There has been an increase in the number of oral antineoplastic medications approved by the US Food and Drug Administration (FDA). In 2011 it was estimated that 25% of the nearly 400 cancer chemotherapy medications in the pipeline were oral agents.¹ It now appears that patients prefer the oral antineoplastic agents to their injectable counterparts, although they are not without numerous concerns, including adverse effects, toxicities, and potential nonadherence.² As with most oral medications, there are also concerns regarding drug-drug, drug-food, drug-supplement, and drug-herbal interactions. Without proper pharmacist counseling, these interactions can lead to reduced efficacy, therapeutic failure, and extra toxicities.² These medications are also costly and they generally need to be obtained from a specialty pharmacy. In many cases, the patient has no personal relationship with the site of medication dispensing.

The 10 most common adverse drug reactions related to antineoplastic therapy are constipation, nausea with or without vomiting, fatigue, alopecia, drowsiness, myelosuppression, anorexia, dermatological effects, mucositis, and diarrhea.³ The newer oral antineoplastic agents list these potential adverse effects, and they also have their own set of adverse effects, such as complex skin reactions and rashes and hand-foot syndrome. All these adverse effects have been on the rise since the introduction of these drugs.² There is also increasing evidence that many patients prescribed oral antineoplastic agents often discontinue them or are nonadherent with their dosing schedule for a variety of reasons including adverse effects, toxicities, and an overall lack of education and/or knowledge regarding the medications.^4-8 These issues represent significant wastes in health care dollars. The issues of adverse effects, discontinuation, and nonadherence need to be addressed.

Health care technology for the production and delivery of cancer chemotherapeutics has made significant advancements in recent years, most of which have been focused on the institutional settings. Computerized order entry has been shown to decrease the overall rate of medication errors within the hospital.⁹ An electronic medication administration record is an organized way to map an individual patient’s medications and any special administration requirements, and it aids in the delivery of the drug to the patient in a safe and timely manner.⁹ Finally, barcoded medication administration helps to ensure that the correct medication is delivered to the correct patient; it works hand-in-hand with the electronic medication administration record.⁹ All of these systems work together to help minimize medication-related errors in the hospital setting, but what happens when the patient leaves the hospital on an oral-based cancer chemotherapy regimen?

Strategies implemented in the past have had some success in maintaining patient adherence to their oral antineoplastic medications, such as providing only a small number of pills at each dispensing.¹⁰ Another way to monitor patients outside of the clinic, which may be just as effective, is by telepharmacy, which is a form of remote pharmacy services.⁹ Traditionally, this system was used to verify in-patient prescription orders, to ensure the proper preparation of medications when the normal institutional pharmacy staff was unavailable, and to provide services in remote areas with limited access to pharmacists, but it has now spread to more diverse niches. 

The telepharmacy system has been shown to be an effective way to monitor patients who need more
one-on-one contact, such as those with chronic obstructive pulmonary disease.¹¹ One study showed that 90% of patients participating in the telepharmacy program reported an overall satisfaction with the intervention as well as improved inhaler usage.¹¹ If this system can work for one chronic disease state, is it an option for oncology patients to ensure they take their medications as well as report any unusual symptoms, adverse effects, or toxicities? If this system does work, it would be a cost-effective way to continuously monitor oncology patients. With the use of online systems such as OutcomesMTM (http://www.outcomesmtm.com/) and Mirixa (http://www.mirixa.com/), these encounters can be easily documented and, in some cases, the pharmacist, pharmacy, and/or the institution can be reimbursed for those services provided.

The prescribing and monitoring of oral antineoplastic medications will be a large issue as we move into the future of the treatment of cancer. These medications are extremely expensive, as is the overall care for patients with cancer. There is a need for effective ways to ensure oncology patients are taking their medications and are able to report any problems they may be experiencing in order to provide the best and most cost-efficient care possible. 

REFERENCES

1. Weingart SN, Spencer J, Buia S, Duncombe D, et al. Medication safety of five oral chemotherapies: A proactive risk assessment. J Oncol Pract. 2011;7(1):2-6. 
2. Aisner J. Overview of the changing paradigm in cancer treatment: Oral chemotherapy. Am J Health Syst Pharm. 2007;64(9 suppl 5):S4-7. 
3. Lau PM, Stewart K, Dooley M. The ten most common adverse drug reactions (ADRs) in oncology patients: Do they matter to you? Support Care Cancer. 2004;12(9):626-633. 
4. Barron TI, Connolly R, Bennett K, Feely J, Kennedy MJ. Early discontinuation of tamoxifen: A lesson for oncologists. Cancer. 2007;109(5):832-839. 
5. Hershman DL, Kushi LH, Shao T, et al. Early discontinuation and nonadherence to adjuvant hormonal therapy in a cohort of 8,769 early-stage breast cancer patients. J Clin Oncol. 2010;28(27):4120-4128.
6. Khandelwal N, Duncan I, Ahmed T, Rubinstein E, Pegus C. Impact of clinical oral chemotherapy program on wastage and hospitalizations. J Oncol Pract. 2011;7(3 suppl):e25s-e29s. 
7. Owsusu C, Buist DS, Field TS, et al. Predictors of tamoxifen discontinuation among older women with estrogen receptor-positive breast cancer. J Clin Oncol. 2008;26(4):549-555. 
8. Ruddy K, Mayer E, Partridge A. Patient adherence and persistence with oral anticancer treatment. CA Cancer J Clin. 2009;59(1):56-66.
9. Bubalo J, Warden BA, Wiegel JJ, Nishida T, Handel E, Svoboda LM, Nguyen L, Edillo PN. Does applying technology throughout the medication use process improve patient safety with antineoplastics? J Oncol Pharm Pract. 2014;20(6):445-460. 
10. Kaddis AA. Partial fill strategies for oral oncolytics to reduce waste and drive persistency. Am J Manag Care. 2013;19(1 Spec No):SP26-SP 27. 
11. Margolis A, Young H, Lis J, Schuna A, Sorkness CA. A telepharmacy intervention to improve inhaler adherence in veterans with chronic obstructive pulmonary disease. Am J Health Syst Pharm. 2013;70(21):1875-1876.

^*Resident, Drug Information Center, College of Pharmacy, Washington State University, Spokane, Washington