1. FACET - European Journal of Cancer Care September 2006 slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies Oakley, C. 1, Bloomfield, J. 2, Plant, H. 3 Slide One *Click on View; Notes Page for explanatory notes Oral anti-cancer therapies – past, present, future What are the issues facing patients prescribed oral chemotherapy, their families and healthcare professionals caring for them?

2. FACET - European Journal of Cancer Care September 2006 slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Slide Two *Click on View; Notes Page for explanatory notes The conference Presentations: Drug developments in recent years Commissioning issues Establishing oral chemotherapy services from the points of view of pharmacy and nursing Research exploring patient experiences of oral chemotherapy Three workshops

3. FACET - European Journal of Cancer Care September 2006 slides available at: www.blackwellpublishing.com/ecc Slide Three *Click on View; Notes Page for explanatory notes Oral anti-cancer therapies (continued) Who should attend a workshop on oral chemotherapy? Clinical nurse specialists 10 Pharmacists 8 Community nurses 6 General practitioner 1 Hospital based consultants 3 Nurses/others 5 Others/managers 20 Patients/users 5 Total 58

4. FACET - European Journal of Cancer Care September 2006 slides available at: www.blackwellpublishing.com/ecc Slide Four *Click on View; Notes Page for explanatory notes Oral anti-cancer therapies (continued) Why use the oral route? It is the normal way!

5. FACET - European Journal of Cancer Care September 2006 slides available at: www.blackwellpublishing.com/ecc Slide Five *Click on View; Notes Page for explanatory notes Oral anti-cancer therapies (continued) Development of oral anti-cancer treatments – the past Early anti-cancer drugs were cytotoxics Oral hormonal agents were used to treat hormone dependent cancers as soon as they became available

6. FACET - European Journal of Cancer Care September 2006 Slide Six *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Development of oral anti-cancer treatments – Capecitabine 5-FU can not be absorbed from the gut so is administered as continuous IV infusion to achieve maximum cell kill Capecitabine is absorbed from the GI tract and converts to 5-FU at the liver, tumour site and other tissues Capecitabine is licensed for metastatic breast and colon cancer and as adjuvant colorectal cancer treatment

7. FACET - European Journal of Cancer Care September 2006 Slide Seven *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Development of oral anti-cancer treatments – the future Tyrosine Kinase Inhibitors (TKI) Hormones Vinorelbine Drugs under development

8. FACET - European Journal of Cancer Care September 2006 Slide Eight *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) The pharmacy model British Oncology Pharmacy Association (BOPA) statement (2004) Principles of safe practice Prescribing Dispensing and labelling Patient education and information Patients access to advice and support when at home General risk management Audit

9. FACET - European Journal of Cancer Care September 2006 Slide Nine *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) The pharmacy model – implementing BOPA recommendations Established oral chemotherapy working party Purpose Achievements Future plans

10. FACET - European Journal of Cancer Care September 2006 Slide Ten *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) The nursing model – nurse supported capecitabine clinic Pathway and role of the nurse Patient education and support is of vital importance Can be a stressful experience. More responsibility placed on patients to adhere to treatment regimens and recognise the onset of side effects. Supporting documentation

11. FACET - European Journal of Cancer Care September 2006 Slide Eleven *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) The patients experience Audit: Looking at the experience of oral chemotherapy through audit Hilary Plant & Jacqueline Bloomfield Research: It is a lot easier to cope with – An exploration of cancer patients experience of oral chemotherapy Catherine Oakley

12. FACET - European Journal of Cancer Care September 2006 Slide Twelve *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Looking at the experience of oral chemotherapy through audit Aims of the audit To gain awareness of issues experienced by those taking oral anti cancer treatment Identify needs – information, practical, social and emotional To identify ways in which health professionals can support these needs Plant & Bloomfield (2005)

13. FACET - European Journal of Cancer Care September 2006 Slide Thirteen *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Findings: Information Additional information needs before commencing treatment: How and when to take. How to store/ manage, handle. What to do if I missed a dose. How the medication works, expectation of outcome of medication (Female respondent aged 37, taking etoposide for several months)

14. FACET - European Journal of Cancer Care September 2006 Slide Fourteen *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Findings: Side-effects and support 86% of respondents reported side- effects as a result of taking oral chemotherapy treatment 90% indicated that they knew who to seek help from to manage these (nurse, hospital doctor, GP) 23% did not seek help or support Because I have been through it before I have not sought help – I just get on with it (Female respondent, retired, taking oral chemotherapy for 7 weeks)

15. FACET - European Journal of Cancer Care September 2006 Slide Fifteen *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Findings: Perceptions and experiences (1) I much prefer taking oral drugs, side effects are no worse than other treatments and oral drugs give me the control which is very important (Female aged 40 taking treatment for 5 months) I did initially feel apprehensive about the responsibility of taking the drugs myself. I didnt feel safe taking such powerful medicine & worried about getting the dose right even though it was clearly explained on the box. I preferred it when the medicine was given intravenously. But Im just about to start my 3rd cycle & feel ok about it now (Female aged 38 taking capecitabine for 3 months)

16. FACET - European Journal of Cancer Care September 2006 Slide Sixteen *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Findings: Perceptions and experiences (2) I have found this type of oral chemo very easy to use and with the least side-effects. My only worry is, is it doing the job of shrinking the tumour and how good the end result would be. Only time will tell. For people with poor or collapsed veins it is a real blessing. (Female aged 65) Oral chemotherapy relies on the diligence and efficiency of the patient. Taking 8 tablets a day is demanding particularly if the side effects, as in my case, were severe (Female aged 46 taking capecitabine)

17. FACET - European Journal of Cancer Care September 2006 Slide Seventeen *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) It is a lot easier to cope with – An exploration of cancer patients experience of oral chemotherapy

18. FACET - European Journal of Cancer Care September 2006 Slide Eighteen *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Main findings Oral therapy is the preferred option Healthcare professionals anxiety –Probable drivers are experience of patients not taking medicine correctly or reporting symptoms Information rushed/repeated with little time to check understanding Patients/caregivers anxious/overwhelmed Patients/caregivers assumed responsibility which they appeared to find stressful Elderly patients stayed with caregivers

19. FACET - European Journal of Cancer Care September 2006 Slide Nineteen *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Main findings (2) Patients may not comply by ringing in if unwell. They: –denied side effects would occur –didnt know when to call in –viewed oral chemotherapy as milder Ive got to accept it and take it… I try to think myself well. Im not going to take too much notice of side effects cause I dont want to let them get to me. I dont want to get that imagination where youre feeling bad. Patient

20. FACET - European Journal of Cancer Care September 2006 Slide Twenty *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) What helps? Confidence in the service /24 hour contact Practical advice Speaking to experienced patients Caregivers helped establish routine I come down and have me breakfast and then (name of caregiver) used to get the bag that is kept on top of the fridge out there and Id sit and shed watch me have me tablets….. we made a list so she ticks it off when Ive had them (laughs)…. Patient I just kept to 7, 7, 7, 7, 7, 7.. I even put me alarm on to 7 oclock so if I should forget it, it would give me a reminder…… Patient

21. FACET - European Journal of Cancer Care September 2006 Slide Twenty One *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Implications for practice/research of audit and research project Preferred option Clear patient pathway Assessment and support Listen and respond Information Contact details Monitoring

22. FACET - European Journal of Cancer Care September 2006 Slide Twenty Two *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Chemotherapy alert card

23. FACET - European Journal of Cancer Care September 2006 Slide Twenty Three *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Workshop outcomes Transforming delivery – identified barriers key issues potential resources Who, where, when Pathway mapping Information/documentation Problem areas Solutions

24. FACET - European Journal of Cancer Care September 2006 Slide Twenty Four *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) Emerging themes Responsibility Support Service structure Community nurses Existing models of care

25. FACET - European Journal of Cancer Care September 2006 Slide Twenty Five *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) The next steps Pathway mapping Model of care- research Hand held diary Repeating the conference

26. FACET - European Journal of Cancer Care September 2006 Slide Twenty Six *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) References and further reading Bedell C.H. (2003) A changing paradigm for cancer treatment: the advent of new oral chemotherapy agents. Clinical Journal of Oncology Nursing 7 (6 suppl), 5- 9. Borner M.M., Schoffski P., de Wit, R., Caponigro F., Comella G., Sulkes A., Greim G., Peters G.J., van der Born K., Wanders J., Boer R.F., Martin C., Fumoleau P. (2002). Patient preference and pharmacokinetics of oral modulated UFT versus intravenous fluorouracil and lecovorin: a randomised crossover trial in advanced colorectal cancer. European Journal of Cancer 38, 349-358. British Oncology Pharmacists Association (BOPA) (2004) Position Statement on Safe Practice and the Pharmaceutical Care of Patients Receiving Oral Anticancer Chemotherapy. January 2004. BOPA, UK.

27. FACET - European Journal of Cancer Care September 2006 Slide Twenty Seven *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) References and further reading (continued) Cassidy J., Scheithauer W., McKendrick J., Kroning H., Nowacki M.P., Seitz J.F., Twelves C., Van Hazel G., Wong A., Diaz-Rubio E., On Behalf of X-act Study Investigators. (2004). Capecitabine (X) vs. bolus 5- FU/leucovorin (LV) as adjuvant therapy for colon cancer (the X-ACT study): efficacy results of a phase iii trial. Proceedings of the American Society of Clinical Oncology vol. 23, 2084-2091. Faithfull S., & Deery P. (2004). Implementation of capecitabine (XELODA) into a cancer centre: UK experience, European Journal of Oncology Nursing 8, S54- S62. Harrold K. (2002). Development of a nurse-led service for patients receiving oral capecitabine. Cancer Nursing Practice 1(8):19-24. Hartigan K. (2002). Patient education: The cornerstone of successful oral chemotherapy treatment, Clinical Journal of Oncology Nursing supplement 7(6):21-24.

28. FACET - European Journal of Cancer Care September 2006 Slide Twenty Eight *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) References and further reading (continued) James R., Bianco C., Farina C. (2003). Savings in staff time as a result of switching from De Gramont to oral capecitabine for patients with advanced colorectal cancer. European Journal of Cancer, Supplements 1(5), S83 (abstract 271). Liu G., Franssen E., Fitch M.I., Warner E. (1997). Patient preferences for oral versus intravenous palliative chemotherapy. Journal of Clinical Oncology 15(1),110- 115. Lokich J. (2004). Capecitabine: fixed daily dose and continuous (non cyclic) dosing schedule. Cancer Investigation 22(5), 713-717. Mayor S. (2003). UK introduces measures to reduce errors with methotrexate. British Medical Journal 372, 70. Mills M., E., and Sullivan K. (1999). The importance of information giving for patients newly diagnosed with cancer: a review of the literature. Journal of Clinical Nursing 8(6) 631-642.

29. FACET - European Journal of Cancer Care September 2006 Slide Twenty Nine *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) References and further reading (continued) Oakley C. (2005) Its a lot easier to cope with, an exploration of cancer patients experience of oral chemotherapy. Unpublished dissertation, Kings College London, London, UK. Partridge A.H., Avon J., Wang P.S., Winer E.P. (2002). Adherence to therapy with oral antineoplastic agents, Journal of the National Cancer Institute, 94(9), 652-661. Plant H. & Bloomfield J. (2005) Looking at the experience of oral chemotherapy through audit. Unpublished audit, Guys and St Thomas NHS Foundation Trust and Kings College London, London, UK. Sanio C., Erickson E. (2003). Keeping cancer patients informed; a challenge for nursing. European Journal of Oncology Nursing 7(1), 39-49.

30. FACET - European Journal of Cancer Care September 2006 Slide Thirty *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/ecc Oral anti-cancer therapies (continued) References and further reading (continued) Twelves C., Boyer M., Findlay M., Cassidy J., Weitzel C., Barker C., Osterwalder B., Jamieson C., Hieke K. on behalf of the Xeloda colorectal cancer study group (2001). Capecitibine (Xeloda) improves medical resource use compared with 5-fluorouracil plus leucovorin in a phase III trial conducted in patients with advanced colorectal carcinoma. European Journal of Cancer 37, 597- 604. Twelves C. Gollins S., Grieve R., Samuel L. (2006). A randomized cross over trial comparing patient preference for oral capecitabine and 5- fluorouracilleucovorin regimens in patients with advanced colorectal cancer. Annals of Oncology 17, 239- 245.