16 American Nurse Today Volume 11, Number 9 AmericanNurseToday.com

FRAN, A TRIAGE NURSE in a busyprimary care office, receives a callfrom Marla Rodriguez, whose moth-er is a long-time patient. Marla saysher mother has an intense red rashover most of her trunk. Fran asksher standard questions based onher triage symptom-managementprotocol for rashes: Does the rashitch? Do you see it anywhere elsebesides the trunk? Do you see pus-tules? How long has your motherhad the rash? Has she started newmedication or used new soaps or lo-tions lately?

Marla replies that her mother juststarted taking a drug called sorafe -nib. Fran accesses Mrs. Rodriguez’sfile in her electronic health record(EHR) and discovers she was recent-ly diagnosed with renal cell carcino-ma and referred to a medical on-cologist. When she asks Marla howlong her mother has been on themedication, Marla says she begantaking it within the last week.

Fran assumes Mrs. Rodriguez isseeing a medical oncologist outsideher facility’s EHR system, as shedoesn’t see notes from an oncologistand Mrs. Rodriguez’s medicationlist isn’t up-to-date. To gain moreinsight into the possible cause of therash, Fran consults scanned docu-ments in her file and finds a letterfrom the medical oncologist sum-marizing her treatment plan andthe side effects of sorafenib, an oralmedication; skin rash is listed as aserious side effect.

In recent years, the Food andDrug Administration has approvedmany new anticancer medicationsthat are taken primarily by mouth.In fact, an estimated 30% of cancerdrugs in development are oral, andthe trend is increasing. Some practitioners tout oral

chemotherapies as more convenientand flexible. But are they really?The change from parenteral to oralcancer medications brings newchallenges. Patients taking oraldrugs may end up being seen bymany different healthcare teammembers, some of whom may beunaware of the possible toxicitiesof these therapies—or even that thepatient’s taking them.

Benefits of oral therapyPatients undergoing treatment for

cancer are living longer, and cancerincreasingly is becoming a chronicillness. Oral chemotherapy has cer-tain obvious benefits. • Patients don’t need to spendhours in a clinic infusion roomreceiving therapy. Patient advo-cates see this as a major quality-of-life improvement because itgives patients more time at homewith their families and doing ac-tivities they enjoy.

• Patients may not need to take as much time off work duringtreatment.

• Patients have more flexibility totravel during treatment.

• Oral therapy eliminates some lo-gistic and financial barriers, suchas transportation to and from I.V.treatment centers and child-careand parking costs. In rural areas,this can be crucial because theclosest treatment center may behours away and weather maycomplicate travel. In urban areas,parking costs can pose a hard-ship to families already strug-gling with high medical costs.

• Oral therapy eliminates the costof I.V. supplies and reducesnursing time in infusion suites.

• Oral therapy nearly eliminatesthe need for venous access andcentral venous access devices,such as peripherally insertedcentral catheters and implantedports—along with the risks andcosts of these devices. Many pa-tients find venous access uncom-

Oral chemotherapy: Not just an ordinary pill

Help your patients achieve optimal benefits from thistherapeutic option.

By Nancy Thompson, MSN, RN, AOCNS, and Amy Christian, MSN, RN, OCN

LEARNING OBJECTIVES

1. Identify the benefits and draw-backs of oral chemotherapy.

2. Discuss nursing interventions re-lated to oral chemotherapy.

3. Describe medication manage-ment of oral chemotherapy.

The authors and planners of this CNE activity havedisclosed no relevant financial relationships withany commercial companies pertaining to thisactivity. See the last page of the article to learnhow to earn CNE credit.

Expiration: 9/1/19

CNE1.1 contact

hours

AmericanNurseToday.com September 2016 American Nurse Today 17

fortable and complain they feellike a pincushion after multipleblood withdrawals and I.V. ses-sions. And central venous accessdevices raise the risk of infectionand bleeding in already im-munocompromised patients,who also may be thrombo -cytopenic.

Drawbacks of oral therapyAlthough most patients appre-ciate the advantages of oral

chemo therapy, the oral routeshifts the burden of proper drugadministration to them and theirfamily. Cancer treatments—includ-ing oral ones—must be given onspecific schedules and may requireeither the presence or absence offood. They may interact with otherdrugs and certain foods and nutri-

Oral chemotherapy may interact with certain drugs, foods, and supplements.Make sure you’re aware of the common interactions below.

Drug interactions • Acid-suppressing drugs, such as proton pump inhibitors• Antibiotics• Anticonvulsants • Antidepressants• Antifungals• Antihypertensives• Coumadin-derived anticoagulants

Food, beverage, and supplement interactions• Alcohol• Calcium• High-fat foods• Grapefruit juice• Lactose or dairy products• Tyramine-rich foods, such as wine, aged cheese, and yogurt • Vitamin and herbal supplements

Common drug and food interactions

Patients, nurses, and healthcare administrators may have misconceptions about oral chemotherapy. Below we separate the mythsfrom the facts.

Myth Fact

Oral chemotherapy is less toxic than Oral chemotherapy can cause just as many dangerous side effects as chemotherapy given by other routes. chemotherapy given by other routes.

Oral chemotherapy is less effective than Oral administration doesn’t make chemotherapy less effective.parenteral chemotherapy.

Oral chemotherapy is more convenient Oral chemotherapy may be less convenient in some ways. Patients (not clinicians) for patients. are responsible for taking drugs, which may have complicated schedules or administration instructions. Also, in some cases, oral chemotherapy is given in combination with parenteral therapy.

All patients prefer oral chemotherapy. Some patients prefer to go to a healthcare facility on a regular schedule for chemotherapy so they don’t have to bother taking it daily.

Asking patients about their medication Studies show patients don’t always tell providers about missed doses or thatadherence is a reliable way to assess adherence. they’ve altered the way they’re taking medications.

Oral chemotherapy requires less nursing and Although oral chemotherapy eliminates nursing time in infusion suites, it may pharmacy time. increase both nursing and pharmacy time for patient education, telephone follow-up, and verifying insurance benefits.

Oral chemotherapy is best for older patients. Older patients may be more forgetful about taking their medications at home and are at greater risk for drug interactions because they typically take multiple drugs in addition to chemotherapy.

Oral chemotherapy is less expensive. Oral chemotherapy can be just as expensive as parenteral chemotherapy and may entail more out-of-pocket expenses for patients.

Myths and facts about oral chemotherapy

18 American Nurse Today Volume 11, Number 9 AmericanNurseToday.com

tional supplements, which can leadto toxicity and inefficacy. (SeeCommon drug and food interac-tions.) Also, some patients on oralchemotherapy complain they feelless supported because they’re notseeing healthcare providers regular-ly to help them manage treatmentand toxicities. Patient adherence can be a con-

cern for providers, who are accus-tomed to knowing exactly whichdrugs their patients have receivedbecause they receive them in aclinic or hospital. Providers mayfind patients don’t always take theirmedications as ordered, with signif-icant ramifications for treatment anddisease outcomes. What’s more, some patients may

decide not to take prescribed thera-pies because they can’t afford them.Or they may forget to take them ormay stop taking them when toxici-ties set in. Some healthcare administrators

mistakenly believe oral cancer ther-apies require less nursing staff. (SeeMyths and facts about oral chemo -therapy.) But experience showsoral chemotherapy requires signifi-cant nursing time for patient educa-tion and telephone consultations.For clinic nurses, determining pa-tients’ insurance coverage, estimat-ing patient costs, and accessingavailable financial assistance pro-grams can be time consuming. (SeeCost considerations.)

Multidisciplinary approachSupporting patients who take oral

chemotherapy at home re-quires a team approachinvolving physicians,nurses, pharmacists, fi-nancial counselors, andother professionals. Manycancer patients have co-morbidities, which increases

the need for a multidisciplinaryapproach. This underscores the importance

of all healthcare team members toidentify themselves in the EHR and

document their care thoroughly, tomake sure everyone knows the pa-tient is receiving oral chemotherapy.Before treating chemotherapy sideeffects, they should refer patients totheir oncology provider or consultwith the oncology team. Cliniciansshould encourage patients receivingoral therapies to contact their pre-scriber’s office to manage side ef-fects. To help prevent drug-drugand drug-food interactions, medica-tion errors, and untoward effects,all team members must be keptcurrent on what drugs the patient’staking.

Mrs. Rodriguez has comorbidhypertension and hyper cholesterol -emia. Her renal cell carcinoma re-quired resection of one kidney,so she’s being followed byher urologist. The oncol-ogist’s summary of hertreatment plan, whichFran found in her file,notes that she’s takingsorafenib at home andlists its potential side effects.So when Fran receives her daugh-ter’s call, she knows to refer Mrs.Rodriguez urgently to her oncolo-gist, who admits her to the intensivecare unit to rule out Stevens-John-son syndrome, a life-threateningskin condition resulting from anallergic drug reaction. The treat-ment summary proves essential inhelping Fran grasp the seriousnessof the patient’s rash—and this en-abled her to intervene quickly andappropriately.

But keeping multidisciplinaryteam members informed isn’tenough. The patient’s family andpersonal caregivers also need to beengaged. With oral chemotherapy,the responsibility of ensuring the“five rights” of medication adminis-tration no longer belongs to thecare team in the I.V. infusion unit.This responsibility shifts to the pa-tient and home caregivers. The emotional burden of caring

for a loved one with cancer can beoverwhelming. Errors can resultfrom family members’ confusion orpoor understanding of the correctdosage, dosing schedule, drug orfood interactions, and how to han-dle and store these potentially haz-ardous medications. Building strong, supportive rela-tionships with patients is vital toensuring they communicatewith the healthcare team.Some patients with side ef-fects or other concerns abouttherapy may minimize them ordecide not to “bother” clinicians

about them. Or they may fear thatif they admit they’re having side ef-fects, their dosage may be de-creased, which could prevent themfrom achieving therapeutic goals.

Assessing patients before oralchemotherapy The success of a patient’s oralchemotherapy depends on regularcomprehensive reviews of bodysystems and side effects throughouttreatment. When care providershave a good rapport with patients,

Oral chemotherapy agents are among the most expensive new drugs on the mar-ket. Of the 12 drugs approved by the Food and Drug Administration for variouscancer conditions in 2012, 11 cost more than $100,000 for 1 year of treatment. After just one or two treatment cycles, some Medicare patients may reach theirMedicare Part D coverage gap (“donut hole”) and may have to pay more towardmedication costs until they qualify for catastrophic coverage.

Although most major pharmaceutical firms provide co-pay assistance and re-sources to help patients obtain insurance approval, Medicare patients are prohib-ited from accepting such assistance. To address this issue, independent charitableco-pay foundations have been established to provide grants to patients unable toafford their out-of-pocket co-pays.

Cost considerations

AmericanNurseToday.com September 2016 American Nurse Today 19

these reviews can be extremelysuccessful in detecting and manag-ing side effects.Before patients start oral treat-

ment at home, assess them to de-termine if they’re good candi-dates—physically and mentally—fororal administration. Patients should:• be able to swallow and digestoral medication

• understand the importance ofadhering to the drug regimen

• have adequate home supervisionto help them adhere to the med-ication schedule. Metastatic brain disease, forget-

fulness, advanced age, or a historyof alcohol abuse or mental illnesscould interfere with the patient’sability to adhere to the regimen. Also review the patient’s history for

polypharmacy and comorbidities,and determine if the patient’s symp-toms are adequately controlled.

Patient educationBefore the patient begins chem -otherapy, provide education usingthe teach-back method by havingthe patient verbally repeat whatyou’ve taught. After assess-ing the patient’s readinglevel and ability to un-derstand complex in-structions, provide easy-to-understand writtenteaching material. Informpatients what to do if theymiss a dose; caution them not todouble up on doses. Also, checkwith the pharmacy on proper med-ication storage, and convey this in-

formation to the patient. (SeeTeaching patients about oralchemotherapy.)

Medication adherence andpersistence Medication adherence refers to theextent to which the patient takesmedication in accordance with theprescribed interval and dose of adosing regimen. Medication persist-ence is the duration from the pa-tient’s drug initiation to discontinua-tion. Both are important in oralchemotherapy.Nonadherence can mean missing

doses or taking them in the wrongamount, at the wrong time, or inthe wrong way (such as with foodif they should be taken on an emp-ty stomach). Adherence issuesaren’t new—or unique to cancerpatients. For years, primary careproviders have dealt with nonad-herent patients with chronic dis-eases, such as hypertension andasthma. In 2003, the World HealthOrganization recognized nonadher-ence as an issue of striking magni-tude and predicted it would onlyget worse as chronic diseases in-crease in our aging population. Dr.C. Everett Koop, former U.S. sur-geon general, pointed out, “Drugsdon’t work in people who don’ttake them.” Cancer care providers may as-

sume that because cancer is a fright-ening disease, patients will showgreater medication adherence andpersistence than patients with otherdiseases. But this assumption isfalse. A study of patients taking

oral tamoxifen for breast can-cer found that 80% initiallyfilled their prescriptionsbut by the fourth year, on-ly 50% were filling them.So although medicationadherence and persistencewith cancer regimens may be

better than with other disease regi-mens, they remain a significant chal-lenge. (See Helping patients adhereto medication regimens.)

If your patient’s taking oral chemotherapy at home, be sure to cover the pointsbelow.

Handling, storing, and discarding medications• Wear disposable gloves when handling medications.• Wash your hands before and after taking medications and after removing

gloves.• Don’t share these (or other) medications with others.• Don’t handle these medications if you’re pregnant or lactating.• Store chemotherapy drugs separately from other drugs to prevent cross-cont-

amination. Unless instructed otherwise, store them in a cool, dry place.• Return unused medication to the pharmacy for proper disposal. Don’t throw it

in the trash or flush it down the toilet (it can contaminate waste water).

Exposure precautions• Know that exposure to drug-contaminated linens and soiled clothing can be

hazardous. Wash soiled linens separately, putting them through two washing-machine cycles.

• Chemotherapy drugs are excreted in body fluids, such as urine, stool, saliva,and sweat, as well as semen and vaginal secretions. To decrease drug exposureto family members, flush the toilet with the lid down; men should urinate sit-ting down.

• Use barrier contraceptive methods. • Know that sharing food, kissing, cuddling, and hugging are safe and don’t

pose a risk.

Taking medication as prescribed• Take the medication at the same time every day, exactly as instructed.• Ask your healthcare provider if you should take the drug on an empty stom-

ach or with food.• Don’t split, cut, or crush tablets because this could cause them to aerosolize.

If tablets need to be split, cut, or crushed, the pharmacy should do it.

Teaching patients about oralchemotherapy

20 American Nurse Today Volume 11, Number 9 AmericanNurseToday.com

Why some patients don’t taketheir medicationsMany theories address why somepatients don’t take prescribed med-ications. Generally, the more com-plex the regimen (including food restrictions, frequent doses, anddosage days that lack an easy-to-remember pattern), the more likelythat errors will occur. Also, the moremedications the patient takes, themore likely some doses will bemissed. And the more side effects adrug has (either anticipated or expe-rienced), the less likely the patient is to take the full dose on schedule. Patients receiving cancer therapy

generally feel better before theystart it, but once they begin theregimen and continue to take it,they experience more side effects,including nausea, skin reactions,and fatigue. When they’re in con-trol of their regimen (as with homeoral chemotherapy), they maychoose to withhold doses as toxici-ties increase. In our case scenario,if Mrs. Rodriguez had simplystopped taking sorafenib and wait-ed for the rash to disappear with-out calling the physician, shewould have received suboptimaltreatment and might have had apoor outcome. Patients have many reasons for

not calling their physician. Theymight assume clinic staff are toobusy to talk to them, reaching anurse is too difficult, or their sideeffect is an expected one that theyjust need to “tough out.” To helppatients manage side effects, urgethem to call their oncologist’s office

(after hours, if necessary) to reportfever, chills, uncontrolled diarrhea,nausea, and vomiting. (See Indica-tions and side effects of common oralchemotherapy drugs at AmericanNurseToday.com/?p=24100.) Many tips and tools have been

created to improve adherence, butfew have been studied to deter-mine their success. The most ef-fective evidence-basedmethod is for the health-care team to develop astrong relationship withthe patient. In today’sbusy clinics, healthcareprofessionals may thinkthey don’t have time to builda rapport with patients. Yet doingso can be crucial to achieving suc-cess with oral chemotherapy, man-aging side effects, and obtainingthe best patient outcomes.

Oral chemotherapy safeguards:An emerging needErrors associated with chemotherapyhave long been a serious concern,prompting healthcare providers todevelop a system of checks andbalances to prevent dangerousdosages from reaching patients.Oral chemotherapy bypasses manyof those checks, underscoring theneed to design and implement newsafeguards. For instance, for oralchemotherapy drugs, standardizedorder sets may not exist and dosagecalculations may not be double-checked. Recently, many clinicshave developed formalized process-es for monitoring and documentingpatients’ medication adherence.

Other concernsLocal pharmacists may be unfamil-iar with oral chemotherapy andtheir dosing schedules. Also, over-whelmed patients may not com-pletely understand all of the in-structions provided. What’s more,some EHR systems don’t includedocumentation tools that carefullyfollow oral chemotherapy dosing.In some cases, nurses have had tocreate their own paper trackingtools to remind them which pa-tients are taking oral chemotherapyand which ones to follow up with.In addition, patient informed

consent is just as important for oralche motherapy as for parental che -mo therapy. Make sure patients un-derstand that an oral chemotherapydrug is just as potent as any otherdrug and carries certain risks.

Nursing’s crucial role With more patients nowusing oral chemothera-py, all healthcare teammembers must stay in-formed about patients onthese regimens. The nurse’s

role in patient education, care co-ordination, and follow-up takes oneven greater importance for pa-tients who take these potent andpotentially dangerous drugs athome. Empower patients to speakup and tell all of their healthcareproviders they are receiving oralchemotherapy. By working withother disciplines as a coordinatedhealthcare team and developingopen, honest communication withpatients and their caregivers, nurs-es can help ensure safe, effectivetreatment.

Nancy Thompson is the director of quality andclinical practice at the Swedish Cancer Institute inSeattle, Washington. Amy Christian is a managerat the Swedish Cancer Institute in Issaquah,Washington.

Visit AmericanNurseToday.com/?p=24100 fora list of selected references and a chart on in-dications and side effects of common oralchemotherapy drugs.

The following resources and tools can help patients adhere to oral chemotherapy:

• patient education handouts from drug manufacturers

• treatment calendars for assistance with dosing schedules

• pillboxes to promote proper dosing schedules

• electronic reminders, such as cellphones, alarm clocks, and smartphone apps

• trusted websites (such as chemocare.com) that provide education, includinghow to manage side effects, eat well during chemotherapy, and understandblood counts.

Helping patients adhere to medication regimens

AmericanNurseToday.com September 2016 American Nurse Today 21

Please mark the correct answer online.

1. Which of the following statementsabout the benefits of oral chemotherapy isnot correct?

a. It eliminates some logistic barriers.b. Patients may not need to take off asmuch time from work.

c. Patients have more flexibility to travelduring treatment.

d. It lessens patients’ burden of properdrug administration.

2. A common source of food or beverageinteraction with oral chemotherapymedications is:

a. orange juice.b. a low-fat food.c. any green vegetable.d. alcohol.

3. Which of the following statementsabout oral chemotherapy is correct?

a. It is less toxic than chemotherapy givenby other routes.

b. It may increase nursing time.c. It is less effective than parenteralchemotherapy.

d. It requires less pharmacy time.

4. Which of the following statementsabout patient selection for oralchemotherapy is correct?

a. Older patients may have more problemsadhering to oral chemotherapy if they’retaking multiple medications.

b. Older patients and those who are frailare ideal candidates for oral chemo -therapy because it causes less stress.

c. Nearly all patients prefer oralchemotherapy when given the choice.

d. Oral chemotherapy is more convenientfor patients.

5. Which statement about costs and oralchemotherapy is correct?

a. Oral chemotherapy medications areamong the least expensive new drugson the market.

b. Oral chemotherapy medications are lessexpensive than chemotherapy deliveredparenterally.

c. Some Medicare patients may reach theirMedicare Part D coverage gap after justone or two treatment cycles.

d. Medicare patients typically don’t reachtheir Medicare Part D coverage gap untilafter four to five treatment cycles.

6. Which of the following patients may bea good candidate for oral chemotherapy?

a. A man with pancreatic cancer who hasmetastatic brain disease

b. A man with gastric cancer who has ahistory of alcohol abuse

c. A woman with lung cancer who adhereswell to her medication regimen

d. A woman with breast cancer who is frailand doesn’t have caregivers

7. Patient education regarding disposal ofunused oral chemotherapy medicationsshould include instructions to:

a. put them in the recycling bin. b. throw them in the trash. c. flush them down the toilet.d. return them to the pharmacy.

8. Patient education regarding safehandling of oral chemotherapy shouldinclude instructions to:

a. proceed with handling the drugs evenwhen pregnant.

b. avoid wearing gloves when handlingthese drugs.

c. store chemotherapy drugs separatelyfrom other drugs.

d. store all drugs in one location topromote medication adherence.

9. Patient education regarding oralchemotherapy should include theinstruction to:

a. crush tablets to make them easier totake.

b. take the medication at the same timeevery day.

c. take the tablet with milk. d. take an extra dose if you’ve missed adose.

10. Patient education related to exposure tooral chemotherapy should include which ofthe following?

a. Postmenopausal women don’t need touse contraception.

b. Kissing poses a risk for exposure.c. Wash soiled linens separately, using twowashing-machine cycles.

d. Men should stand up when they urinate.

11. Which statement about medicationadherence and persistence is accurate?

a. Pillboxes typically aren’t useful in helpingpatients take oral chemotherapymedications as prescribed.

b. Patients with cancer are more likely totake their oral chemotherapy drugs asinstructed.

c. Medication adherence refers to theduration from the patient’s druginitiation to discontinuation.

d. Medication persistence refers to theduration from the patient’s druginitiation to discontinuation.

12. A common side effect of capecitabine is: a. hand-foot syndrome.b. pulmonary embolism.c. hypokalemia.d. vaginal discharge.

13. A common side effect of tamoxifen is: a. hand-foot syndrome.b. pulmonary embolism.c. hypokalemia.d. vaginal discharge.

POST-TEST • Oral chemotherapy: Not just an ordinary pill Earn contact hour credit online at http://www.americannursetoday.com/continuing-education/

Provider accreditationThe American Nurses Association’s Center for Continuing Edu-cation and Professional Development is accredited as aprovider of continuing nursing education by the AmericanNurses Credentialing Center’s Commission on Accreditation.ANCC Provider Number 0023.

Contact hours: 1.1

ANA’s Center for Continuing Education and Professional Devel-opment is approved by the California Board of Registered Nurs-ing, Provider Number CEP6178 for 1.4 contact hours.

Post-test passing score is 80%. Expiration: 9/1/19

ANA Center for Continuing Education and Professional Devel-opment’s accredited provider status refers only to CNE activi-ties and does not imply that there is real or implied endorse-ment of any product, service, or company referred to in thisactivity nor of any company subsidizing costs related to the activity. The authors and planners of this CNE activity have dis-closed no relevant financial relationships with any commercialcompanies pertaining to this CNE. See the banner at the top ofthis page to learn how to earn CNE credit.

CNE: 1.1 contact hours

CNE

This chart lists common indications and side effects of selected oral chemotherapy drugs.

Generic name Brand name Common indications Common side effects

Abiraterone Zytiga® Prostate cancer • Arthralgia • Fluid retention • Hypokalemia • Myalgia

Capecitabine Xeloda® Colorectal and breast cancer • Diarrhea • Hand-foot syndrome • Nausea and vomiting • Neutropenia • Stomatitis

Everolimus Afinitor® Breast, renal, and pancreatic cancer • Infection • Hyperglycemia • Stomatitis

Ibrutinib Imbruvica® Chronic lymphocytic leukemia • Anemia • Diarrhea • Neutropenia • Thrombocytopenia

Imatinib mesylate Gleevec® Chronic myeloid leukemia, • Diarrhea myelodysplastic syndrome, acute • Fluid retention lymphoblastic leukemia • Nausea and vomiting • Neutropenia • Thrombocytopenia

Lenalidomide Revlimid® Multiple myeloma • Fatigue • Itching • Rash • Neutropenia • Thrombocytopenia

Palbociclib Ibrance® Breast cancer • Fatigue • Neutropenia • Pulmonary embolism

Sorafenib Nexavar® Liver, renal, and thyroid cancer • Erythema • Hand-foot syndrome • Hypertension • Rash

Tamoxifen Nolvadex® Breast cancer • Bone pain • Hot flashes • Thromboembolism • Vaginal discharge

Temozolomide Temodar® Brain cancer • Leukopenia • Nausea and vomiting • Thrombocytopenia

Indications and side effects of common oral chemotherapy drugs

Online Sidebar