The  Adherence  to  Oral  Anti-­‐cancer  therapy  in  Metastatic  Breast  Cancer  Patients  in  London  Cancer  

Gabrielle  Perriera,  Pinkie  Chambers,  Rebecca  Roylance,  Ian  Bates,  Alicia  Salisbury,  Anish  Tailor,  Simon  Wan,  Simon  Jenkinson,  Evelyn  Holmes,  Andie  David,  Nicola  Akar,  Blessing  Kamudyariwa  and  Chris  Gallagher  

 

Introduction  

Oral  therapy  is  commonly  used  in  the  treatment  of  Cancer.    In  2008  an  NPSA  alert  was  published  regarding  the  risks  associated  with  oral  anticancer  treatment.    The  report  concluded  that  patients  receiving  oral  treatment  for  cancer  should  be  given  the  same  level  of  information  and  support  as  the  patients  receiving  intravenous  therapy  (IV).    This  led  to  trusts  developing  measures  to  reduce  the  number  of  incidents  occurring,  including  patient  counselling  and  improved  patient  information.  

Oral  anti-­‐cancer  treatment  is  routinely  given  to  patients  to  take  home  on  the  same  day  as  their  clinic  assessment  appointment.    Usually,  for  a  patient  this  means  they  spend  a  long  day  at  their  hospital.    The  actual  time  spent  on  the  day  is  dependant  on  factors  such  as  clinic  wait,  wait  for  blood  results  and  wait  for  dispensing  of  medication.    The  long  day  may  leave  a  patient  feeling  dissatisfied  and  this  may  lead  to  poor  adherence.      The  information  given  on  this  day  may  not  have  been  heard  or  understood  correctly.  This  may  also  impact  on  adherence  and  the  management  of  any  low  grade  toxicities.  

Breast  Cancer  with  its  high  incidence  requires  effective  treatment  options  that  are  practical,  selective  and  well  tolerated.    Oral  treatment  in  this  patient  group  is  commonly  used  and  there  are  further  agents  under  investigation.  There  have  been  many  studies  investigating  a  patient  perceptions  to  oral  anticancer  treatment  and  it  is  recognised  that  adherence  can  be  affected  by  general  prejudices  and  uncertainties  relating  to  the  correct  usage  of  their  medicines  [1,2,3,4,5].  .  Key  issues  that  have  been  identified  for  successful  treatment,  are  for  patients  to  understand  the  treatment  in  general,  the  specifics  of  their  oral  chemotherapy  agent  and  their  schedule  [6,7]    .        

Breast  Cancer  patients  have  been  targeted  for  this  pilot  study.    They  commonly  receive  oral  anticancer  treatment  as  2nd  or  3rd  line  therapy.  They  would  have  previously  had  support  from  chemotherapy  nurses  when  they  had  IV  treatment  and  may  miss  the  support  that  they  had  previously  had.      The  aim  of  the  audit  will  be  to  determine  whether  there  is  a  correlation  between  elements  of  the  service  that  a  patient  receives  in  hospital  with  adherence  and  satisfaction.      

 

 

 

 

Methods  

The  oral  chemotherapy  pathway  was  documented  and  patient  adherence  and  satisfaction  were  assessed  through  questionnaires  given  to  patients  at  each  trust  that  enquired  about  medicines  conversations,  missed  doses,  clinic  visit  duration,  and  satisfaction  with  the  service  for  a  period  of  one  month  to  capture  one  cycle  of  treatment.  

Patients    

The  patients  were  from  8  hospitals:  University  College  London  (UCLH),  Whittington  Health,  Royal  Free,  Barts  Health  (including  Newham),  North  Middlesex,  Barking,  Havering  and  Redbridge  University  Trust  (BHRUT),  and  Princess  Alexandra  Hospital  (PAH)  and  Barnet  Hospital  (although  Barnet  is  now  part  of  Royal  Free  this  study  was  done  prior  to  the  merger  and  so  Barnet  will  be  considered  separately).  The  patients  were  identified  by  the  healthcare  professionals  i.e.  CNS,  chemotherapy  nurses  or  the  specialist  pharmacists,  when  visiting  the  oncology  clinic,  with  staff  on  hand  to  support  if  there  were  any  queries.  Phone  call  interviews  were  also  conducted,  after  patients  were  made  aware  of  the  survey  being  conducted  at  some  of  the  hospitals,  which  were  conducted  by  the  staff  at  the  trust.    

 

Questionnaires  

The  primary  source  of  data  collection  occurred  with  the  use  of  a  structured  questionnaire  comprising  of  21  questions:  13  multiple-­‐choice  questions,  6  rating  scales  questions  and  2  qualitative  open  ended  questions  (See  appendix  1).      

This  questionnaire  was  created  using  various  articles  as  a  basis,  looking  at  the  questionnaire  formats  such  as  the  Modified  Morisky  Model  and  MARS  Scale,  which  are  designed  to  capture  adherence.  Also,  incorporating  and  adapting  questions  found  in  the  National  Chemotherapy  Patient  Experience  Survey.[8]  Before  releasing  this  questionnaire  to  patients,  it  underwent  modifications  from  feedback  provided  from  the  hospitals  participating  in  this  study,  the  London  Cancer  breast  pathway  board  and  supervisors  of  the  project  (PC,  RR,  IB).    This  was  to  ensure  that  patient  understanding  was  optimal  to  assure  that  responses  were  meaningful  for  the  purpose  of  the  project.  The  questionnaire  assesses  a  number  of  factors  from  a  patient  perspective  from  consent  to  service  evaluation  scoring.  The  survey  ran  from  February  2014  to  May  2014;  ultimately,  to  capture  one  treatment  cycle  response  from  each  hospital.    

 

Patient  Pathways  

Prior  to  patient  responses  to  the  questionnaire,  the  pathways  of  each  hospital  trust  were  also  mapped.  Using  questions  compiled  from  the  general  chemotherapy  pathway[9]  and  the  guidelines  of  the  Kent  and  Medway  Cancer  Network  as  an  example  [10]  the  key  components  of  the  service  were  identified.  Health  care  professionals  from  each  hospital  were  asked  a  number  of  questions  regarding  details  of  the  pathway  of  care.    

 

Statistical  Analysis  

The  completed  questionnaires  were  analysed  using  the  SPSS  software,  using  a  coding  system  for  the  multiple  closed  question  responses.  Nonparametric  testing  was  used  to  find  correlations  and  relationships  between  question  responses,  e.g.  spearman’s  rank  correlation  coefficient.    

   

 

Results    

40  out  of  50  questionnaires  given  out  were  completed.  Table  1  shows  the  percentage  of  responses  from  each  hospital.    

The  largest  percentage  (47.5%)  of  patients  who  completed  the  questionnaire  were  within  the  age  range  of  ‘60  and  above’.  

The  majority  of  patients,  using  grouped  ethnicities,  who  responded  were  Caucasian  (65%)  and  around  20%  were  Black  or  Black  British  and  10%  Asian  or  Asian  British.  

Barnet  and  Chase  Farm  agreed  to  distribute  the  questionnaire,  however,  during  the  collection  period  there  were  no  patients  on  oral  treatment  for  this  metastatic  breast  cancer.  

 

 

 

 

 

 

 

 

Table  1  Proportion  of  patient  responses  at  each  trust  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Questionnaire  results  

Questions  relating  to  consent  

When  given  the  option  to  start  oral  chemotherapy,  the  majority  of  patients  didn’t  have  any  questions  that  were  not  addressed  that  day  (85%).  However,  there  remained  the  15%  who  had   a   number   of   questions,   one   patient   stated   ‘I   was   still   in   shock   and   found   it   all  overwhelming  to  register  information’.  

 

Medicines  Related  Conversation  

Question   4   stated   “Before   you   took   home   your   1st   course   of   medication   did   you   have   a  discussion  with  anyone  other  than  your  doctor  regarding  your  treatment  schedule  e.g.  what  time  to  take  your  tablets/  capsules?”  

All   patients   reported   to  have  had  a  medicines   related   conversation  whether   it  was  with  a  pharmacist   in   clinic,   in   the   outpatient   pharmacy   or   a   nurse   in   clinic.     44.4%   of   patients  reported  having  this  discussion  with  a  nurse  in  clinic.  The  duration  of  the  medicines  related  conversations  patients  had  with  a  health  care  professional  was  over  15  minutes   for  23/40  patients     (57.5%).     Patients   were   asked   if   they   were   given   a   timed   appointment   for   this  conversation?    62.5%  reported  “yes,  on  the  same  day”  to  this.  

 

Hospital   Frequency   Percent  (%)  

St  Bartholomews   9   22.5  

UCH   7   17.5  

Whittington   3   7.5  

Newham   2   5.0  

BHRUT   6   15.0  

Royal  Free   2   5.0  

North  Middlesex   5   12.5  

PAH   6   15.0  

 

Total   40   100.0  

Patients  were   asked   to   rank   out   of   10   the   usefulness   of   the   information   they  were   given  during  their  conversation,  10  being  very  good.    This  ranged  from  6  to  10,  50%  rated  10/10  (Fig.1).  There  was  no  significant  association  between  the  usefulness  of  the  information  given  and  the  length  of  time  of  the  discussion  (Spearman’s  Rank  Correlation  Coefficient  0.079).    It  was  also  shown  the  value  given  was   independent  of  the  healthcare  professional  giving  the  information  to  the  patient.    

 

Figure  1.    The  Value  of  the  medicines  related  conversation.  

 

Visits    

Question   12   addressed   the   number   of   times   a   patient   has   visited   the   hospital   before  receiving  their  next  course  of  medication.  The  responses  ranged  between  once  to  five  times.    The  visits  were  for  scans,  blood  tests  and  tablet  collections.  

Question  13   asked   the  number  of   times   a  patient  had   called  or   visited   the  hospital   or  GP  since  their  last  treatment  outside  of  their  clinic  appointment.    72.5%  didn’t  have  any  further  visits.   However,   9/40   patients   did   call/visit   (22.5%).     The   reasons   were   mainly   due   to  toxicities  of  treatment,  nausea,  pain,  sore  hands  and  feet.  

There  was  found  to  be  small  correlation,  0.106,  with  less  calls/  visits  made  with  patients  who  visited   the   hospital  more   before   receiving   their   next   course   e.g.   blood   test   on   a   separate  day.    This  may  have  been  due  to  having  additional  contact  with  healthcare  staff.  

72.5%  of  patients  reported  to  have  their  blood  test  the  day  before  treatment.    When  asked  where  patients  have  their  bloods  taken  and  whether  there  was  a  choice  in  this,  42.5%  were  

not  given  a  choice.    Only  5%  of  patients  had  their  blood  test  at  their  GP  practice,  15%  at  their  local   hospital   and   the   remainder   at   their   treatment   centre.     The   questionnaire   did   not  address  the  reasons  for  patients  opting  to  choose  their  treatment  centre  for  blood  tests  and  this  may  be  explored  in  future  questionnaires.  

 

Missed  Doses  and  Adherence  

The  information  regarding  missed  doses  was  well  understood  by  65%  patients  across  trusts.  However,   17.5%   didn’t   receive   any   information   regarding   this,   despite   having   a   pre-­‐chemotherapy   conversation   with   a   nurse   or   a   pharmacist.     This   maybe   as   they   didn’t  remember  being  given  the  information  or  that  this  was  missed  in  the  conversation.      52.5%  took  four  or  more  different  types  of  tablets  daily;  these  were  additional  to  their  anticancer  treatment.    There  was  no  correlation  between  missed  doses  and  the  treatment  centre  that  they  were  receiving  treatment.  75%  of  patients  didn’t  miss  any  doses  of  their  medication  in  the  past  month  of  treatment,  25%  missed  ‘some’  or  ‘quite  a  few’  (fig.3).  Those  who  missed  ‘quite   a   few’   doses   (5%),   were   taking   over   7   types   of   oral   medications.       Some   patients  recorded   the   medications   that   they   were   taking   in   addition   to   their   treatment   and   a  medication  review  may  have  minimised  this  for  patients.  

There  was  a  positive  relationship  found  between  missed  doses,  Q17,  and  the  number  of  oral  medication   taken,   Q16.   Using   non-­‐parametric   spearman’s   rank   correlation   comparing   the  number  of   tablets  taken  and  missed  doses,  a  positive  correlation  was  found,  r=0.3  p=0.05.    This  would   suggest   the   higher   the   number   of   tablets   the   patient   takes   per   day   the  more  likely  a  patient  is  to  miss  a  dose  during  the  course  of  their  treatment.  

 

Duration  of  time  in  Hospital  

There  was  a  wide  range  of  responses  to  the  question  regarding  the  time  spent   in  hospital.  39%   of   patients   reported   this   time   to   be   greater   than   4   hours.   There  was   no   correlation  found   between   duration   of   wait   and   hospital   service   rating.     These   ratings   ranged   quite  widely,  with  patients  still  giving  very  high  levels  of  satisfaction  (score  10)  and  waiting  over  4  hours.   However,   despite   these   high   ratings,   many   patients   stated   in   the   free   text,  dissatisfaction  with   the  waiting   times.  One  patient   gave   a   score   10/10   for   the   service   but  mentioned  the  ‘Pharmacy  isn’t  great  at  all,  the  wait  times  can  be  very  long’,  this  suggests  a  disparity   between   the   ratings   given   and   comments  made.    Many   patients   reported   in   the  comments  as  “pharmacy  being  the  cause  of  delays’  and  none  of  the  patients  were  receiving  treatment  via  homecare.    It  is  known  that  patients  will  often  rate  their  trust  very  highly  and  write  comments  that  do  not  match  the  same  level  of  satisfaction.      

 

Hospital  Service  

The  general  response  towards  the  overall  hospital  care  service  was  rated  4  and  above  on  a  scale  of  1-­‐10,  10  being  the  best.    47.5%  of  patients  rated  their    service  10/10.  

 

The  average  scoring  between  each  trust  is  represented  in  fig.2.  PAH  was  found  to  have  the  highest   score   with   a   mean   of   9.8   and   a   small   standard   deviation   suggesting   a   general  unanimity  from  patients  with  level  of  satisfaction  with  the  service  provided.  BHRUT  received  an  average  score  of  9.6,  this  hospital  didn’t  receive  any  negative  comments,  this  may  be  due  to  the  nurses  in  the  clinic  providing  patients  with  their  oral  anticancer  agents,  minimising  the  wait   that   they  may  have  experienced   if   collecting  at   the  pharmacy.      Some  London  Cancer  trusts  have  adopted  a  similar  system  where  dispensing  of  treatment  will  be  done  ahead  of  the  patient  arriving  to  the  clinic.    A  nurse  or  pharmacist  will  keep  the  treatment  in  the  clinic  environment  until   the  patient   has  been  assessed   and   is   considered   “fit   for   treatment”.     If  blood  results  are  pending,  the  nurse  or  pharmacist  will  sometimes  allow  the  patient  to  take  home  the  medicines  and  ensure  they  are  phoned  when  results  return.    They  will  inform  the  patient  to  start  treatment.    Allowing  a  patient  to  leave  with  medication  when  blood  results  are   still   pending   will   depend   on   many   factors   including   the   patients   understanding   of  process  and  the  cost  of  the  medication.      

 

 

Figure  2.    Ratings  for  Hospital  care  at  trusts  

*  There  is  no  error  bar  for  Royal  Free  as  both  patients  from  the  trust  rated  the  same  score.  

 

 

Recommendations  

 

Adherence  to  anticancer  treatment  is  important  to  maximise  the  benefits  of  treatment  and  improve  outcomes.  Adherence  is  also  related  to  good  and  early  management  of  toxicities.      9/40  patients  that  were  having  oral  treatment  contacted  their  treatment  centre  or  GP  regarding  toxicity  management.    We  could  not  assess  whether  these  toxicities  may  have  been  preventable  or  managed  earlier.    Early  patient  identification  and  reporting  of  toxicities  is  important  and  methods  of  how  to  achieve  this  should  be  explored.    There  is  also  a  place  for  pro-­‐active  monitoring  of  certain  patients.    This  pro-­‐active  assessment  can  be  via  a  telephone  call,  in  the  clinic  environment  or  in  the  community.    

 

Prescribers  in  clinic  should  ensure  that  the  patient  understands  the  importance  of  taking  their  medicines  and  ensure  that  low-­‐grade  toxicities  are  managed  appropriately.  

 

Many  patients  receiving  oral  treatment  were  having  their  blood  test  taken  the  day  before  attendance  for  a  toxicity  assessment  (79%).    Despite  this  39%  of  patients  would  still  wait  over  4  hours  at  their  hospital.    Treatment  centres  should  consider  allowing  these  patients  to  have  just  one  visit  and  attempt  to  improve  their  current    blood  test  waiting  times  for  patients.  

 

Although  there  was  no  correlation  between  satisfaction  with  the  service  and  adherence,  it  is  still  essential  to  acknowledge  comments  made  by  patients  and  make  improvements  to  the  service  where  issues  are  highlighted.    There  were  many  comments  regarding  pharmacy  waiting  times.    Some  trusts  were  able  to  implement  simple  solutions  to  address  these  problems  including  advance  dispensing,  and  such  solutions  are  important  for  shared  learning  between  trusts      

 

Medication  reviews  are  important  for  patients  taking  4  or  more  different  types  of  medicines  and  this  should  be  addressed  through  better  communication  with  primary  care.    There  is  a  drive  for  community  pharmacists  to  be  proactive  in  conducting  medication  reviews.    This  is  aided  by  better  communication  from  secondary  care.    Understanding  of  the  prognosis  of  a  patient  is  essential  for  the  person  conducting  a  medication  review  and  the  communication  from  secondary  to  primary  care  should  reflect  this  

 

 

 

 

Figure  3.    Amalgamation  of  Oral  Pathways  across  London  Cancer.

References  

 

1.   Horne,  R.W.,  J.;  Barber,  N.;  Elliott,  R.;  Morgan,  M.  ,  Concordance,  adherence  and  compliance  in  medicine  taking  :  report  for  the  National  Co-­‐ordinating  Centre  for  NHS  Service  Delivery  and  Organisation  R  &  D  2005.  

2.   Abetz,  L.,  et  al.,  Development  of  the  cancer  therapy  satisfaction  questionnaire:  item  generation  and  content  validity  testing.  Value  Health,  2005.  8  Suppl  1:  p.  S41-­‐53.  

3.   Saratsiotou,  I.,  et  al.,  Treatment  adherence  of  cancer  patients  to  orally  administered  chemotherapy:  insights  from  a  Greek  study  using  a  self-­‐reported  questionnaire.  J  Oncol  Pharm  Pract,  2011.  17(4):  p.  304-­‐11.  

4.   Timmers,  L.,  et  al.,  Adherence  and  patients'  experiences  with  the  use  of  oral  anticancer  agents.  Acta  Oncol,  2014.  53(2):  p.  259-­‐67.  

5.   Fallowfield,  L.,  et  al.,  Patients'  preference  for  administration  of  endocrine  treatments  by  injection  or  tablets:  results  from  a  study  of  women  with  breast  cancer.  Ann  Oncol,  2006.  17(2):  p.  205-­‐10.  

6.   NPSA,  Oral  anti-­‐cancer  medicines:  risks  of  incorrect  dosing.  2008(22  January  2008).  7.   NPSA,  Additional  information  to  support  The  National  Patient  Safety  Agency’s  Rapid  Response  Report  Risks  of  incorrect  dosing  of  oral  

anti-­‐cancer  medicines.  2008.  8.   Health,  Q.,  National  Cancer  Patient  Experience  Survey  2012-­‐13  National  Report.  

2013.  9.   Waters,  C.N.B.,  Systemic  Anti-­‐Cancer  Therapy  Care  Pathway  -­‐  Guidelines  on  the  safe  

use  of  Oral  Anti-­‐cancer  Medicines.  2012    Expected  Review  date  2014.  10.   Schott,  S.,  et  al.,  Acceptance  of  oral  chemotherapy  in  breast  cancer  patients  -­‐  a  

survey  study.  BMC  Cancer,  2011.  11:  p.  129.  11.   Catania,  C.,  et  al.,  Perception  that  oral  anticancer  treatments  are  less  efficacious:  

development  of  a  questionnaire  to  assess  the  possible  prejudices  of  patients  with  cancer.  Breast  Cancer  Res  Treat,  2005.  92(3):  p.  265-­‐72.  

12.   Picton,  C.W.,  H.,  Medicines  Optimisation:  Helping  patients  to  make  the  most  of  medicines  

Good  Practice  guidance  for  healthcare  professionals  in  England.  Royal  Pharmaceutical  Society,  2013.  

13.   MHRA,  MIMS:  Monthly  Index  of  Medical  Specialities  March-­‐May  2014.  2013,  New  Malden:  Haymarket  Business  Media.  

 

 

 

 

 

 

 

APPENDIX  1.