“[Nonadherence] it’s a nursing problem, “said Jakel,” find out which patients think they are taking their own [medications] correctly [can still be mistaken]. … Try to help patients ensure that all medications, especially oral medications, are taken correctly. It really has an impact on overall life expectancy. “
In his presentation to 4th year School of Nursing Oncology on the management of systemic toxicity in breast cancer, Jakel, an advanced practice nurse at the University of California, Los Angeles (UCLA) Santa Monica Medical Center, associate professor of nursing care with the UCLA School of Nursing, a patient with breast cancer herself and chief co – director of Cancer nursing news, discussed the best supportive therapy strategies that should accompany breast cancer therapy.
Adherence rates to drugs for breast cancer patients range from 15% to 87%, with an average of 50%. Poor adherence associated with patients over 65 years of age, non-cancer prescriptions, drug interactions of polypharmacy and high copayment were found. Poor adherence to medications, whether due to adverse events or confusion about how to take these medications, can lead to worse patient outcomes such as disease progression, development of resistance to certain medications, and even death.
Numerous therapeutic agents are currently available for patients with estrogen receptor (ER) positive breast cancer, including selective ER response modulators such as tamoxifen (Soltamox), toremifene (Fareston) and raloxifene (Evista); Luteinizing hormone releasing agents for ovarian suppression such as goserelin (Zoladex), leuporolide (Lupron) and triptorelin (Triptodur); aromatase inhibitors (AI) such as anastrozole (Arimidex), exemestane (Aromasin) and letrozole (Femara); and ER-regulators as fulvestrant. The adverse events that accompany these endocrine therapies can lead to therapeutic non-adherence, according to Jakel.
In addition to pain in the joints and bones, other known adverse events include hot flashes, menopause symptoms, loss of libido, blood clots and osteoporosis and may contribute to the reduction of long-term adherence to oral endocrine therapies. This non-adherence problem can affect between 30% and 80% of patients, particularly those who have received these therapies for at least 5 years.
“[One patient] stopped [treatment of her AI] because of bone pain, “explained Jakel. “We tend not to think about it … but probably about 40% of patients have quite severe bone pain which makes it difficult to get up from the couch.”
Patients who are given CDK4 / 6 inhibitors also tend to experience adverse events such as diarrhea, although this can be managed through other agents such as loperamide hydrochloride (Diamode) and octreotide (Sandostatin), which are likely to be effective. That said, agents such as amifostine (ethylol) and neomycin (Neo-rx) have been seen to balance the benefits with the harms.
Jakel also said that encouraging a BRAT diet – bananas, rice, apple sauce, toast – in patients with diarrhea is another expert opinion in this space worth exploring. Fatigue is also prevalent among patients undergoing breast cancer therapy. Although there are numerous drugs that can help manage it, Jakel stressed that exercise is the best way to help patients feel better, coupled with adequate sleep hygiene such as reducing shielding time with electronic devices and reduced alcohol consumption.
Low-grade nausea is another gastrointestinal AE that occurs with CDK 4/6 inhibitors that can be managed through recommendations. “What time of day should it be [patients] to take [their CDK4/6 inhibitor]? ” Jakel asked. “How should they take it? Should they take it with food? Should they take it before going to bed? They should take it in the morning and [risk] nausea during the day? Have that conversation [with patients] because if it’s only once a day, even if many drugs are twice a day, you can play with the time of day [patients] take it to help with nausea. “
A large proportion of breast cancer patients experience cognitive impairment or “chemotherapy” following treatment (75%), which can lead to confusion and memory loss. So far, cognitive training has proven to be an effective way to manage cognitive impairment. Other activities that help focus the mind, such as yoga, meditation and psychoeducation interventions can also help, however, their effectiveness has not yet been established.
Another AE that isn’t talked about enough, according to Jakel, are the ongoing problems with sexual function, a problem that reports half of all cancer survivors. Especially following anti-estrogen breast cancer therapies, a large number of female patients report having no sex drive (64%) or low sex drive (48%). Symptoms of menopause and dyspareunia that lead to painful intercourse can be 2 contributing factors.
Male breast cancer patients can also experience sexual adverse events. Over half of the patients receiving anti-androgen therapy (54%) reported no sexual desire after one year of treatment. In addition, 80% to 90% of patients develop difficulties with erectile function. Problems with body image following reconstructive surgery can also play an important role in sexuality-related adverse events.
“We need this conversation about reproductive health,” said Jakel. “We have some endocrine oncologists we can count on, [but] often in our lymphoma population, [the disease] it’s really fast. You have to treat them quickly. If patients come to the hospital and [receive a diagnosis of breast cancer]trying to get sperm samples in an acute environment is a nightmare. It’s a little too sterile, it’s a little too uncomfortable, so these conversations should be done before patients enter the hospital. “
There are some models in space to facilitate these conversations about sexual health, such as the PLISSIT model: ask patients’ permission, provide limited information to the patient’s family members, provide specific suggestions and if a patient is undergoing intensive care, Jakel said he gives good references.
There is also the BEST model, which has existed for the longest time, but is still effective. This implies bringing up the issue of sexual health, explaining that sex is an important part of the quality of life, talking to the patient about resources, explaining how, even if the timing is incorrect, that resources are available, providing education on any sexual adverse events that can occur during treatment and keeping a record to document that the topic has been discussed.
Even with patient education and understanding, adverse events still contribute to the breakdown of drug compliance among cancer patients. Full compliance with drugs is approximately 47%. About 12% of the drugs are not filled by patients, 12% of the drugs have not started and 29% of the drugs have not ended.
Even if the patient seems to understand, it is important to predict that there will be some degree of confusion, explained Jakel. With more than 25 oral systemic cancer therapies, it is important to ensure that patients adhere to regimens outside the clinic. “Interview patients and don’t forget to do a drug reconciliation,” he concluded. “[Ask patients], “How are you taking your medications at home?” You can count pills, pharmacies are much more involved than before, so rely on yours [pharmacists]. You can look at disease response rates and ask [your patient] if they are taking their medicine. “
Jakel P. Breast cancer: management of systemic toxicity. Presented to: 4th year School of Nursing Oncology; July 31-August 1, 2020; virtual. Access to 31 July 2020.