September 2006 - Oral anti-cancer therapies Oakley, C ...

FACET - European Journal of Cancer CareSeptember 2006

slides available at: www.blackwellpublishing.com/ecc

Oral anti-cancer therapiesOakley, C.1, Bloomfield, J.2, Plant, H.3

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*Click on “View”; “Notes Page” for explanatory notes

Oral anti-cancer therapies – past, present, future

What are the issues facing

patients prescribed oral

chemotherapy, their families

and healthcare professionals

caring for them?



Oral anti-cancer therapies (continued)

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The conference

Presentations:

• Drug developments in recent years

• Commissioning issues

• Establishing oral chemotherapy services from the points of view of pharmacy and nursing

• Research exploring patient experiences of oral chemotherapy

Three workshops



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Who should attend a workshop on oral chemotherapy?

• Clinical nurse specialists 10

• Pharmacists 8

• Community nurses 6

• General practitioner 1

• Hospital based consultants 3

• Nurses/others 5

• Others/managers 20

• Patients/users 5

Total 58



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Why use the oral route?

It is the normal way!



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Development of oral anti-cancer treatments – the

past

• Early anti-cancer drugs

were cytotoxics

• Oral hormonal agents

were used to treat

hormone dependent

cancers as soon as they

became available


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Development of oral anti-cancer

treatments – Capecitabine

• 5-FU can not be absorbed from the gut so is administered as continuous IV infusion to achieve maximum cell kill

• Capecitabine is absorbed from the GI tract and converts to 5-FU at the liver, tumour site and other tissues

• Capecitabine is licensed for metastatic breast and colon cancer and as adjuvant colorectal cancer treatment


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Development of oral anti-cancer

treatments – the future

• Tyrosine Kinase Inhibitors (TKI)

• Hormones

• Vinorelbine

• Drugs under development


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The pharmacy model

British Oncology Pharmacy Association (BOPA) statement (2004)

• Principles of safe practice

• Prescribing

• Dispensing and labelling

• Patient education and information

• Patients access to advice and support when at home

• General risk management

• Audit


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The pharmacy model –

implementing BOPA recommendations

• Established oral chemotherapy working party

• Purpose

• Achievements

• Future plans


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The nursing model – nurse supported

capecitabine clinic

• Pathway and role of the nurse

• Patient education and support is of vital importance

• Can be a stressful experience.

• More responsibility placed on patients to adhere to treatment regimens and recognise the onset of side effects.

• Supporting documentation


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The patient’s experience

Audit: Looking at the experience of oral chemotherapy through audit

Hilary Plant & Jacqueline Bloomfield

Research: “It is a lot easier to cope with” – An exploration of cancer patients’ experience of oral chemotherapy

Catherine Oakley


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Looking at the experience of oral

chemotherapy through audit

Aims of the audit

• To gain awareness of issues experienced by those taking oral anti cancer treatment

• Identify needs – information, practical, social and emotional

• To identify ways in which health professionals can support these needs

Plant & Bloomfield (2005)


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Findings: Information

Additional information needs

before commencing

treatment:

“How and when to take. How

to store/ manage, handle.

What to do if I missed a dose.

How the medication works,

expectation of outcome of

medication”

(Female respondent aged 37, taking etoposide for several months)


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Findings: Side-effects and support

• 86% of respondents reported side-effects as a result of taking oral chemotherapy treatment

• 90% indicated that they knew who to seek help from to manage these (nurse, hospital doctor, GP)

• 23% did not seek help or support

“Because I have been through it before I have not sought help – I just get on with it”

(Female respondent, retired, taking oral chemotherapy for 7 weeks)


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Findings: Perceptions and experiences (1)

“I much prefer taking oral drugs, side effects are no worse than other treatments and oral drugs give me the control which is very important”

(Female aged 40 taking treatment for 5 months)

“I did initially feel apprehensive about the responsibility of taking the drugs myself. I didn’t feel safe taking such powerful medicine & worried about getting the dose right even though it was clearly explained on the box. I preferred it when the medicine was given intravenously. But I’m just about to start my 3rd cycle & feel ok about it now”

(Female aged 38 taking capecitabine for 3 months)


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Findings: Perceptions and experiences (2)

“I have found this type of oral chemo very easy to use and with the least side-effects. My only worry is, is it doing the job of shrinking the tumour and how good the end result would be. Only time will tell. For people with poor or collapsed veins it is a real blessing”.

(Female aged 65)

“Oral chemotherapy relies on the diligence and efficiency of the patient. Taking 8 tablets a day is demanding particularly if the side effects, as in my case, were severe”

(Female aged 46 taking capecitabine)


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“It is a lot easier to cope with” – An

exploration of cancer patients’ experience of

oral chemotherapyDay 1OUTPATIENT ATTENDANCE

Day 15HOME VISIT

Participant observation

Informal interviews

Involvement of patients and professionals

Formal interview with patient at home

Field notes collected

Reflective diary maintained


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Main findings• Oral therapy is the preferred

option

• Healthcare professionals anxiety

– Probable drivers are experience of patients not taking medicine correctly or reporting symptoms

• Information rushed/repeated with little time to check understanding

• Patients/caregivers anxious/overwhelmed

• Patients/caregivers assumed responsibility which they appeared to find stressful

• Elderly patients stayed with caregivers


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Main findings (2)

Patients may not comply by ringing in if unwell. They:

– denied side effects would occur

– didn’t know when to call in – viewed oral chemotherapy

as milder

“I’ve got to accept it and take it… I try to think myself well. I’m not going to take too much notice of side effects cause I don’t want to let them get to me. I don’t want to get that imagination where you’re feeling bad.”

Patient


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What helps?• Confidence in the service /24

hour contact

• Practical advice

• Speaking to experienced patients

• Caregivers helped establish routine

“I come down and have me breakfast and then (name of caregiver) used to get the bag that is kept on top of the fridge out there and I‘d sit and she’d watch me have me tablets….. we made a list so she ticks it off when I’ve had them (laughs)….”

Patient

“I just kept to 7, 7, 7, 7, 7, 7 .. I even put me alarm on to 7 o’clock so if I should forget it, it would give me a reminder……”

Patient


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Implications for practice/research of audit and research

project

• Preferred option

• Clear patient pathway

• Assessment and support

• Listen and respond

• Information

• Contact details

• Monitoring


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Chemotherapy alert card


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Workshop outcomes

Transforming delivery – identified

• barriers

• key issues

• potential resources

Who, where, when

• Pathway mapping

Information/documentation

• Problem areas

• Solutions


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Emerging themes

• Responsibility

• Support

• Service structure

• Community nurses

• Existing models of care


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The next steps

• Pathway mapping

• Model of care- research

• Hand held diary

• Repeating the conference


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References and further reading

• Bedell C.H. (2003) A changing paradigm for cancer treatment: the advent of new oral chemotherapy agents. Clinical Journal of Oncology Nursing 7 (6 suppl), 5-9.

• Borner M.M., Schoffski P., de Wit, R., Caponigro F., Comella G., Sulkes A., Greim G., Peters G.J., van der Born K., Wanders J., Boer R.F., Martin C., Fumoleau P. (2002). Patient preference and pharmacokinetics of oral modulated UFT versus intravenous fluorouracil and lecovorin: a randomised crossover trial in advanced colorectal cancer. European Journal of Cancer 38, 349-358.

• British Oncology Pharmacists Association (BOPA) (2004) Position Statement on Safe Practice and the Pharmaceutical Care of Patients Receiving Oral Anticancer Chemotherapy. January 2004. BOPA, UK.


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References and further

reading (continued)

• Cassidy J., Scheithauer W., McKendrick J., Kroning H., Nowacki M.P., Seitz J.F., Twelves C., Van Hazel G., Wong A., Diaz-Rubio E., On Behalf of X-act Study Investigators. (2004). Capecitabine (X) vs. bolus 5-FU/leucovorin (LV) as adjuvant therapy for colon cancer (the X-ACT study): efficacy results of a phase iii trial. Proceedings of the American Society of Clinical Oncology vol. 23, 2084-2091.

• Faithfull S., & Deery P. (2004). Implementation of capecitabine (XELODA) into a cancer centre: UK experience, European Journal of Oncology Nursing 8, S54-S62.

• Harrold K. (2002). Development of a nurse-led service for patients receiving oral capecitabine. Cancer Nursing Practice 1(8):19-24.

• Hartigan K. (2002). Patient education: The cornerstone of successful oral chemotherapy treatment, Clinical Journal of Oncology Nursing supplement 7(6):21-24.


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References and further reading (continued)

• James R., Bianco C., Farina C. (2003). Savings in staff time as a result of switching from De Gramont to oral capecitabine for patients with advanced colorectal cancer. European Journal of Cancer, Supplements 1(5), S83 (abstract 271).

• Liu G., Franssen E., Fitch M.I., Warner E. (1997). Patient preferences for oral versus intravenous palliative chemotherapy. Journal of Clinical Oncology 15(1),110-115.

• Lokich J. (2004). Capecitabine: fixed daily dose and continuous (non cyclic) dosing schedule. Cancer Investigation 22(5), 713-717.

• Mayor S. (2003). UK introduces measures to reduce errors with methotrexate. British Medical Journal 372, 70.

• Mills M., E., and Sullivan K. (1999). The importance of information giving for patients newly diagnosed with cancer: a review of the literature. Journal of Clinical Nursing 8(6) 631-642.


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• Oakley C. (2005) It’s a lot easier to cope with, an exploration of cancer patients’ experience of oral chemotherapy. Unpublished dissertation, Kings College London, London, UK.

• Partridge A.H., Avon J., Wang P.S., Winer E.P. (2002). Adherence to therapy with oral antineoplastic agents, Journal of the National Cancer Institute, 94(9), 652-661.

• Plant H. & Bloomfield J. (2005) Looking at the experience of oral chemotherapy through audit. Unpublished audit, Guy’s and St Thomas’ NHS Foundation Trust and Kings College London, London, UK.

• Sanio C., Erickson E. (2003). Keeping cancer patients informed; a challenge for nursing. European Journal of Oncology Nursing 7(1), 39-49.


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• Twelves C., Boyer M., Findlay M., Cassidy J., Weitzel C., Barker C., Osterwalder B., Jamieson C., Hieke K. on behalf of the Xeloda colorectal cancer study group (2001). Capecitibine (Xeloda) improves medical resource use compared with 5-fluorouracil plus leucovorin in a phase III trial conducted in patients with advanced colorectal carcinoma. European Journal of Cancer 37, 597-604.

• Twelves C. Gollins S., Grieve R., Samuel L. (2006). A randomized cross over trial comparing patient preference for oral capecitabine and 5-fluorouracilleucovorin regimens in patients with advanced colorectal cancer. Annals of Oncology 17, 239-245.

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