title: The effectiveness of therapeutic patient education on adherence to oral anti-cancer medicines in adult cancer patients in ambulatory care settings: a systematic review.
abstract: BACKGROUND
  Adherence to oral cancer medicines is a challenge for adult patients with cancer. Education specifically tailored for an individual patient with cancer may improve adherence. Therapeutic patient education when utilized effectively may maximize health outcomes and positively affect the quality of life of adult patients with cancer. Currently, there are no published systematic reviews specific to the effectiveness of therapeutic patient education on improvement of oral anti-cancer medicines adherence in patients with cancer.
  
  
  OBJECTIVE
  To synthesize the best available evidence on the effectiveness of therapeutic patient education on adherence to oral anti-cancer medicines in adult cancer patients 18 years and older in an ambulatory care setting.
  
  
  METHODS
  Types of participants: This review considered studies involving adults of any ethnicity, race or gender, aged 18 years or older who were diagnosed with any form of cancer, receiving oral anti-cancer medicines in an ambulatory care setting. Types of intervention(s): This review considered studies on the use of therapeutic patient education as the additional intervention to routine patient education for promoting oral anti-cancer medicine adherence in adult patients with cancer in an ambulatory care setting. Routine patient education was considered as a comparator. Types of outcomes: The outcome considered was adherence to prescribed oral anti-cancer medicines. Types of studies: This review considered experimental and observational studies.
  
  
  METHODS
  The literature search included published and unpublished studies in the English Language from 1953 through August 2014. A search of PubMed, CINAHL, Excerpta Medica Database, Academic Search Premier, Cochrane Library, PsycINFO, and Health Source: Nursing/Academic Edition was conducted using identified keywords and indexed terms across all included databases. A search for grey literature and electronic hand searching of relevant journals was also performed.
  
  
  METHODS
  Two reviewers independently evaluated the included studies for methodological quality utilizing standardized critical appraisal instruments from the Joanna Briggs Institute.
  
  
  METHODS
  Standardized data extraction tools were used by two reviewers independently as per the Joanna Briggs Institute for data extraction.
  
  
  RESULTS
  Due to clinical and methodological heterogeneity between the included studies, statistical meta-analysis was not feasible. The results are presented in a narrative form.
  
  
  RESULTS
  Two studies were included in this review, one randomized controlled trial and one cohort study. Both studies had small sample sizes and were moderate and low quality. The clinical significance of therapeutic patient education interventions and the relationship between behavior changes and health outcome changes remain unclear. The randomized clinical trial found a benefit in medication adherence rates in the tailored education intervention group compared to the standard education group at two and four months. Adherence rates measured by self-report (91.3% and 95.1%) and pharmacy refill rates (80% and 73.7%) were superior for the intervention group; however pharmacy refill rates were lower than self-reports of adherence. Tailored educational interventions were only beneficial on pharmacy refill rates (p=.0048) for promoting adherence at the two-month time interval. The cohort study found the intensified pharmaceutical educational intervention group demonstrated enhanced overall medication adherence then the standard education group (97.9% vs. 90.5%, p=0.069). The intervention group also showed a higher mean daily adherence to medication (96. 8% vs. 87.2%, p=0.029). The relative risk of the intervention group deviating from the medication intake interval of 12 hours was 0.51(95%CI, 0.46-0.56) compared to the control group (p<0.05, Chi-square test).The two studies showed no statistically significant differences, only modest to low evidence that therapeutic educational interventions support the clinical outcome of oral anti-cancer medicine adherence.
  
  
  CONCLUSIONS
  There is a paucity of research evidence on the effectiveness of therapeutic patient educational interventions for improving patient adherence to oral cancer medicines. The effect of therapeutic patient educational interventions on oral anti-cancer medicine adherence has yet to be determined. Therapeutic patient educational interventions remain questionable, differing in format and educational strategies. A specific standardized methodology and evaluation approach to therapeutic patient education may reduce symptomatology, prevent side effects, maximize health outcomes and positively affect the quality of life and survival of adult patients with cancer.
  
  
  CONCLUSIONS
  There is limited evidence that therapeutic patient educational interventions improve oral anti-cancer medicine adherence in adult patients with cancer in ambulatory care settings. A growing number of patients with cancer are being prescribed oral anti-cancer medicines; a better understanding of how therapeutic patient education strategies are effectively implemented may promote patient self-motivation and oral anti-cancer medicine adherence. This review recommends the development of a specific standardized methodology and evaluation approach to therapeutic patient education that may empower patients to increase their adherence to self-managed medication and achieve positive health outcomes
  
  
  CONCLUSIONS
  Clinical trials with larger sample sizes, standardization of content, comparing specific adherence education or tailored education interventions are needed.
authors.affiliation: College of Health Professions, Pace University, New York, United States of America.
authors.forename: Gilly
authors.initials: G
authors.lastname: Arthurs
authors.affiliation: College of Health Professions, Pace University, New York, United States of America.
authors.forename: Janice
authors.initials: J
authors.lastname: Simpson
authors.affiliation: College of Health Professions, Pace University, New York, United States of America.
authors.forename: Andrea
authors.initials: A
authors.lastname: Brown
authors.affiliation: College of Health Professions, Pace University, New York, United States of America.
authors.forename: Ohnma
authors.initials: O
authors.lastname: Kyaw
authors.affiliation: College of Health Professions, Pace University, New York, United States of America.
authors.forename: Sharon
authors.initials: S
authors.lastname: Shyrier
authors.affiliation: The Northeast Institute for Evidence Synthesis and Translation (NEST): a Collaborating Centre of the Joanna Briggs Institute; Lienhard School of Nursing, Pace University, New York, United States of America.
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Concert
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000553:Ambulatory Care; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D055118:Medication Adherence; D009369:Neoplasms / Q000188:drug therapy*; D010353:Patient Education as Topic
chemical_list: D000970:Antineoplastic Agents
keywords: Adult; cancer; medication adherence; medication compliance; neoplasm; oral chemotherapy; patient compliance; patient education; therapeutic education