Managing Cancer as a Chronic Condition
Cancer as a Chronic Disease
Significant advances have been made in cancer care, so that even when cure is not possible, many cancers can be controlled and managed for long periods of time. Many physicians and practitioners consider patients being treated for some types of cancer as living with a chronic condition. However, these patients require ongoing therapy to control their condition, and this treatment now often takes the form of oral drugs that patients can administer themselves – much like people with diabetes or high blood pressure. When once patients were bound to regular visits to their doctor in order to receive chemotherapy intravenously or through injection, now many chemotherapy regimens can be delivered in prescription pill form. This, however, requires patients to take responsibility for their disease management, and success requires them to adhere carefully to their treatment plan and take their prescribed medication properly. Compliance with oral drug therapies is paramount to the effectiveness of the treatment.
Ethan Basch, MD, medical oncologist and health services researcher at Memorial Sloan Kettering Cancer Center in New York, who has expertise in patient-reported outcomes, clinical informatics, and drug regulatory policy , says it is vital for patients with cancer to fill prescriptions and take medication as directed, and explains the implications for not doing so.
"Many medications are prescribed based on studies evaluating benefits and risks at specific doses and schedules of administration. Therefore, if these medications are not taken as directed, they may not yield the expected effects," says Dr. Basch.
Some patients stop taking their medication because of unpleasant side effects, but this tendency is cautioned against, and instead Dr. Basch recommends patients discuss these symptoms with their doctor. "If a patient is experiencing side effects possibly related to a medication," Dr. Basch says, "the best approach is to start by discussing this with the prescribing clinician to assess possible causes, and to consider changes in the dose or schedule based on best practices, or to consider alternative treatments."
In addition to side effects, Dr. Basch says there are many other reasons people do not take medications as directed. "Cost, inconvenience, confusing dosing schedules (for example, treatments that require intermittent dosing), and simply forgetting are common causes," he says.
Dr. Basch offers the following suggestions to stay on track:
- Clear communication and reminders are the best solutions to minimize missed or incorrect doses. This starts at the point of care, with a clear discussion between clinician and patient, and easy-to-understand information provided to the patient to take home. This information can be written/printed or electronic, such as on a secure patient portal Web site. Patients should be encouraged to call the office with any concerns or questions, such as about dosages or schedules.
- For patients taking multiple medications, with confusing regimens, or at risk for forgetting doses, the clinician's office should consider follow-up telephone calls to assess for compliance and proper dosing. Organizing oral medications with pill boxes or electronic dispensing devices may also help.
Follow Directions Carefully
Gene A. Wetzstein, PharmD, BCOP, director of pharmacy services at Moffitt Cancer Center in Tampa, Florida, says it is very important for patients to pay close attention to dosing guidelines and following directions carefully.
"If the directions say to take it with food and it isn't, the way that the medication is absorbed and used by the body can be affected. It will make some medicine more toxic if it is to be taken with food. Just the opposite is true for other medication, as the medicine can be made ineffective if not taken exactly as directed," says Wetzstein.
Furthermore, he points out that drugs are also metabolized at different rates, and sticking to a schedule is vital. "For example, if a patient took the medicine 8 hours apart instead of 12 hours apart, the outcome can also be very different."
"It is also important that one actually begins and stops the medicine on the same schedule that the prescriber instructs," he adds, saying some drugs work synergistically, and if the medicine is not being taken when the prescriber thinks it is, it may not have the same result. "It is very important for the patient to call if they are having trouble obtaining the medication or cannot start on the date instructed," Wetzstein says.
Suzette Walker, MSN, FNP-C, AOCNP, Co-Director Symptom Management and Supportive Care Program, University of Michigan Comprehensive Cancer Center in Ann Arbor, Michigan, outlines some of the issues that may prevent patients from following doctors' orders:
- Poor understanding and education of risks/benefits associated with the drugs
- Complexity of regimens
- Polypharmacy (multiple drugs)
- Misperception or feeling that the medicine is NOT doing anything because no physical changes are experienced
- Adverse side effects
Because many cancers are now considered chronic conditions that require ongoing treatment for management and control, Walker says, "Support groups are important for some; family and friends are important to all." With medical advancements allowing increasing numbers of patients to live as cancer survivors, Walker adds that "Having a safe place to talk about what [they are] thinking and feeling is crucial for the long run. Monitoring patients for late side-effects and chronic side-effects is crucial."