Managing Systemic Toxicities and Limiting Therapy Non-Adherence in Breast Cancer

Patricia Jakel, RN, MN, AOCN

One of the most important tasks that oncology nurses face is ensuring that patients are taking their medications consistently and correctly, and that adverse events (AEs) are properly managed—specifically in those patients with breast cancer, according to Patricia Jakel, RN, MN, AOCN.

“[Nonadherence] is a nursing issue,” Jakel emphasized, “Learn that patients who think they’re taking their [medications] correctly [can still be mistaken]. …Try to help patients make sure that all medications, especially oral medications, are taken correctly. It really does have an impact on overall life expectancy. ”

In her presentation at the 4th Annual School of Nursing Oncology on systemic toxicity management in breast cancer, Jakel, an advance practice nurse with University of California, Los Angeles (UCLA) Santa Monica Medical Center, an associate professor of nursing with UCLA School of Nursing, and a patient with breast cancer herself, discussed the best supportive care strategies that should accompany breast cancer therapy.

Medication adherence rates for patients with breast cancer range from 15%-87%, with a mean of 50%. Poor adherence has been found to be associated with patients over the age of 65, non-oncologist prescriptions, polypharmacy drug interactions, and high copayments. Poor adherence to medications—whether its due to AEs or confusion around how to take said medications—can lead to worse patient outcomes such as disease progression, developing resistance to certain medications, and even death.

A number of 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 (AIs) such as anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femara); and ER down-regulators such as fulvestrant. AEs that accompany these endocrine therapies can lead to therapy non-adherence, according to Jakel.

Aside from joint and bone pain, other known AEs include hot flashes, menopausal symptoms, libido loss, blood clots, and osteoporosis and may be a contributor to a decrease in long-term adherence to oral endocrine therapies. This issue of nonadherence may be affecting between 30%-80% of patients, especially those who have been receiving these therapies for at least 5 years.

“[One patient] stopped [treatment of her AI] because of bone pain,” Jakel explained. “We tend to not think about that…but probably about 40% of patients have pretty severe bone pain that makes it hard to get up off the couch.”

Patients who are given CDK4/6 inhibitors additionally tend to experience AEs such as diarrhea, though this can be managed through other agents such as loperamide hydrochloride (Diamode) and octreotide (Sandostatin), which are likely to be effective. That being said, agents such as amifostine (Ethyol) and neomycin (Neo-rx) and have been seen to balance benefits with harm. 

Jakel also stated that encouraging a BRAT diet— bananas, rice, applesauce, toast—in patients with diarrhea is another expert opinion in this space that is worth exploring. Fatigue is also prevalent AE among patients undergoing breast cancer therapy. Though there are numerous medications that can help to manage this, Jakel emphasized that exercise is the best way to help patients to feel better, coupled with proper sleep hygiene such as decreasing screen 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 [patients] take [their CDK4/6 inhibitor]?” Jakel asked. “How should they take it? Should they take it with food? Should they take it before bed? Should they take it in the morning and [risk] being nauseated during the day? Have that conversation [with patients] because if it’s only once a day—though many drugs are twice a day—you can play around with the time of day [patients] take it to help with nausea.”

A large portion of breast cancer patients experience cognitive impairment or “chemo brain” following treatment (75%), which can lead to confusion and memory loss. Thus far, cognitive training has shown to be an effective way to manage cognitive impairment. Other activities that help to focus the mind, such as yoga, meditation, and psychoeducation interventions may also help, however, their effectiveness has not yet been established. 

Another AE that is not spoken about enough, according to Jakel, is ongoing problems with sexual function—an issue that half of all cancer survivors report. Especially following anti-estrogen breast cancer therapies, a large number of female patients report having no sexual desire (64%) or low sexual desire (48%). Menopausal symptoms and dyspareunia leading to painful intercourse may be 2 contributing factors.

Male patients with breast cancer can also experience sexual AEs. Over half of patients who receive an anti-androgen therapy (54%) reported no sexual desire following a year of treatment. Additionally, 80% to 90% of patients develop difficulties with erectile function. Issues with body image following reconstructive surgery can also play an important role in sexuality-related AEs.

“We need have to this conversation about reproductive health,” Jakel said. “We do have some endocrine oncologists we can rely on, [but] oftentimes in our lymphoma population, [the disease] is really quick. You have to treat them quickly. If patients come into the hospital and [receive a diagnosis of breast cancer], trying to get sperm samples in the acute setting is a nightmare. It’s a little too sterile, it’s a little too uncomfortable, so these conversations should be done before the patients come into the hospital.”

There are a handful of models in the space to help make these conversations around sexual health easier, such as the PLISSIT model: Ask patients for permission, give limited information to the patient’s family members, provide specific suggestions, and if a patient undergoes intensive therapy, Jakel said to give good referrals.

There is also the BETTER model, which has been around longer, but it is still effective. This involves bringing up the topic of sexual health, explaining that sex is an important part of quality of life, telling the patient about resources, explaining how even if the timing is not right that resources are available, providing education about any sexual AEs that may occur during treatment, and maintaining a record to document that the topic has been discussed.

Even with education, and patient understanding, AEs still contribute to the breakdown of medication adherence among patients with cancer. Full medication compliance is approximately 47%. Approximately 12% of medications are not filled by patients, 12% of medications are not started, and 29% of medications are not finished. 

Even if the patient appears to understand, it is important to anticipate that there will be some degree of confusion, Jakel explained. With more than 25 systemic cancer therapies given orally, it is important to ensure that patients are adhering to regimens outside of the clinic. “Interview patients and don’t forget to do a medication reconciliation” she concluded. “[Ask patients], ‘How are you taking your medications at home?’ You can do pill counts, pharmacies are much more involve then they used to be, so rely on your [pharmacists]. You can look at disease response rates and ask [your patient] if they’re taking their medication.”

Reference

1. Jakel P. Breast cancer: systemic toxicity management. Presented at: 4th Annual School of Nursing Oncology; July 31-August 1, 2020; virtual. Accessed July 31, 2020.