Take Your Medicine

Author: Harold J. Burstein MD, PhD
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Drugs remain at the heart of medical interventions for most cancers, and the armamentarium expands each year. This issue of JNCCN Special Edition: NCCN Oncology Pharmacy & Policy advances many important discussions on new trends in pharmacological therapy for cancer patients. The rapid development of novel agents in oncology, agents that are often complex biological compounds and that are often extraordinarily expensive, underscores the need for evolving pharmacy policy in oncology care. That the years to come will see greater consideration of the costs of acquiring and delivering cancer drugs in the discussions of how best to use new treatments seems inevitable. This dialogue will require a far more sophisticated understanding of the definitions of and rules concerning generics and bio-generics, as well as an appreciation for the various layers of cost required in supportive care and treatment delivery for oncology products. The oncology pharmacist will have a critical role in explaining these issues to oncologists and patients alike.

Meanwhile, oncologists need pharmacy and nursing colleagues to assist with a different task: asking patients if they are taking their medicines.

A large and growing body of literature points to high rates of noncompliance or nonadherence with medications among oncology patients. These studies typically show that between a quarter and a third of patients take substantially less than the recommended dosing of oral medications. This is a startling percentage. Of course, a few caveats are warranted. The bulk of these reports are derived from studies of women taking adjuvant therapy for hormone receptor-positive breast cancer. Such patients often have a favorable prognosis and might reasonably be expected to have different degrees of commitment to their therapy than, say, a patient with leukemia who is prescribed imatinib. Furthermore, these percentages are likely not to be unique to oncology patients—similar findings are seen in chronic administration of almost any therapy including anti-hypertensives, anti-glycemics, and other drugs with long-term use requirements.

We know some predictors of compliance with oral medication, including treatment-related side effects (more side effects means less compliance), convenience, access to medications, patients' socioeconomic status, patient age, and drug costs. A recent report on the use of adjuvant endocrine agents in breast cancer found that out-of-pocket expenses on the order of an additional $1 per day dropped treatment adherence by 30%. This observation reflects the vast gulf between real-world pricing and the invisible pricing of most oncology drugs. Even for well-tolerated, effective treatments, $1 per day radically changes patient behavior, a threshold hugely below the cost of most new biologic agents. Aside from cost, how many other factors can be easily modified by the care team remain to be determined.

One thing the team can easily do, however, is simply ask, “Are you taking your medicines?” We need to be far more vigorous about asking patients this question. Further, because patients often tell doctors what they think the doctor wants to hear, pharmacists and nurses might get more honest answers. A gentle but persistent inquiry of patients—“How are you doing on the medicine? Are you taking the pills most of the time? Do you have questions about how to take them?”—would be a simple, cheap, and timely way to see what is happening in the real world of daily life, would be an immense contribution to the care of many patients, and would likely start a dialogue that would be helpful to all.

Harold J. Burstein, MD, PhD, editor-in-chief of JNCCN, is an Associate Professor of Medicine at Harvard Medical School and a medical oncologist at Dana-Farber Cancer Institute and Brigham & Women's Hospital. He is a clinician and clinical investigator specializing in breast cancer.

Dr. Burstein attended Harvard College and earned his MD at Harvard Medical School, where he also earned a PhD in immunology. He trained in internal medicine at Massachusetts General Hospital and was a fellow in medical oncology at Dana-Farber before joining the staff.

Dr. Burstein's clinical research interests include novel treatments for early- and advanced-stage breast cancer and studies of quality of life and health behavior among women with breast cancer. He has written widely on breast cancer in both traditional medical journals and on the web, including New England Journal of Medicine and Journal of Clinical Oncology. International committees focusing on cancer treatments that he has or continues to participate in include the NCCN Clinical Practice Guidelines Breast Cancer Panel, St. Gallen Breast Cancer Panel, CALGB Breast Cancer Committee, ASCO Health Services Research and Clinical Research Committees, the National Quality Forum Breast Cancer Technical Panel, and other ASCO expert panels. The ideas and viewpoints expressed in this editorial are those of the author and do not necessarily represent any policy, position, or program of the NCCN.

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