The effectiveness of therapeutic patient education on adherence to oral anti-cancer medicines in adult cancer patients 18 years and older in an ambulatory care setting: a systematic review protocol

Review question In adult cancer patients, 18 years and older, what is the effectiveness of therapeutic patient education on adherence to oral anti-cancer medicines (OAMs) in an ambulatory care setting? Background The International Agency for Research on Cancer (IARC), estimates that there will be 14.1 million new cancer cases each year worldwide.1 The United States (US) anticipates that 1.7 million new cancer cases will occur in 2014.2 The management of patients with cancer has expanded from traditional surgical intervention, radiation therapy and conventional intravenous chemotherapy agents to include innovative oral anti-cancer medicine (OAM).3 Oral anti-cancer medicine are drugs that have direct anti-tumor activity including cytotoxic agents or targeted therapies.3, 4 The development of OAMs in 1953 has made it possible for cancer patients to receive oral agents instead of invasive intravenous chemotherapy.5, 6 The number of adult patients with cancer receiving OAM treatments have grown in the last decade.3, 4, 7 “Approximately 25-30% of the oncology drug pipeline involves oral agents and there are now over 50 OAMs approved by the Food and Drug Administration.”8(p.231) Cost-effectiveness, patient preference, patient convenience, responsibility of self-management of medication administration, and the less invasive medication option are factors in favor of OAM treatment.3, 5–7, 9, 10 In the ambulatory care setting, which includes outpatient clinics, community health centers, group practices and primary care practices,11 the oncology practitioner can prescribe an OAM after a comprehensive assessment and patient examination.11,12 Patient understanding of OAM treatment will be essential to promote patient safety and adherence to the prescribed regimen.3 Opportunities for educating patients about dosage, medication scheduling, adherence and side effects can support optimal use of OAM therapy.12 A “one-size fits all” approach to educating patients on OAMs can be harmfulandeducation should be tailored for each individual patient to ensure appropriate and patient-specific information is provided regarding OAM treatment and adherence.3,5–7,12 The World Health Organization (WHO) defines adherence as the extent to which a person's behavior corresponds with a healthcare professional's agreed recommendations.13 The patient's values, lifestyle and beliefs should be aligned with the healthcare provider's advice and opinion to promote medication adherence. Patients with cancer who are receiving OAMs require them on a continual basis without any interruption to maximize their effectiveness in targeting the cancer cells.14 Currently, there is no gold standard method to measure adherence.15,16 Estimates of adherence to long-term OAM regimens range from 17% to 80%.17 Patient adherence to an OAM is key to resolving symptoms, enhancing treatment efficacy, improving quality of life and overall survival.14 The impact of patient non-adherence to OAMs can result in increased utilization of health care services, rising health care costs and poor health outcomes.8, 17 Poor adherence to OAMs can involve the patient's understanding of their diagnosis and how OAMs can improve their prognosis.18 A multitude of factors including psychosocial and socioeconomic factors, medication cost, complicated dosing schedules, drug-drug interactions, food-drug interactions, adverse effects, inconsistent patient follow up, inadequate educational information and medication accessibility can influence patient adherence to OAMs.8, 19 Non-adherence to OAMs may decrease the effectiveness of the patient's cancer treatment.20 Understanding factors that contribute to poor adherence of OAMs are essential to improve health behaviors.21 Health care professionals will need effective and sustainable measures to monitor patient adherence to OAMs, however establishing practical methods for measuring OAM adherence is not an easy task when the patient is self-administering medications at home.8,13,19,22 Patient's self-reporting of issues surrounding medication adherence can be ascertained through interview and diaries to provide insight into patient-perceived barriers.23,24 A short tool such as the Medication Adherence Questionnaire (MAQ)is a simple scale to administer and score; it is validated in many patient populations, and is a good tool to assess adherence in patients with cancer in an ambulatory care setting.22 Other valid and reliable instruments that assess medication adherence are the Morisky Medication Assessment Scale, the Medication Adherence Self-Efficacy Scale (MASES), the Medication Adherence Report Scale (MARS), and the Beliefs about Medicine Questionnaire (BMQ), Brief Illness Perception Questionnaire(IPQ).23,24 Pill counts, pharmacy refill records and medication event monitoring systems (MEMs) are objective methods to measure patients’ adherence to OAMs.24 Fewer than 50% of patients who receive routine education correctly follow treatment instructions because instructions tell patients what to do without knowing what is relevant to their learning needs.25 Routine patient education is a process for healthcare professionals to communicate information to the patient verbally or in writing, that may alter one's health behaviors or improve health status.25 Patients with cancer receiving routine education in the ambulatory care setting may not have continual monitoring by the health care professional. Lack of consistency in monitoring patients may not ensure a change in knowledge, health behavior or possible improvement to medication adherence.25 Routine education may not provide enough specific, comprehensive patient oriented information, focused on motivation and a change in behavior to make a difference in patients at risk for poor adherence to OAMs.25,26 According to the WHO, the evolution of innovative changes for educating patients with a chronic disease such as cancer is to transition from routine patient education to a therapeutic patient education approach.27 Therapeutic patient education is defined as a coordinated set of educational activities proposed by the healthcare team that involve other professionals, the patient and family members.27 Therapeutic educational interventions are multidimensional strategies that can guide clinical decisions; align patient beliefs to promote self-management skills and medication adherence therefore reducing treatment complications.28-31 The implementation of therapeutic education strategies can be achieved with the use of teaching tools. The Multinational Association of Supportive Care in Cancer (MASCC) is a simple, therapeutic and comprehensive standardized tool developed for health care providers to educate cancer patients receiving OAMs.32, 33 The tool is well known worldwide and is available in several languages.32, 33 Additional therapeutic patient educational approaches are the B-SMART model and ACE-ME model.34-36 These models contain teaching tools and activities related to assessment, collaboration, education, monitoring and evaluation of patient's medication adherence.34-36 The patient with cancer can collaborate and partner with trained healthcare professionals to acquire knowledge, skills, and ownership for their disease, that may improve OAM adherence and their quality of life.30-37 In the ambulatory care setting, patients receiving OAMs may be supported by behavioral strategies that can sustain motivation, promote self-management and encourage adherence in their everyday life38. Therapeutic patient education using evidence-based educational resources, weekly follow-up, telephone communication, drug package reminders and calendars is one strategy that may be used to guide patients.27,31–39 Initiation and reinforcing of information can promote understanding of the drug's purpose, side effects and the need for continued adherence, taking into account that transitions and changes can occur in patients’ lives.27,32–38 The challenge for adherence is to ensure that patients are well informed, supported and capable of managing their OAMs as prescribed. The utilization of simple and cost effective therapeutic patient educational tools may improve OAM adherence in adult patients with cancer in an ambulatory care setting when the education provided encourages knowledge enhancement and motivates patients to assume a certain level of responsibility for their own health care. No systematic reviews were found on the effectiveness of utilizing therapeutic patient education to improve adherence of OAMs in adult cancer patients during the preliminary search of CINAHL, PubMed, The Cochrane Library, Google Scholar and The JBI Database of Systematic Reviews and Implementation Reports. A systematic review on OAM treatment adherence in adult cancer patients and the use of therapeutic education would efficiently integrate existing evidence and provide data for rational decision making in patients with cancer in an ambulatory care setting.