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Help patients adhere to oral therapies: as seen in the Clinical Journal of Oncology Nursing.

An increasing number of cancers are being treated with oral medications in the outpatient setting; as such, helping patients adhere to oral treatments has become a significant nursing consideration. As the first line of contact for patients with cancer, oncology nurses are in a key position to support patients in their oral cancer treatment regimens. In her article in the August 2010 Clinical Journal of Oncology Nursing, Winkeljohn discussed the barriers patients may experience when taking oral chemotherapy and what oncology nurses can do to prevent or remove those barriers.

Side Effects

All cancer treatments are associated with side effects, which, depending on the severity, have the potential to affect or delay treatment, regardless of how the drug is administered. However, patients who come to the clinic for IV treatments have more opportunities to interact with the healthcare team and seek treatment for any distressing side effects. Patients undergoing oral treatment at home may feel more isolated and may skip doses in an effort to manage their side effects.

When patients are receiving oral therapies, oncology nurses should provide ample education about the expected side effects and instruction on when and where to call for support during and after clinic hours. See Table 1 for a list of side effects and recommended patient education.

Nausea and vomiting: "Poor control of nausea and vomiting can make patients anxious about taking the next dose," Winkeljohn said. Nausea prevention strategies include prescribing antiemetics, instructing patients to take oral therapies with food unless contraindicated, and, if dosing is once daily, instructing patients to take the dose at night. If nausea and vomiting develop, patients should hydrate and try to eat regularly. Instruct patients to call if they are unable to keep food or fluid down or if nausea and vomiting continue 24 hours after antiemetic treatment.

Diarrhea: Patients should be instructed to use over-the-counter antidiarrheals such as loperamide, to follow a bland diet (e.g., soft foods with minimal seasoning, such as mashed potatoes or cream of wheat) or the BRAT diet (i.e., bananas, rice, applesauce, and toast), and to maintain hydration. If diarrhea is not controlled, patients should call the clinic to determine whether IV hydration or hospitalization is required.

Hypertension: Sorafenib and sunitinib are associated with increased risk of hypertension. Blood pressure can be monitored at clinic visits, but patients should also be instructed on recording blood pressures at home, including equipment use and what readings should prompt a call to the healthcare team. Persistent hypertension can be managed with antihypertensives.

Cutaneous reactions: A number of oral agents are highly linked to reactions such as skin rash and hand-foot syndrome. Specifically with tyrosine kinase inhibitors, a rash may indicate that the treatment is working, which may cause some patients to increase adherence. However, others may find the rash distressing (it most often appears on the face and neck) and decrease adherence as a result. Oncology nurses should instruct patients to call the clinic when they first notice a rash, wash the area with mild soap and water, and use topical treatments such as hydrocortisone or clindamycin gel. Systemic antibiotics may be necessary if the lesions become infected. Although the rash is sometimes called acneform, it is not acne, and acne treatments will only irritate it further.
Table 1. Common Side Effects for Oral Cancer Therapies and Key Points
for Patient Education

Side Effect Patient Education

Abnormal values Frequent laboratory tests Replacement of
(e.g., hypokalemia, minerals (may increase nonadherence) Monitor
hypocalcemia, symptoms. Electrocardiograms if needed

Bone marrow Frequent laboratory tests Neutropenic
suppression precautions Bleeding precautions Transfusions
 for anemia

Cutaneous reactions Use of emollients or creams Antibiotic cream
(e.g., rash, or oral steroids Frequent skin checks and
hand-foot syndrome) clinic visits Medication break or dose

Diarrhea Use of loperamide, diphenoxylate hydrochloride
 or atropine sulfate, atropine, or tincture of
 opium Increase fluid intake Bland or BRAT diet
 IV fluid replacement in clinic Perineal and
 rectal hygiene

Hypertension Monitor weekly for six weeks from start of
 symptoms. Teach patients to monitor blood
 pressure at home. Add oral antihypertensive
 (e.g., thiazide diuretic, ACE inhibitor, beta
 blocker, calcium channel blocker).

Nausea and vomiting Prescribe oral antiemetic 30 minutes prior to
 dose. Increase fluids. Monitor patient weight.
 Instruct patients to take medications with

Thrombosis Increase activity. Increase fluid intake.
 Elevate legs. Prescribe low-dose aspirin or
 warfarin. Monitor frequently.

Hand-foot skin reactions such as paresthesia of the fingers, palms, and feet can be treated with over-the-counter salicylic acid or urea-containing lotions. Patients should be checked during clinic visits and be taught to avoid prolonged pressure to the feet and hands and to wear cotton gloves, socks, and appropriate shoes. If hand-foot syndrome develops and becomes severe, dose modification may be necessary.

Myelosuppression: Patients may experience grade 3-4 myelosuppression with some oral agents. They should be educated on normal laboratory values and what it means if they develop neutropenia or thrombocytopenia. For neutropenia, patients should follow precautions such as hand washing and monitoring body temperature; instruct patients to call if their temperature is 100.5[degrees]F or higher. For thrombocytopenia, instruct patients on bleeding precautions and symptoms of anemia (e.g., dizziness, fatigue, shortness of breath, headache, tachycardia).

Monitoring Adherence

Most methods of monitoring patients' adherence to oral agents are unreliable. Patients usually want to demonstrate to the healthcare team that they are being "good patients" and may manipulate pill counts or microelectronic monitoring systems. Monitoring prescription refills is time consuming and costly and may be impossible if patients use more than one pharmacy. Medication diaries can help patients and providers keep track of their pills and side effects, but patients usually need to be highly motivated to use the diary regularly.

Oncology nurses can help prevent patient nonadherence through "frequent patient assessments, careful side-effect management, and [ensuring] access to healthcare providers when patients need them, even when the clinic is closed," Winkeljohn said. Although adherence is far from optimal, the development of programs, instructions, and interventions can help improve outcomes.

For more information about helping patients adhere to oral therapies, refer to the full article by Winkeljohn (2010).

Key Definitions

Hand-foot syndrome: also known as palmer-plantar erythrodysesthesia; early stages present as erythema of the palms and soles, with pain and swelling; later stages can progress to skin fissures or desquamation of the skin

Myelosuppression: decreased bone marrow activity, resulting in fewer red blood cells, white blood cells, and platelets. Neutropenia (i.e., decreased neutrophils [a type of white blood cell]) and thrombocytopenia (i.e., decreased number of platelets) are types of myelosuppression.

Winkeljohn, D. (2010). Adherence to oral cancer therapies: Nursing interventions. Clinical Journal of Oncology Nursing, 14, 461-466. doi: 10.1188/10.CJON.461-466

[By Elisa Becze, BA, ELS, ONS Staff Writer]
COPYRIGHT 2010 Oncology Nursing Society
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2010 Gale, Cengage Learning. All rights reserved.

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Author:Becze, Elisa
Publication:ONS Connect
Geographic Code:1USA
Date:Oct 1, 2010
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