5 Ways to Help Your Cancer Patients Be More Compliant

Neil Chesanow

Disclosures

June 19, 2014

In This Article

Find Out How Much Information Your Patients Want

Studies show that patients prefer patient-centered over physician-centered communication.[17] In the latter, the doctor sets the agenda, assumes the patient will volunteer any important thoughts, tends to steer the conversation away from feelings, and equates decision-making with physician judgment.

In patient-centered communication, the physician builds an agenda based on elicited patient concerns, explicitly asks about the patient's thoughts, encourages the expression of feelings, and solicits patient involvement in decision-making.[17] However, how much decision-making patients want varies with the patient.

In one study of patients with hematologic malignancies undergoing stem cell transplantation, for example, "a large proportion of patients (44%) preferred a shared decision-making model in which the physician and patient made decisions together.[18] A significant minority, however, preferred to make the decision themselves, with some input from the physician (14%) or completely on their own (9%). Another significant minority preferred that their physician make the decision, with some input from the patient (17%) or relying strictly on the physician's judgment (18%)."

In other words, "a patient-centered approach involves some negotiation about how much the patient wants to be involved in decisions."[17]

Use Pharmacies That Can Help

Even mastery of such methods, which may help to improve compliance in your patients, isn't enough to finish the job. Improving compliance takes patient monitoring, and monitoring is a team effort.

"It's important to realize that we are not alone," says Duke's S. Yousuf Zafar. "We need to rely on our team members to help focus on adherence. At my institution, for example, I rely heavily on our pharmacists. Our pharmacists evaluate insurance plans for patients before I order oral chemotherapy for them. They provide chemotherapy education, and they follow up with patients after they've started treatment. To be honest, I don't have the time to do that sufficiently for all of my patients."

Of course, neither do community oncologists, who may not have a pharmacist on staff. With the advent of oral oncolytics -- Walgreens' specialty pharmacies now carry 32 of them, says Rick Miller, RPh, MBA, Senior Director of Specialty Services -- the challenge of monitoring patients has been greatly magnified. The Affordable Care Act calls for retail pharmacists to lend a hand. Major chains, such as CVS Caremark, Rite Aid, and Walgreens, now assiduously monitor compliance in patients with chronic conditions, and none more aggressively than cancer patients.

"Ten to 15 years ago, patients would receive their medications by visiting an oncologist's office or infusion clinic, a needle would be placed in their arm, and the oncologist knew exactly what dose was being given at the exact time," Miller observes. "With the advent of oral oncolytics, the prescriber is now handing a prescription to the patient, and all that responsibility is shifted to the patient. So the patient is responsible for adherence to and continuing the therapy. What that does is take the oncologist out of the loop in terms of understanding how many doses the patient has been taking."

"With that mindset, what we do supports or fills that vacuum of information that oncologists no longer have by providing them with the information they need related to their patients and how they're adherent to therapy," Miller says.

In the first month after an oncologist sends a script to the pharmacy, a specialty pharmacist reaches out patients three times, Miller explains. "We talk to them at day 0, before they receive their medication, and we proactively educate them on the medication, as well as the side effects to expect to experience and when those side effects may occur," he says. "Then we talk to them on day 10 to assess them on their adherence, as well as how well they're tolerating the therapy. And on that day-10 call, if the patient is experiencing any issues, we reach out to the prescriber to let them know what the patient is experiencing."

A pharmacist reaches out again on day 20, Miller says. "On that day-20 call, we also will assess patients for adherence -- how many doses they have left, how many they missed, when they missed them, why, and any side effects they may be having -- and then also at that time schedule their next delivery," he explains.

Patient education focuses on how and when to take the drugs prescribed. "Many of these medications have cycle dosing, meaning that patients will take a drug for X number of days per month, then they're off it for X number of days per month, and then they repeat that cycle," Miller says. "So we work with them on that. Some of these medications have to be taken with or without food. We want to make sure patients understand proper administration."

Another key focus is common side effects, foreknowledge of which may help patients stay compliant during periods of extreme discomfort.

"There are oral oncolytics that we know will cause hand-and-foot syndrome, where the skin on the hands and feet will crack, the hands and feet will feel inflamed, and they will swell," Miller says. "It's very uncomfortable for patients. We will proactively educate them that this is going to happen. Here's what you can do to minimize this happening, and when it does happen, here's what you can do to treat it to minimize the pain."

Such adherence programs can go a long way toward offsetting the time and personnel that many community oncologists lack to monitor their patients.

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