ONS Oral Adherence Toolkit

ONS Oral Adherence Toolkit

Oral formulations of chemotherapy and hormonal therapies have been used for decades and include many familiar agents, such as cyclophosphamide, melphalan, and tamoxifen. Cancer treatment has experienced a rapid increase in oral oncolytics, including cytotoxic agents, small-molecule inhibitors, and agents targeted at receptors that regulate cellular differentiation, growth, and survival. The expansion of oral oncolytics is projected to continue, as an estimated 25% of anticancer agents in the research pipeline are designated for oral administration (Michaud & Choi, 2008). The increase in oral oncolytics affects the infrastructure of chemotherapy administration as the site of care moves from intermittent IV infusions in an infusion center to continuous oral dosing taken in the patient’s home. With the increase in oral cancer therapies, concerns about adherence also have increased. This paradigm shift affects how oncology nurses will manage patients under their care and requires nursing resources above and beyond traditional on-site chemotherapy teaching and monitoring.

Defining Adherence and Recognizing Its Prevalence

The World Health Organization ([WHO], 2003) defined adherence as the extent to which a person’s behavior in taking medication or executing lifestyle changes agrees with recommendations from a healthcare provider. A patient is considered to be nonadherent if he or she misses doses, takes additional doses to those prescribed, or takes doses either in the wrong quantity or at the wrong time (Ruddy, Mayer, & Partridge, 2009). Considering all medications given for all reasons, WHO projects that only about 50% of patients typically take their medicines as prescribed. Adherence issues are not unique to oncology—primary care healthcare providers (HCPs) have acknowledged the high prevalence of nonadherence to treatment regimens for chronic diseases such as diabetes, heart failure, and HIV antiretroviral therapy. Oncology HCPs generally assume that patients with cancer will adhere to treatment recommendations because of the seriousness of a cancer diagnosis; however, reports in the literature have demonstrated adherence levels as low as 20% (Lebovits et al., 1990; Partridge, Avorn, Wang, & Winer, 2002; Thompson, Dewar, Fahey, & McCowan, 2007).
Adherence to prescribed cancer therapy is more than taking the medicine on time—nonadherence can result in drug resistance and suboptimal response to therapy, disease progression, and death. Poor adherence to tamoxifen, for example, has been significantly associated with increased risk of death from breast cancer (Thompson et al., 2007).

Using This Toolkit

Oncology nurses recently have begun to identify and address the challenges of supporting an increasing number of patients being treated with oral cancer agents. Osterberg and Blaschke (2005) stated that the ability for an HCP to recognize nonadherence is poor and that results are mixed for standard interventions to improve adherence. The Oral Adherence Toolkit provides strategies and resources that nurses can use to facilitate adherence among patients with cancer related to
  • Safety concerns: drug-drug and food-drug interactions, adverse effects
  • Pharmacy and reimbursement/financial resources
  • Monitoring of adherence
  • Motivational interviewing and counseling
  • Change theory and helping patients to change nonadherence into adherence
Throughout this toolkit you will find links to multiple tools that will provide additional information and resources that can help facilitate care of patients receiving oral therapies. These tools may be printed and copied for your use.
View the complete printable version.
Funding for development of this toolkit was provided by Takeda Oncology.
ONS is solely responsible for the criteria, objectives, content, quality, and scientific integrity of its programs and publications.


Lebovits, A.H., Strain, J.J., Schleifer, S.J., Tanaka, J.S., Bhardwaj, S., & Messe, M.R. (1990). Patient noncompliance with self-administered chemother­apy. Cancer, 65, 17–22. doi: 10.1002/1097-0142(19900101)65:1<17::AID-CNCR2820650106>3.0.CO;2-I

Michaud, L.B., & Choi, S. (2008, November 25). Oral chemotherapy: A shifting paradigm affecting patient safety. HemOnc Today. Retrieved from http://www.hemonctoday.com/article.aspx?rid=33070

Osterberg, L., & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353, 487–497. doi: 10.1056/NEJMra050100

Partridge, A.H., Avorn, J., Wang, P.S., & Winer, E.P. (2002). Adherence to therapy with oral antineoplastic agents. Journal of the National Cancer Institute, 94, 652–661. doi: 10.1093/jnci/94.9.652

Ruddy, K., Mayer, E., & Partridge, A. (2009). Patient adherence and persistence with oral anticancer treatment. CA: A Cancer Journal for Clinicians, 59, 56–66. doi: 10.3322/caac.20004

Thompson, A.M., Dewar, J., Fahey, T., & McCowan, C. (2007). Association of poor adherence to prescribed tamoxifen with risk of death from breast cancer [Abstract 130]. ASCO Breast Cancer Symposium. Retrieved from http://www.asco.org/ASCO/Abstracts+&+Virtual+Meeting/Abstracts?&vmview=abst_de­tail_view&confID=52&abstractID=40326

World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Retrieved from http://www.who.int/chp/knowledge/publications/adher­ence_report/en/index.html