Download The Adherence to Oral Anti-‐cancer therapy in Metastatic Breast

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 Hospital Frequency St Bartholomews 9 Percent (%) 22.5 17.5 7.5 5.0 15.0 5.0 UCH 7 Whittington 3 Newham 2 BHRUT 6 Royal Free 2 North Middlesex 5 12.5 PAH 6 15.0 Total 40 100.0 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. 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.
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