ABSTRACT: Oncology nurses play a pivotal role in educating the cancer patient who is about to commence oral chemotherapy. Increasing numbers of patients are receiving oral chemotherapy at home, and with this move to oral self-administration, there has been a critical shift in responsibility of management from the provider to patient. Oral regimens pose new challenges in patient selection and education. Recognition of factors that affect patient compliance will be particularly important with oral chemotherapy. Strategy tools for the patient and provider will need to be developed to ensure optimal compliance and safety. [ONCOLOGY 15(Suppl 2):37-40, 2001]
Introduction
Nurses have always played a key role in the education and symptom management of patients undergoing chemotherapy. Now, with increasing numbers of patients self-administering oral chemotherapy at home, the support of the oncology nurse will be central to the effective management of these patients.
Patients often think of chemotherapy in terms of needles and intravenous lines, and there appears to be a wishful, but unfortunately false, perception that oral chemotherapy is going to be essentially nontoxic. Patients are inclined to think of it as the "cancer pill" and assume it will be similar to taking a vitamin or some over-the-counter headache remedy. Unfortunately, although the side-effect profiles of many oral chemotherapy agents are relatively favorable, serious systemic side effects can still occur, making early recognition with prompt intervention critical.
It is imperative that oncology nurses become familiar with new oral cytotoxic agents, such as the fluorinated pyrimidine analogues capecitabine(Drug information on capecitabine) (Xeloda) and UFT (Orzel [uracil, tegafur(Drug information on tegafur)]). The primary focus must be to develop educational strategies to ensure patient understanding of medication administration, potential side effects, and self-care measures. This article will outline the active role that nurses must play in the management of patients who are self-administering oral chemotherapy.
Patient Selection
Appropriate patient selection is central to the successful and safe administration of any chemotherapy. In this area, oral regimens pose new challenges to patients and providers. Oncology nurses can play an active role in the identification of appropriately motivated patients for these self-administered therapies.
Compliance
To a large degree, an appropriate patient can be defined as a patient who is likely to exhibit adequate compliance. Compliance is reflected in many aspects of patient behavior over and above compliance with the dose and schedule. Compliant patients are responsible about keeping their scheduled appointments and are able to accurately answer questions regarding symptoms and side effects. These are patients who call when they suspect something is wrong, and who go to the doctor’s office or the emergency room when they have a fever.
With oral chemotherapy, "good patient behavior" takes on a new dimension. These patients still need to keep their scheduled visits, but they may need to contact the physician or nurse sooner when side effects (that may possibly warrant a treatment break) develop at home. If side effects are left unreported, necessary dose adjustments may not be made, and serious consequences can occur that can impact their life and further therapy.
Factors Influencing Patient ComplianceOncology nurses who are involved with patients taking oral chemotherapy must understand what factors affect compliance and how identification of these factors can aid in the development of educational strategies that will help assure patient compliance. Cameron[1] has identified several specific factors involved in promoting compliance with a therapeutic regimen. These and other factors are outlined in Table 1.
Compliance is affected by the patient’s knowledge and understanding of the specific regimen. The information must be perceived correctly, and to that effect, educational materials must be at an appropriate level of understanding for patient comprehension.
The quality of the patient-provider relationship also can profoundly affect compliance. The patient needs to feel comfortable with his or her physician or nurse in asking questions and reporting side effects. A patient’s support system—including family, friends, or home care nurses—also greatly influences the likelihood of compliance with therapeutic regimens. Is there someone to remind the patient to take his or her medication? Are caregivers in the home aware that they need to notice and inquire about side effects or clinical changes?
Compliance will also be influenced by each patient’s pre-existing beliefs and attitudes about health, disease, and medical treatments. These can affect not only how the patient follows his or her drug schedule, but also what he or she is willing to report or discuss regarding complications and side effects.
Compliance may be variable over time, with motivation and actual compliance potentially diminishing with the increasing duration of a patient’s illness. The complexity of the regimen will also affect the patient’s ability to comply.
Additional Factors in Patient Selection
Other factors in patient selection must include a patient’s physical limitations, especially in elderly patients. These limitations might include limited sight and limited manual dexterity in handling pills. Also, older patients are more likely to be taking multiple oral medications, and the addition of oral chemotherapy to this patient’s regimen may not be feasible, either due to the increased complexity or potential drug interactions.
A last consideration in patient selection is simply the patient’s ability to tolerate an oral medication. One must evaluate whether or not a patient is able to swallow pills and whether there is adequate gut function and absorption.
Who Monitors the Treatment?
Self-administered oral chemotherapy greatly shifts responsibility for dose monitoring and adjustments from the provider to the patient. There are many favorable aspects to this degree of patient empowerment, but there are also potential dangers.
In traditional parenteral chemotherapy, the healthcare provider has far greater control of dose and dose adjustments. The physician and nurse determine the presence or absence of side effects at office visits, and make judgments about dose adjustments. With oral chemotherapy, the patient—to some degree—is responsible for making dose adjustments in his or her own therapy; eg, the patient must decide whether to continue taking medication in the face of mild to moderate side effects. Perhaps more importantly, the patient must decide whether to withhold medication in the presence of more severe side effects, not knowing that failure to do so could result in substantial, and even life-threatening, toxicities. The important thing is to stress to the patient that it is important to call his/her physician or nurse at any sign of a symptom or side effect.
The Role of the Oncology Nurse
As educators, it will be a challenge to oncology nurses to provide the training and support to ensure the safety of patients taking on the responsibility of taking oral chemotherapy at home. The oncology nurse’s responsibilities include patient education, symptom management, and proactive follow-up.
First and foremost, patients need to know the correct dose and administration schedule.
Next, the toxicity profile of the oral agent needs to be discussed. Finally, the importance of early recognition of side effects and prompt reporting need to be stressed.
Patients are often reluctant to notify the nurse of side effects because they fear that their therapy may be interrupted or their dose will be lowered.
Patients will be helped if they can understand the importance of early reporting. This can be remedied by simply explaining to patients that
1. Most side effects resolve with a brief interruption of therapy.
2. Any necessary dose reduction is simply a customization of dose to that individual’s needs.
3. A dose reduction does not necessarily lessen the chance of antitumor effects.
