Technological preferences of aging cancer patients for delivery services and devices to solve drug-related problems in oncology.

AIM: To identify the technological preferences of aging cancer patients with regard to the delivery services and devices for preventing/solving three common drug-related problems (DRPs): medication nonadherence, lack of knowledge in medications, and side effects management. METHODS: A survey was conducted at a cancer center from May to August 2011. Delivery services included in the interviewer-administered questionnaire included voice-activated dispensing, voice reminders, electronic messages, helplines, and mobile phone applications, among others. Three devices were proposed-watches, bracelets, and mobile phones. Descriptive statistics and chi-square tests were performed. RESULTS: A total of 361 surveys were analyzed. Median age of respondents was 61 years. The majority of respondents were female (57.3 %), Chinese (88.9 %), and 65 years and younger (73.4 %). More than half (59.0-63.2 %) were receptive to the use of the delivery services. Patients preferred voice reminder alerts (28.0 %) and electronic messages (17.7 %) to help with their medication nonadherence, and helplines for medications (52.6 %) and side effects management (47.4 %). Higher educated patients were more likely to want delivery services to improve their medication adherence (p = 0.045) and knowledge in medications management (p = 0.050). Middle age patients (age 50-65) were also more likely to want delivery services for the latter DRP (p = 0.009). Among those who wanted delivery services, most preferred mobile phones. CONCLUSION: Middle age and elderly cancer patients are accepting of delivery services to help them with their DRPs. With middle aged patients being more receptive of the delivery services, technology can potentially play an important role in minimizing DRPs.

Impact of cancer-related fatigue on chemotherapy-induced nausea and vomiting in Asian cancer patients.

INTRODUCTION: Cancer-related fatigue (CRF) has been suggested to be associated with the occurrence of chemotherapy-induced nausea and vomiting (CINV). This study aims to evaluate the potential of CRF in predicting the occurrence of CINV. METHOD: This is a prospective, observational study. Recruited patients received moderately to highly emetogenic single-day chemotherapy regimens. On the day of chemotherapy, patients were instructed to provide a score (Likert scale of 0-10) to describe how CRF interfered with his or her ability to engage in daily activities and a score for how severe it was. Patients were then given a standardized 5-day diary to document their CINV events. RESULTS: A total of 473 eligible patients (median age: 55 years, interquartile range (IQR): 48-61 years) were recruited, with most of the patients diagnosed with gastrointestinal (45%) and breast (37%) cancers. The median score of fatigue interference was 3 (IQR: 0-5). After confounders were adjusted for, patients with low fatigue interference scores (≤3) were more likely to achieve complete protection (no nausea, no vomiting, and no breakthrough antiemetics) of CINV (adjusted odds ratio = 1.57, 95%CI [1.05, 2.35], p = 0.027). CONCLUSION: This is the largest study to date to evaluate the association between CRF and CINV. Patients experiencing CRF possessed a higher risk of poor control for CINV.

Affordability of cancer treatment for aging cancer patients in Singapore: an analysis of health, lifestyle, and financial burden.

BACKGROUND: With the expected rise in newly diagnosed cancer cases among the elderly in Singapore, the affordability of cancer treatments, particularly of targeted therapies, will be a growing concern for patients. This study examines the perspectives of aging cancer patients on the financial burden of their cancer treatments. METHODS: A single-center, prospective study was conducted in the largest ambulatory cancer center in Singapore. Older (50 years old and above) cancer patients receiving treatment were recruited. Patients completed three sets of self-reporting tools assessing their (a) demographics and lifestyles, (b) health-related quality of life, and (c) perceptions of cancer treatment costs. The association between targeted therapy utilities and their perceived financial burden was evaluated using a multivariable logistic regression. RESULTS: Five hundred and sixteen patients were included in the study. The majority of the respondents (69.6 %) were between 50 and 64 years old. The majority were Singaporeans (97.7 %), belonged to the ethnic Chinese group (88.4 %), and most were female (59.1 %). The users of targeted therapies were 2.92 times more likely to perceive that the amount of cash that they spent on cancer treatment was more than expected and 2.52 times more likely to have difficulty paying for cancer treatments. Fortunately, the majority of the respondents (70.6 %) found their existing financial schemes helpful in reducing the necessary out-of-pocket expenses. CONCLUSIONS: Although aging cancer patients feel that the financial schemes in Singapore have helped them tremendously, the general perception is that they require further help to offset their out-of-pocket expenses. This is especially true for users of targeted therapies and those who have a poorer health status.

Computational prediction of state anxiety in Asian patients with cancer susceptible to chemotherapy-induced nausea and vomiting.

State anxiety, a risk factor for chemotherapy-induced nausea and vomiting (CINV), is a subjective symptom and difficult to quantify. Clinicians need appropriate anxiety measures to assess patients' risks of CINV. This study aimed to determine the anxiety characteristics that can predict CINV based on computational analysis of an objective assessment tool. A single-center, prospective, observational study was carried out between January 2007 and July 2010. Patients with breast, head and neck, and gastrointestinal cancers were recruited and treated with a variety of chemotherapy protocols and appropriate antiemetics. Chemotherapy-induced nausea and vomiting characteristics and antiemetic use were recorded using a standardized diary, whereas patients' anxiety characteristics were evaluated using the Beck Anxiety Inventory. Principal component (PC) analysis was performed to analyze the anxiety characteristics. A subset known as principal variables, which had the highest PC weightings, was identified for patients with and without complete response, complete protection, and complete control. Chemotherapy-induced nausea and vomiting events and anxiety characteristics of 710 patients were collated; 51%, 30%, and 20% were on anthracycline-, oxaliplatin-, and cisplatin-based therapies, respectively. Most patients suffered from delayed CINV, with decreasing proportions achieving complete response (58%), complete protection (42%), and complete control (27%). Seven symptoms (fear of dying, fear of the worst, unable to relax, hot/cold sweats, nervousness, faintness, numbness) were identified as potential CINV predictors. This study demonstrates the usefulness of PC analysis, an unsupervised machine learning technique, to identify 7 anxiety characteristics that are useful as clinical CINV predictors. Clinicians should be aware of these characteristics when assessing CINV in patients on emetogenic chemotherapies.

Antiemetic effectiveness and nausea and vomiting incidence during capecitabine and oxaliplatin chemotherapy.

BACKGROUND: Capecitabine and oxaliplatin (XELOX) chemotherapy causes nausea and vomiting, despite adequate administration of antiemetics. Furthermore, specific risk factors that increase this risk are not elucidated. OBJECTIVE: To appraise the effectiveness of antiemetics to prevent XELOX-induced nausea and vomiting. METHODS: This was a single-center, prospective, cohort study. Patients were recruited on the day of chemotherapy and received follow-up after 5 days to assess nausea and vomiting and use of antiemetics. Patients were assessed for nausea and vomiting control and clinical endpoints of complete response, complete protection, and complete control. Multivariate logistic regression was used to evaluate the risk factors. RESULTS: Mean age of the 156 patients analyzed was 60 years (SD = 9.0) with 88 men (56.4%) and 68 women (43.6%). Patient proportions achieving complete response (87.8%), complete protection (80.8%), and complete control (62.8%) within 24 hours after chemotherapy declined throughout the follow-up period to 76.9%, 64.7%, and 48.7%, respectively. Patients with fewer than three risk factors (odds ratio [OR] = 3.13, p = .006), those receiving oxaliplatin less than 100 mg/m (OR = 3.23, p = .009) and capecitabine less than 1,500 mg/m (OR = 5.00, p = .04), were more likely to achieve complete response. CONCLUSIONS: An unacceptably high proportion of patients receiving XELOX were identified as being unable to attain adequate control of nausea because of inadequate usage of delayed antiemetic prophylaxis. Clinicians should be aware of the chemotherapy-induced nausea and vomiting patterns in this subgroup of patients on XELOX and tailor appropriate management plans. Incorporation of delayed antiemetics to existing institutional guidelines for chemotherapy-induced nausea and vomiting management may improve patients' tolerance of XELOX.

Electronic database to detect drug-drug interactions between antidepressants and oral anticancer drugs from a cancer center in Singapore: implications to clinicians.

BACKGROUND: Electronic drug interaction databases are often utilized in clinical practice to detect for possible drug-drug interactions between drug pairs. It is uncertain, however, whether most of these detections interactions are clinically important in practice. To demonstrate these issues, this study utilized a comprehensive drug-drug interaction (DDI) electronic database to elucidate the prevalence of DDIs at a cancer centre between antidepressants and oral anticancer drugs (ACDs). METHODS: Drug utilization reports were retrieved to determine the patients who were prescribed with antidepressants oral ACDs between 2006 and 2009 at a cancer center. Medication records of these patients were retrospectively examined using OncoRx, an internet-based oncology-specific database that allows the identification of DDIs. RESULTS: Out of 910 users of antidepressants, about one-third (281 patients, 30.9%) used an oral ACD and an antidepressant concomitantly. From these patients, about one-fifth (21.0%) had potential DDIs. These patients were users of 17 potentially interacting drug pairs. Ten out of the 17 drug pairs could potentially cause pharmacokinetic interactions, and the rest were pharmacodynamic interactions, with only three out of the 17 drug pairs were clinically documented to cause interacting events. CONCLUSION: The lack of screening conditions may have led to an over detection of DDI combinations by electronic DDI databases. Many of the detected interactions may not deem high significance in clinical practice. This study exposed a major weakness of current electronic DDI databases for detecting oral ACDs and antidepressants DDIs.

Assessment of the relationship between adherence with antiemetic drug therapy and control of nausea and vomiting in breast cancer patients receiving anthracycline-based chemotherapy.

BACKGROUND: There are little prevalence data in the literature on nonadherence to outpatient antiemetic regimens for prophylaxis of chemotherapy-induced nausea and vomiting (CINV). It is unclear whether adherence with outpatient antiemetic regimens is associated with better CINV control. Our previous survey research supports the work of clinical pharmacists in collaborative practice with medical oncologists in improving adherence with antiemetic therapy in women undergoing highly emetic chemotherapy for breast cancer. OBJECTIVES: To (a) evaluate the impact of adherence to delayed antiemetics (days 2-4 following anthracycline-based chemotherapy) on CINV control in breast cancer patients after anthracycline-based chemotherapy and (b) identify patient-related factors associated with nonadherence to delayed antiemetics. METHODS: A single-center, prospective, observational study was conducted from December 2006 to January 2011 in breast cancer patients receiving anthracycline-based chemotherapy (doxorubicin or epirubicin) and antiemetics at the National Cancer Centre Singapore (NCCS), the largest ambulatory cancer center in Singapore. Included patients were aged 21 years or older with confirmed diagnoses of breast cancer and receiving anthracycline-containing chemotherapy with antiemetics. Patients were excluded if they (a) were diagnosed with intestinal obstruction or received concurrent radiotherapy that predisposed them to nausea and vomiting, (b) had vomited in the 24 hours preceding chemotherapy, or (c) had brain metastases that would impair their judgment. Patients documented in a standardized diary their emesis events, severity of nausea, use of rescue therapy with metoclopramide, and compliance with dose instructions for antiemetic drug therapy for 5 days: day 1 was the day of chemotherapy and first day of antiemetic therapy, and day 5 was the day after completion of delayed antiemetic therapy (days 2-4). Three definitions were used to describe the CINV outcomes: (a) complete response (no emetic episodes and no rescue therapy); (b) complete protection (no emetic episodes, no rescue therapy, and no significant nausea [Likert score 2 or less]); and (c) complete control (no emetic episodes, no rescue therapy, and no nausea). The delayed (days 2-5 post-chemotherapy) phase of these endpoints was analyzed. Nonadherence was defined as missing at least 1 dose of the delayed antiemetics from the prescribed regimen. Pearson chi-square or Fisher's exact tests and multiple logistic regression analysis were used to assess the relationship between adherence and CINV outcomes. RESULTS: Of 519 eligible patients, 88 (17.0%) patients declined participation; 35 (6.7%) were lost to follow-up; and another 35 (6.7%) were excluded due to the absence of therapy with delayed antiemetics according to guideline protocol. Of the 361 (69.6%) patients included in the final analysis, the mean (SD) age was 50.0 (8.9); the majority was Chinese (80.1%) and diagnosed with stage 2 or higher breast cancer (88.1%). A total of 152 patients (42.1%) self-reported nonadherent use of delayed antiemetics. Among all the nonadherent patients (n=152), 16.4% (n=25) achieved complete control; 34.2% (n=52) achieved complete protection; and 58.6% (n=89) achieved complete response, compared with rates of 26.8% (n=56), 39.7% (n=83), and 62.7% (n=131), respectively, for adherent patients (n=209). The rate of adherence to dexamethasone, which was prescribed for all study patients, was low (62.6%). After adjusting for potential confounders (ethnicity, educational level, and disease stage), adherent patients were more likely to achieve complete control of CINV (adjusted odds ratio=1.74, 95% CI=1.01-3.01, P=0.048). Among the demographic and CINV risk-factor variables, higher education, alcohol consumption, and prior exposure to other (nonanthracycline-based) chemotherapy regimens were associated with nonadherence (P < 0.05). CONCLUSIONS: Although 42% of breast cancer patients receiving anthracycline-based chemotherapy were nonadherent with the dose administration protocol for post-chemotherapy antiemetic therapy, there was no significant difference in control of CINV compared with adherent patients except for the category of complete CINV control, defined as no nausea, no emesis, and no use of the rescue medication metoclopramide.

Exploring Chemotherapy-Induced Toxicities through Multivariate Projection of Risk Factors: Prediction of Nausea and Vomiting.

Many risk factors exist for chemotherapy-induced nausea and vomiting (CINV). This study utilized a multivariate projection technique to identify which risk factors were predictive of CINV in clinical practice. A single-centre, prospective, observational study was conducted from January 2007~July 2010 in Singapore. Patients were on highly (HECs) and moderately emetogenic chemotherapies with/without radiotherapy. Patient demographics and CINV risk factors were documented. Daily recording of CINV events was done using a standardized diary. Principal component (PC) analysis was performed to identify which risk factors could differentiate patients with and without CINV. A total of 710 patients were recruited. Majority were females (67%) and Chinese (84%). Five risk factors were potential CINV predictors: histories of alcohol drinking, chemotherapy-induced nausea, chemotherapy-induced vomiting, fatigue and gender. Period (ex-/current drinkers) and frequency of drinking (social/chronic drinkers) differentiated the CINV endpoints in patients on HECs and anthracycline-based, and XELOX regimens, respectively. Fatigue interference and severity were predictive of CINV in anthracycline-based populations, while the former was predictive in HEC and XELOX populations. PC analysis is a potential technique in analyzing clinical population data, and can provide clinicians with an insight as to what predictors to look out for in the clinical assessment of CINV. We hope that our results will increase the awareness among clinician-scientists regarding the usefulness of this technique in the analysis of clinical data, so that appropriate preventive measures can be taken to improve patients' quality of life.