Research critique

Background
Regnier Denois, V., Poirson J., Nourissat A., Jacquin J., Guastalla J. P, & Chauvin F. (2011) European Journal of Cancer Care 20, 520-527. Adherence with oral chemotherapy: results from a qualitative study of the behavior and representations of patients and oncologists. This study was conducted to evaluate the importance of partnership between the patient and the prescriber in oral chemotherapy adherence. 42 patients taking Capecitabine for the treatment of metastatic breast or colon cancer and 10 oncology prescribers were interviewed to evaluate the practice behavior of the prescriber and assess patients’ understanding of therapy adherence. The study aimed at obtaining the perspectives of both patients and the prescribing oncologists. The findings of this study show that patients did not deliberately ignore to take their medication, it shows poor adherence to treatment schedule, poor or failure to report adverse effects and toxicity was the most important finding. It also shows there is no standard of practice for the process of prescribing and educating the patients. Each prescriber selected the patients based on available treatment guidelines and individual experience.

Problem Statement The use of oral chemotherapy is increasing as more new targeted therapy drugs are developed. Oncologists prescribe oral chemotherapy based on the disease, recommended guidelines and patients are selected based on the prescriber’s past experiences. The weight of the responsibility shifts to the patient and sometimes, prescribers rely on trusting the patients to follow the advice to take the chemotherapy as prescribed and report problems.
The authors identified the clinical problem as studies related to oral therapy adherence rarely evaluate how well patients follow the prescriber’s recommendations for self monitoring and reporting adverse effects, particularly toxicity in relationship to the prescriber’s practice behavior. Understanding the patient’s thinking and the prescriber’s standard of practice, putting both together to clarify prescriber’s missed steps and patient’s misunderstanding will improve patient-prescriber communication and desired outcome. Though not sure about what led this Capecitabine study, it appears there may have been a growing concern with patients on Capecitabine not reporting side effects promptly, some of which can be debilitating and also findings of poor education on the part of the healthcare team.
The study caught my attention because the author mentioned the value of oral chemotherapy as a way to improve quality of life for cancer patients by decreasing side effects, hospitalization and cost reduction but did not directly tie the cost reduction to hospitalization. Sometimes, the cost of oral chemotherapy is higher than parenteral or hospitalization as majority of targeted therapy is new, Capecitabine being one of them. High insurance copay and deductible can make oral chemotherapy unaffordable.

Purpose and Research Questions
The authors did not mention the purpose, however the abstract mentioned that the results from the study aimed to describe and understand current practice for Capecitabine. The objectives was mentioned in the second paragraph under the methods used to collect data in the study, it should have been defined in the beginning along with a statement of purpose. The objective of the study was to evaluate the perceptions and descriptions of patients and oncologists about prescribing Capecitabine without influencing the results with hypothesis that would influence the responses of the participants. Therefore, no hypothesis was presented since the researchers wanted the patient and prescriber perspective.
Since the study was aimed at understanding 2 perspectives, patient and oncologist, the interview topics were designed and outlined separately. This was appropriate in order to achieve the objective of the study. However, a questionnaire was not used in this study at any stage of the data collection. I believe mailing out a questionnaire to the patient population or handing out during clinic visits would have allowed for a larger initial response and screening. According to the report, 98 patients were contacted by phone call, 42 participated, 37 women, mean age 65.4. Years of disease varied, duration of oral chemotherapy varied from less than 6 months more than 1 year. The Professional experience, oral chemotherapy experience or the number of patients treated with oral Capecitabine by each prescribing oncologist was not mentioned. More exposure in prescribing the drug may improve the prescriber-patient communication ( Graham et al. 2012)
The researcher utilized qualitative and convenient method at 2 comprehensive cancer centers. The researchers reported an observational phase during several appointments with patients (42) taking Capecitabine and the prescribing oncologist (10) followed by semi-directive interview approach and focus group interviews to reduce biases from different methods. The researchers were able to meet the objectives as this method provided adequate answers to the interview topic in discussion. However, I’m not sure about the observation phase. There could have been some behavior modification in the process since both patients and prescribers could have taken additional step towards positive behavior while been observed. The observation though described the prescribing process, some prescribers wrote for Capecitabine and supportive therapy to manage side effects while some waited till side effects manifested to treat. Some schedule follow up every 2 weeks while others go 4-6 weeks. The study failed to describe the interaction and communication between the patients and oncologists.

Literature Review
Several relevant literatures were cited by the researchers, both qualitative and quantitative such as cancer oral therapy observance studies (Partridge et al. 2002, 2008; Chau et al. 2004; Atkins & Fallowfield 2006; Escalada & Griffiths 2006) and the importance of good observation (WHO, 2003) Though some of the literatures was more than 5 years, it proved the point of the researchers of not enough studies in this area. The researchers evaluated and discussed the weaknesses and what is missing from the other studies such as unclear methods or only focusing on measuring the amount patients are taking, assuming cancer patients take oral chemotherapy as prescribed due to the severity of the disease or using age as a predictor of adherence. These studies rarely assess how well patients follow recommendations for side effect self monitoring and reporting, particularly toxicity. None of the studies evaluated the behavior of the prescriber in the prescribing process along with the patients’ understanding of adherence. Hence the need for this study to evaluate for adherence to therapy to include the role of the prescriber and healthcare team in providing adequate teaching and standard of practice in observance of adherence from 2 different perspectives. However, more participants and similar studies are needed to better understand these perspectives (Spoelstra et al. 2013)

Theoretical Framework
The researchers focused on patient and prescriber perspective to address the issue of poor adherence. Several analytical methods including comprehensive approach to connect the various elements in discourse at interviews also with each focus group (patients and oncologists) The focus group topics covered was then coded and used for initial structuring of the content analysis, the diagram was included as the summary of the study process. It included the 2 centers, patients contacted, participants and oncologists. No framework related to the findings was included. The diagram should have included the findings following the processing of the data.
Conclusion
The study finding shows there is no standardized practice among oral chemotherapy prescribers. Furthermore, patients are left to determine what is bearable or reportable adverse effect of therapy. Prescribers do not talk about adherence because they trust the patients to take the drug as prescribed and talking about adherence may break the trust. Patients on the other hand do not think enough information was provided in the prescribing process and follow up visits. Even though poor adherence was not deliberate, some patients took matters into their own hands by modifying the plan of care. Some do not report side effects for fear of therapy interruption. Clearly, there is more education needed for patients and awareness for prescribers and the healthcare team to discuss adherence in person or by phone to ensure patient safety and improved outcome. (Sommers et al. 2012)

References

Graham DM, Bambury RM, Ismail JRM, O’Keefe M, Drake C, O’Shea A, Moylan EJ, Power DG, O’Reilly S. Oral anti-cancer therapy: Does the patient understand? J Clin Oncol 30(Suppl):abstr #e16506, 2012
Partridge AH, Avorn J, Wang PS, Winter E. Adherence to therapy with oral antineoplasticageants. J Natl Cancer Insti 94(9):652-661, 2012
Regnier Denois, V., Poirson J., Nourissat A., Jacquin J., Guastalla J. P, & Chauvin F. (2011) Adherence with oral chemotherapy: results from a qualitative study of the behavior and representations of patients and oncologists. European Journal of Cancer Care 20, 520-527
Sommers RM, Miller K, Berry DL. Feasibility pilot on medication adherence and knowledge in ambulatory patients with gastrointestinal cancer. Oncol Nurs Forum 39(4):E373-E379, 2012