 My name is Laurie Appleby. I'm a nurse practitioner at the Dana-Barber Cancer Institute in Boston, Massachusetts. And I'm going to talk to you about how you take your anti-cancer drugs. As the slide says, it may not be as easy as you think. Research shows that some patients, for some patients, adherence to their anti-cancer medications can be as low as 50%. Now, this isn't because the patient is obstinant or contrary, but rather there are a whole host of outside forces that can influence one's ability to adhere to a particular medication regimen. So what can go wrong? Well, cost is a major factor. These drugs are expensive. And although there are benefit programs to limit high co-pays, for most patients not everyone has access to these programs. And even those that do, sometimes with the assistance, the co-pay can be quite high, as high as $500 in some cases, which renders the drug prohibitive for many. If you couple that with other co-pays a patient may have, then it becomes a real problem, sometimes forcing people to choose which disease or medical problem they want to treat. Work and life responsibilities also can interfere with one's ability to adhere to a medication program. We tend to put our own priorities below those of our loved ones, and when that happens, sometimes that can interfere with taking your medication on a regular basis. The convenience or inconvenience of dosing the drug also can interfere. So drugs taken once a day are maybe easier to adhere to than those taken several times a day. The timing is also important. If a drug needs to be taken on an empty stomach, that certainly can interfere with one's ability to take it on a regular basis. Also taking it with other medications, can it be taken with other medications or does it have to be taken by itself? So work and life responsibilities cost and timing of the drug can be problematic for folks. What else can go wrong? If you're developing side effects, as you know, there is a long and daunting list provided by your pharmacist that accompanies the prescription. And although the list is meant to be informative, it may prompt some of the individuals to wonder, gee, is this drug going to do me more harm than good? Also, they wonder if this is the drug that's right for them. Development of unpleasant side effects might tempt you to skip doses. This is particularly true for people who have an important business or social event and don't want to be inconvenienced by an unpleasant side effect. I had a patient in the office this week whose granddaughter was married two weeks ago and the wedding took place on Cape Cod on the beach. And this particular patient is on Nexivar, her main side effect is diarrhea. And although she controls it very well with anti-diarrheal medications, just to be on the safe side, she stopped her Nexivar for a week before the wedding so that she would be sure to be able to enjoy the wedding without having to deal with any side effects from her Nexivar. So these are some but not all of the factors that can lead to improper dosing of your anti-cancer medication. So what do you need to know? Knowledge is power. And studies show that the more we know about a particular medication or a particular treatment regimen, the more likely we are to follow the program. So you need to know how the medication works. What does it do? You need to know how it will benefit you in particular. You may know how it works in general, but what about its effects on you in particular? And are there other options? For example, if you have a very busy schedule and you're on a drug that needs to be dosed multiple times a day on an empty stomach, that may be inconvenient. You may know right off the bat you're not going to be able to stick to it. So ask your clinician, is there anything else that might be more appropriate for me? You also, of course, need to know time of day, frequency, number of times a day. Do you take it with or without food? Can the tablet be crushed? Can it be taken with other medications? Are there scheduled breaks, as with sous-tent? You also need to know, and these two are very important, what do you do if you skip a dose and what do you do if you take too many doses? Also, is there anything you should avoid while you're taking your anti-cancer medication? Such as grapefruit, most of us know that, but did you know that you also shouldn't eat star fruit? Alcoholic beverages may be contraindicated, such as if you're on votrient, really should not drink alcohol. Some nutritional supplements, if not all, maybe should be best be avoided when you're on these medications. Of course, you need to know what the side effects are. What can you expect and when can you expect it? Are you going to get it immediately, or do these side effects occur two or three weeks into therapy, or maybe two or three months into therapy? And then, most importantly, what can you do about these side effects if you do develop them? Your clinicians have a wide array of strategies to help you manage many of the most common side effects that are associated with these drugs. And that's why it's important to know how to reach your clinicians during the day, during off hours, and on the weekends. So, knowledge is power for your doctors and nurses as well. And so what we need to know is a complete and accurate list of all your medications. And we suggest that people keep a list, an up-to-date list, on their person at all times. Are you taking any non-prescription medications, such as vitamins, dietary supplements, herbal supplements, and as we mentioned before, nutritional supplements? Do you have any allergies? What are your habits? Do you smoke? Do you drink? Do you use any illicit drugs, such as marijuana? These are important things for your doctors and nurses to know so that we can advise you properly on your medication regimen. What else do we need to know? Well, we need to know your health history. There are a lot of medical conditions that are important considerations when developing a treatment plan for you. Other health problems such as high blood pressure, heart disease, and diabetes are important things to know. What is your living situation? Do you live alone? And if you do, do you have a social support network, family and friends who you can call on? Do you live with a spouse or partner? Are you a primary caretaker for that spouse or partner? And are you responsible for another person's health and welfare? We also need to know insurance information. Do you have prescription drug coverage? And if so, what is it? The name and number of your local pharmacy and the name and number of your mail order pharmacy. Most insurers require mail order pharmacies for dispensing of these medications. If we have that information ahead of time, it makes the process of obtaining the medication go a little more smoothly and a little more quickly. So what can you do to improve adherence? We've talked about being knowledgeable about your medications, sharing information with your healthcare provider about your health history and your social situation. Other things that you can do, and the more nitty-gritty things that you can do is use a pill box or calendar as a way of keeping track of doses. Who hasn't ever said, gee, I wonder if I took that pill this morning? But if you have a pill box, it's much easier to track whether you did. Make sure someone else knows your medication schedule as well. They can help serve as reminders. Other reminders could be an alarm clock, a smartphone, set to go off at a certain time to remind you to take your medication. Read the handouts. Again, knowledge is power. The more you know, the better it is for you. And don't be afraid to ask questions. Even if you have to ask the same question multiple times, always ask. Because when in doubt, you need to ask your healthcare provider whether that's in the office or in a phone call. They can help you with side effects. We can change the dose schedule if needed. Offer help with co-pay assistance as well. And these are some of the resources that we use to recommend for patients so that they can gain more knowledge about their disease and their treatment. The Kidney Cancer Association in particular has an excellent website, and included in that website is information about patient advocacy. So I would encourage you all to visit that website as it is very informative. National Cancer Institute and American Cancer Society also has good information. And for patient assistance programs, all of the drug, the pharmaceutical companies that have anti-cancer medications have patient assistance programs. And these assistance programs are excellent resources. If you fail to qualify for their particular program, they often have other programs where they can refer you. But I would not hesitate to utilize these assistance programs when needed. So thanks very much for your attention and remember, ask questions and talk to your healthcare provider. Good luck and thank you.