Adherence Concepts for the Patient

Adherence Concepts for the Cancer Patient

Benyam Muluneh, PharmD, BCOP, CPP

Objectives

? Discuss the shift from intravenous to oral chemotherapy over the past few decades

? Assess the various dimensions of adherence ? Manage patients who are non-adherent to

oral chemotherapy ? Explain how to advocate for legislation that

can improve access to oral chemotherapy

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Adherence: Not so straightforward

"Adherence is the single most important modifiable factor that compromises treatment outcome." -World Health Organization, 2003

THE BIG PICTURE

DEFINING THE PROBLEM

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Pros and Cons

Benefits

Concerns

Convenient Patient Empowerment ?Decreased toxicity ?Increased efficacy

Adherence Cost Storage/handling Therapy monitoring

Adherence to Therapy

Definition: Extent to which a patient's behavior coincides with medical advice

Consequences of Non-adherence

Poor outcomes

Increased Toxicity

Increased health care costs

Partridge et al. J Clin Oncol. 2009. 124-128

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Non-adherence in chronic diseases

Frequency of Administration

Per Day Once 80% Twice 70% Three times 65% Four times 50%

43-78% in clinical trials

$100 Billion per year in health-care costs

Higher in acute vs. chronic diseases

Non-adherence in cancer: Major barrier to positive outcomes

Percent Adherence Over Six Cycles of Capecitabine in Adjuvant Breast Cancer CALGB 60104

22%

Partridge AH. J Clin Oncol 28:2418-2422.

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Consequences

Marin et al. J Clin Oncol 28:2381-2388

Non-adherence literature

Author/Year Demissie et al. / 2001 Partridge et al. / 2003

Atkins et al. / 2006 Barron et al. / 2007 Darkow et al. / 2007 G?th et al. / 2008 Owusu et al. / 2008 Kimmick et al. / 2009 Noens et al. / 2009 Hersman et al. / 2010 Patridge et al. / 2010 Marin et al. / 2010 Eliasson et al. / 2010 Nekhlyudov et al. / 2011 Neugut et al. / 2011 Streeter et al. / 2011 Bhatia et al. / 2012

Diagnosis Breast Cancer Breast Cancer Breast Cancer Breast Cancer

CML Breast Cancer Breast Cancer Breast Cancer

CML Breast Cancer Breast Cancer

CML CML Breast Cancer Breast Cancer Various ALL

OA Tamoxifen Tamoxifen Tamoxifen Tamoxifen Imatinib Endocrine Tamoxifen Endocrine Imatinib Endocrine Endocrine Imatinib Imatinib Endocrine Endocrine

Various 6-MP

Method Self-report Refill data Self-report Refill data Refill data Self-report Refill data Refill data

BAAS1 Refill data

MEMS2 MEMS2 MEMS2 Refill data Refill data Refill data MEMS2

Outcome 15% d/c 13% not filling rx 55% non-adherent 22% non-persistence 31% interruption 11% non-adherent 49% d/c 36% not filling rx 33% non-adherent 32% d/c 25% non-adherent 26% non-adherent 20% non-adherent 21% d/c 21% non-persistence 10% abandonment 10% non-adherent

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CLOSER LOOK

UNDERSTANDING THE DIMENSIONS OF ADHERENCE

Dimensions of Adherence

Health system

Social/ economic

Condition- Therapy- related related

Patient- related

Evidence for Action. World Health Organization. 2003

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Health System

? Poorly developed health services ? Poor medication distribution systems ? Lack of knowledge and training of health care providers ? Lack of incentives on feedback and performance

Social / Economic

? Poor socioeconomic ? Long distance from

status

treatment center

? Poverty

? High cost of transport

? Illiteracy

? High cost of medication,

? Low level of education ? Changing

? Unemployment

environmental

? Lack of effective social support networks

? Unstable living conditions

situations, culture and lay beliefs about illness and treatment, and family dysfunction

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Condition

? Severity of symptoms ? Level of disability

? Physical ? Psychological ? Social ? Vocational

? Rate of progression and severity of the disease ? Availability of effective treatments

Therapy

? Complexity of the medical regimen ? Duration of treatment ? Previous treatment failures ? Frequent changes in treatment ? Immediacy of beneficial effects ? Side-effects and the viability of medical

support to deal with them

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