008
  9. 9. <ul><li>23% of breast cancer patients failed to take tamoxifen in 1 out of 5 days with </li></ul><ul><li>adherence falling from 89 to 50% over 4 years </li></ul><ul><ul><ul><ul><ul><li>(Partridge et al, 2003) </li></ul></ul></ul></ul></ul><ul><li>A small survey on self reported adherence in 53 women found that 62% acknowledged having missed at least one dose of tamoxifen in the previous 6 months, with 24% missing at least one dose per week </li></ul><ul><ul><ul><ul><ul><li>(Murthy et al, 2002). </li></ul></ul></ul></ul></ul>E.Gustafssson 2008
  10. 10. It has been suggested that non-adherence to treatment is the result of three factors; <ul><li>lack of information about the advantages and disadvantages </li></ul><ul><li>lack of visible benefits </li></ul><ul><li>need for psychological adaptation in order to realise the necessity for treatment </li></ul>E.Gustafssson 2008
  11. 11. <ul><li>Intentional non-adherence may occur when the benefits of treatment are not obvious. </li></ul><ul><ul><ul><ul><ul><li>( Elwyn et al, 2003) </li></ul></ul></ul></ul></ul>E.Gustafssson 2008
  12. 12. <ul><li>Evidence suggests that the experience of unpleasant side effects may alter the cost-benefit analysis and disrupt adherence to medications. </li></ul><ul><ul><ul><ul><ul><li>(Grunfeld et al, 2005) </li></ul></ul></ul></ul></ul>E.Gustafssson 2008
  13. 13. Adjuvant treatment <ul><li>The burden of adjuvant therapy may be underestimated by healthcare professionals, thus, treatments may appear more favourable and acceptable than they are. </li></ul><ul><ul><ul><ul><ul><li>Fallowfield 2005 </li></ul></ul></ul></ul></ul>E.Gustafssson 2008
  14. 14. The acceptance of adjuvant treatment is dependent on: <ul><li>information about available options </li></ul><ul><li>likely therapeutic gains </li></ul><ul><li>side effect profiles </li></ul><ul><li>convenience of treatment </li></ul><ul><li>as well as prior knowledge, experience and expectations </li></ul><ul><ul><ul><ul><ul><li>( Fallowfield 2005) </li></ul></ul></ul></ul></ul>E.Gustafssson 2008
  15. 15. <ul><li>A qualitative study with the aim to describe the experiences of women with breast cancer in relation to decision-making in adjuvant endocrine therapy (AET). </li></ul><ul><li>Interviews with 32 women with breast cancer from eight European countries. </li></ul><ul><li>(Gustafsson, Wengström submitted ) </li></ul>E.Gustafssson 2008
  16. 16. <ul><li>The majority of the women perceived a low level of partnership in the decision-making process </li></ul><ul><li>They expressed compliance with rather than adherence to medication </li></ul>E.Gustafssson 2008
  17. 17. <ul><li>The women who perceived a high level of partnership in decision-making expressed that they made the decision by themselves or a joint decision between themselves and the health care professionals. </li></ul><ul><li>They reported taking control of the decision-making process and adhering to treatment. </li></ul>E.Gustafssson 2008
  18. 18. <ul><li>An understanding of the patient’s choice of degree of partnership is essential in patient centred care. </li></ul>E.Gustafssson 2008
  19. 19. Information <ul><li>Information about the benefits and risks of the treatment </li></ul><ul><li>To be able to make an informed choice </li></ul><ul><li>“ There should be a full explanation of the benefits and risks with emphasis on the purpose of the treatment.” </li></ul><ul><li>(Woman with breast cancer about AET) </li></ul>E.Gustafssson 2008
  20. 20. Communication <ul><li>To achieve optimal adherence, there is a need for effective communication between patients and health care professionals. </li></ul><ul><li>This can be a challenge in the adjuvant situation if the need for or benefit of the treatment is not clear to the patient </li></ul><ul><ul><ul><ul><ul><li>(Grunfeld 2005) </li></ul></ul></ul></ul></ul>E.Gustafssson 2008
  21. 21. The role of the health care professionals <ul><li>Important to be able to trust the doctors and nurses. </li></ul><ul><li>Reassuring with a a professional approach and the fact that the healthcare professionals take part in international conferences and research. </li></ul><ul><li>(Gustafsson, Wengström submitted ) </li></ul>E.Gustafssson 2008
  22. 22. <ul><li>Studies have revealed that nurses play a central role in all phases of the cancer trajectory and seem to be under-used as a potential source of support. </li></ul><ul><ul><ul><ul><ul><li>(Ferrell 2003; McCaughan 2007; Wengström 2007 ) </li></ul></ul></ul></ul></ul>E.Gustafssson 2008
  23. 23. <ul><li>Health care professionals need to develop better strategies to educate patients about treatment choices and help them to function better in their preferred decision role. </li></ul>E.Gustafssson 2008

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