Background: With the cancer treatment paradigm shifting from the use of infusion chemotherapy that is administered in a clinical setting by oncology nurses to the use of oral chemotherapy that is self-administered by patients in the home setting, adherence to therapy and symptom management become challenges in ensuring safe, quality care for cancer patients. At Cedar City Hospital, a gap existed in the education, continual nursing assessment, and follow-up regarding symptom management and adherence of patients receiving oral chemotherapy. A review of the literature demonstrated the effectiveness of the use of tailored nursing interventions in addition to patient education to improve symptom management and adherence for these patients.
Objectives: To improve education and intervention by oncology nurse navigators (ONNs) to promote effective symptom management in patients receiving oral chemotherapy.
Methods: To enhance the education of patients receiving oral chemotherapy agents, a patient-centered assessment and education protocol utilizing the Multinational Association of Supportive Care in Cancer (MASCC) Teaching Tool for Patients Receiving Oral Agents for Cancer (MOATT) was implemented by the ONN. Before the initiation of oral chemotherapy, patients met with the ONN for education. During the education session, the ONN provided information regarding oral chemotherapy using the 4 sections of MOATT. A tailored nurse follow-up telephone call protocol for the continual assessment of symptom management and adherence was implemented by the ONN. Patients receiving oral chemotherapy received a phone call weekly for the first month of initiating treatment, twice monthly for the second and third months, and then monthly for the course of their treatment. During the telephone conversations, using the Adherence Starts with Knowledge (ASK-12) tool, the ONN assessed barriers to or facilitators of the patient’s adherence and addressed symptoms and side effects. The patient’s responses were used to develop tailored adherence and symptom management strategies to meet the patient’s individual needs.
Results: During the 3-month pilot project of the patient-centered assessment and education protocol and the tailored nurse follow-up telephone call protocol, 24 patients with various types of cancer initiated oral chemotherapy. All 24 cancer patients received patient-centered education, continual nursing assessment, and follow-up telephone calls to assess and promote symptom management and adherence. Based on the responses to structured questions and the ASK-12 tool, all patients reported that the education program, the individualized written information, and the follow-up telephone contact reinforced their knowledge and understanding of their oral chemotherapy as well as enhanced their comfort level in being able to manage and adhere to their treatment.
Conclusion: The patient-centered assessment and education protocol and the tailored nurse follow-up telephone call protocol were effective in promoting symptom management and adherence during the pilot project and have become a standard of practice for oral chemotherapy patients at Cedar City Hospital. With competency as a patient advocate in providing patient education, the ONN played a valuable role in supporting this pilot project to improve nursing practice and the care of patients receiving oral chemotherapy agents.
The administration of chemotherapy drugs has shifted dramatically in the past 15 years from parenteral infusion to oral administration, with oral cancer therapies accounting for 10% of treatments in 2010 and rising to 25% of all cancer therapies in 2013.1 With the cancer treatment paradigm shifting from the use of infusion chemotherapy administered in controlled, supervised clinical settings to the use of oral chemotherapy self-administered by patients in the home setting, adherence to therapy and symptom management become challenges in ensuring safe, quality care for cancer patients. Oral chemotherapy agents offer many advantages to cancer patients, including greater flexibility and convenience, and less disruption of activities of daily living for the patient and family/caregiver.
Along with the advantages, the increased use of oral chemotherapy agents introduces new challenges for oncologists, oncology nurses, and patients. With the cancer treatment paradigm shift, ensuring medication adherence—the right drug being administered in the right amount and at the right time in a controlled setting—is being taken out of the hands of the oncologist and is being placed on the cancer patient/family/caregiver. Factors that have frequently been associated with nonadherence to oral chemotherapy include patient-related factors (cognition, support, depression, and belief in value of therapy), treatment-related factors (side effects, complexity of treatment, drug interactions, and label warnings), and healthcare system–related factors (lack of physician availability, lack of financial resources/insurance coverage, delays in obtaining prescription/refills, and delay in follow-up care).2 With the shift in cancer treatment from infusion to oral chemotherapy, cancer patients have less contact with nurses and fewer opportunities for education on treatment and symptom management, so patients face the increased responsibility of maintaining their own healthcare.
In the practice at Intermountain – Southwest Cancer Center of Cedar City Hospital, cancer patients prescribed parenteral infusion and/or oral chemotherapy received written and verbal education on the oral chemotherapy agent from the oncology nurse navigator (ONN). Whereas patients receiving parenteral infusion chemotherapy were assessed by the oncology nurses at the time of their treatment, a gap existed in the practice for the continual nursing assessment and follow-up of patients receiving oral chemotherapy regarding symptom management and adherence. The ONN posed the research question: in adult cancer patients receiving oral chemotherapy agents, are tailored nurse coaching interventions in addition to patient education more effective than standard chemotherapy education alone in improving symptom management and patient adherence? For the pilot project, the ONN recommended the implementation of a comprehensive patient-centered assessment and education protocol to enhance the education of patients/families/caregivers on oral chemotherapy agents. The ONN also recommended the implementation of a tailored nurse-initiated follow-up telephone call protocol for the continual assessment of symptom management and adherence.
With the increasing use of oral chemotherapy agents in cancer treatment, patient adherence is critical to successful treatment outcomes. ONNs need to take a lead role in improving nursing practice and in caring for patients receiving oral chemotherapy agents by identifying barriers and implementing strategies to assure adherence, and, therefore, improve clinical outcomes. Patient-related barriers, such as educational barriers and lack of understanding of the importance of the medication, how to take the medication, and potential side effects and management of side effects, can lead to nonadherence.2 Disease/treatment factors such as complex treatment regimen, side effects, comorbidities, and concomitant medications are associated with nonadherence to oral chemotherapy by cancer patients.3 Oral chemotherapy patient education should include an assessment of comorbidities, concurrent medications, and education on drug/food interactions. Spoelstra and colleagues conducted an exploratory study of 30 adults receiving oral chemotherapy to evaluate the prevalence, severity, and attribution of symptoms, as well as the interference with management of comorbidities.3 Their findings indicated that patients with a greater number of comorbidities were more likely to include comorbidities in symptom attribution and reported interference from the oral chemotherapy agents in managing comorbid conditions.3
Cancer patients receiving oral chemotherapy need education on the agents, side effects, and symptom management and assessment to reduce the risk of nonadherence, and to ensure safety. Patient education and tools to enhance adherence and reduce drug interactions and adverse effects are vital to the plan of care for patients receiving oral cancer therapies and to the success of oral chemotherapy treatment. Patient education is the cornerstone of oral chemotherapy and should be systematically implemented for every patient who initiates this type of therapy. As educators, ONNs need to be proactive in providing information on the purpose of the oral chemotherapy, the dose and schedule on which to take the medication, side effects and symptom management, and safety.
Tailored patient chemotherapy education using strategies of prioritization of information, sensory needs, illustrations to reinforce messages, simple language, and teach-back has the potential to enhance patient safety, promote adherence, and enhance quality of life.4 Patient education should be thorough and include information on how, when, and whom to call for healthcare support; management and prevention of side effects; importance of and tools for adherence; and safety issues.5 Oral chemotherapy agents are considered hazardous drugs by the Occupational Safety & Health Administration and require special storage, handling, administration, and disposal to minimize short- and long-term effects to patients and caregivers. Thus, it is essential to incorporate information about safe handling and disposal of oral chemotherapy agents as well as expanded information about adherence and potential side effects.6 In 2009, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) published standards for the safe use of infusion chemotherapy.7 In 2013, with the increasing use of oral chemotherapy and targeted agents in the treatment of cancer, ASCO and ONS expanded the chemotherapy administration safety standards to include oral agents.7 The newly developed standards address the importance of patient and family education (materials appropriate for the patient’s reading/literacy level and documentation of education reflecting understanding) regarding administration schedules, expectation procedures, disposal of unused oral medication, and aspects of continuity of care.7 The 2013 ASCO/ONS chemotherapy administration guidelines strengthen the evidence-based recommendations on prescribing patient education and ongoing monitoring for patients receiving oral chemotherapy by incorporating monitoring in the treatment plan, assessing for adherence to the regimen, and assessing for toxicity at each visit.8
An example of a tailored intervention tool for patient education, developed by the Multinational Association of Supportive Care in Cancer (MASCC), is the MASCC Teaching Tool for Patients Receiving Oral Agents for Cancer (MOATT) (Figure 1). MOATT is a resource to assist healthcare providers to assess and teach patients about oral chemotherapy treatment by addressing key assessment questions, generic education discussion points, drug-specific education, and evaluation questions to help ensure that patients and caregivers understand the information provided.9 Nursing interventions such as MOATT that incorporate patient education, assessment of barriers to and facilitators of adherence, early symptom identification and management, and reminder prompts can promote adherence and improve outcomes.9 The results from a cross-sectional study of Australian oncology nurses conducted by Johnson and Adler indicated a desire to improve oral chemotherapy education and supportive care for patients using formal education, including MOATT and additional interventions of follow-up calls, and implementing the use of patient calendars/diaries.10
One key element to improve medication adherence is to provide close follow-up contact and support (affective strategy) for adherence.11 Consistent follow-up and enhanced communication between patients and healthcare providers create opportunities for patients to ask questions and relay concerns related to their medications and disease process, reinforce education, serve as reminders for medication administration, and facilitate motivational coaching, all of which serve to improve medication adherence.2 Using nurse coaching interventions to promote adherence helps patients manage symptoms and ensures that medications are taken safely.2 Cancer patients on oral chemotherapy and targeted agents tend to undergo long-term treatment, and the concepts of consistent follow-up, symptom management, and adherence are important for successful treatment outcomes.2
A 2-stage study of mixed-method approach and use of descriptive statistics by Griffiths and Pascoe evaluated a nursing-led education program promoting patient knowledge by utilizing MOATT and a posteducation follow-up call to facilitate adherence and promote safety and well-being.12 In this study, all participants reported that the provision of tailored information enhanced their knowledge about their oral chemotherapy treatment and that with the follow-up phone call in conjunction with the education, they felt well prepared, more confident, and less distressed about their treatment.12 Schneider and colleagues conducted a randomized trial of 45 patients on oral chemotherapy; the control group received standard chemotherapy education, and the intervention group received standard chemotherapy education plus a tailored nurse-led phone call weekly for the first month and then twice a month for 6 months until completion of treatment.13 Patient adherence rates were measured in both the control and the intervention groups at 2 and 4 months with higher adherence rates seen for the intervention group, suggesting that tailored coaching follow-up call intervention was beneficial in promoting adherence.13 A nonexperimental descriptive feasibility pilot study by Sommers and colleagues evaluated the feasibility of face-to-face patient education, a nurse-initiated follow-up telephone call, and the use of a medication diary to support the patient’s self-reported medication adherence and knowledge of oral chemotherapy for patients with gastrointestinal cancer.14 The analysis of the data revealed improved symptom management with the utilization of the nurse-initiated follow-up telephone call and a high self-reported adherence rate with completed medication diaries.14
A review of the literature demonstrated the effectiveness of tailored nurse coaching interventions in addition to patient education in improving symptom management and adherence for oral chemotherapy patients. The ONN implemented the development of a comprehensive patient-centered assessment and education protocol to enhance the education of patients/families/caregivers about oral chemotherapy agents. The ONN also implemented a tailored nurse-initiated follow-up telephone call protocol for the continual assessment of symptom management and adherence.
For the pilot project, the ONN recommended enhancing the education of cancer patients/families/caregivers about oral chemotherapy by initiating the usage of MOATT. MOATT provides a structured format to ensure that all key areas of patient assessment and teaching are addressed, but it also allows for patient-centered individualization of teaching and uses evidence-based tenets in patient education.12 Prior to the initiation of self-administration of oral chemotherapy, patients and their families/caregivers met with the ONN, who provided information and education regarding the oral chemotherapy using the 4 sections of MOATT. In the first section, the ONN used a series of questions to assess the patient’s knowledge of the treatment plan, current medications, and ability to obtain and administer the oral chemotherapy. In the second section, the ONN provided the patient/family/caregiver general instructions applicable to all oral chemotherapy agents, such as storage, handling, and disposal, and identified a patient-preferred individual system for remembering to take the oral chemotherapy (calendars, medication diaries, cellular phone alarm) and actions to take for various situations such as a missed dose. In the third section, the ONN provided agent-specific information such as dose and schedule, side effects, symptom management, and potential interactions (drug and food) by reviewing the patient’s medication list. In the fourth section, the ONN evaluated the understanding of the patient/family/caregiver of the information provided through a series of questions listed on the tool for teach-back. The tool provided an outline for patients/families/caregivers to ensure that assessment, symptom management, and strategies for adherence are addressed. The information gathered from the tool assessment and education was documented in the patient’s medical record and a copy of the completed tool provided to the patient as a reference.
For the pilot project, the ONN contacted oral chemotherapy patients via telephone weekly for the first month after initiating treatment, twice a month for the second and third months, and monthly thereafter for the course of their treatment. During the telephone conversations, using the Adherence Starts with Knowledge (ASK-12) tool, the ONN assessed barriers to or facilitators of the patient’s adherence and addressed symptoms and side effects (Figure 2). The patient’s responses were used to identify and implement tailored specific adherence strategies to meet the patient’s individual needs. The follow-up calls, patient responses, and interventions were documented in the patient’s electronic record. Subsequent follow-up telephone calls assisted in evaluating the implemented tailored interventions. Proactive education and follow-up are critical with home-based oral chemotherapy. ONNs can effectively reinforce patient education, review the patient’s medication schedule, monitor adherence, evaluate early side effects, and implement appropriate symptom management through telephone assessment and follow-up.
During the 3-month pilot project of the patient-centered assessment and education protocol and the tailored nurse follow-up telephone call protocol, 24 patients initiated oral chemotherapy. All 24 patients received patient-centered education, continual assessment, and follow-up telephone calls. Based on the responses to structured questions and the ASK-12 tool, all patients reported that the education program, the individualized written information, and the follow-up telephone contact with the ONN reinforced their knowledge and understanding of their oral chemotherapy as well as enhanced their comfort level in being able to manage and to adhere to their treatment. Nurse-led education and follow-up telephone calls helped patients to better understand the schedule and side effects associated with their medication. With a better understanding of their oral chemotherapy, patients felt more comfortable and confident to self-administer and adhere to their cancer treatment. As shown by the teach-back responses to MOATT during patient education sessions and the responses to the ASK-12 tool during the follow-up telephone calls, effective teaching and follow-up benefited cancer patients in the pilot project by improving side effect management, decreasing anxiety, promoting adherence, empowering patients to be included in their care, and improving quality of life.
The limitation of the 3-month pilot project is the small number of cancer patients initiating oral chemotherapy participating in the study.
Patient education and tools to enhance adherence and reduce drug interactions and adverse effects are vital to the plan of care for patients and to the success of oral chemotherapy treatment. With more cancer patients self-administering chemotherapy outside of the infusion center, a greater need exists to develop improved strategies for assessment, patient education, adverse effect management, and ongoing monitoring of care. ONNs are the advocates for patients undergoing oral chemotherapy. ONNs need to become informed about the ever-developing new oral chemotherapy agents, educate patients about oral chemotherapy agents, and develop tools to assist patients with adherence and the management of adverse effects to improve patient quality of life.
Patients receiving oral chemotherapy need to receive patient education and regular assessment for symptom management and adherence from an oncology nurse. Cancer patients on oral chemotherapy need education on the agents, side effects, and symptom management to reduce the risk of nonadherence and to ensure safety. Literature on medication adherence, including oral chemotherapy, indicates that patients cope more effectively when they are educated about their diagnosis and treatment.2 Effective teaching and follow-up benefit cancer patients by improving side effect management, decreasing anxiety, promoting adherence, empowering patients to be included in their care, and improving quality of life.12 The shift to treating cancer using oral chemotherapy agents has created a new paradigm in cancer care, and ONNs need to take a lead role in improving nursing practice and in caring for patients receiving oral chemotherapy agents.
- Moody M, Jackowski J. Are patients on oral chemotherapy in your practice setting safe? Clin J Oncol Nurs. 2010;14:339-346.
- Given B, Spoelstra S, Grant M. The challenges of oral agents as antineoplastic treatments. Semin Oncol Nurs. 2011;27:93-103.
- Spoelstra S, Given CW, Sikorskii A, et al. Treatment with oral anticancer agents: symptom severity and attribution, and interference with comorbidity management. Oncol Nurs Forum. 2015;42:80-88.
- Rigdon A. Development of patient education for older adults receiving chemotherapy. Clin J Oncol Nurs. 2010;14:433-441.
- Winkeljohn D. Adherence to oral cancer therapies: nursing interventions. Clin J Oncol Nurs. 2010;14:461-466.
- Lester J. Safe handling and administration considerations of oral anticancer agents in the clinical and home setting. Clin J Oncol Nurs. 2012;16:E192-E197.
- Neuss MN, Polovich M, McNiff K, et al. 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. J Oncol Pract. 2013;9(suppl):5s-13s.
- Esper P. Identifying strategies to optimize care with oral cancer therapy. Clin J Oncol Nurs. 2013;17:629-636.
- Kav S, Schulmeister L, Nirenberg A, et al. Development of the MASCC teaching tool for patients receiving oral agents for cancer. Support Care Cancer. 2010;18:583-590.
- Johnson C, Adler K. The role of the nurse in patient education and followup of people receiving oral anti-cancer treatment: an Australian survey. Australian J Cancer Nurs. 2014;15:4-12.
- Schneider SM, Hess K, Gosselin T. Interventions to promote adherence with oral agents. Semin Oncol Nurs. 2011;27:133-141.
- Griffiths T, Pascoe E. Evaluation of an education program to facilitate patient adherence, toxicity monitoring and promote safety and wellbeing in the self-administration of oral chemotherapy in the home setting: an Australian study. Australian J Cancer Nurs. 2014;15:30-38.
- Schneider SM, Adams DB, Gosselin T. A tailored nurse coaching intervention for oral chemotherapy adherence. J Adv Pract Oncol. 2014;5:163-172.
- Sommers RM, Miller K, Berry DL. Feasibility pilot on medication adherence with knowledge in ambulatory patients with gastrointestinal cancer. Oncology Nurs Forum. 2012;39:E373-E379.