Cancer and was responsible for 8.8 million deaths in

has a long history of troubling mankind as a disease itself. It often ends
one’s life within a very short period of time. Thus, it can be quite
debilitating for the patients and their loved ones. Therefore, it is crucial
that treatment options for different types of malignancies are explored. Due to
the complexity of cancer cells and their mechanism of action, treatment options
are very limited. Even today it’s an ongoing challenge to find a definite cure
for this disease. This further signifies the importance of continuing to
conduct research into this area of medicine. 


cancer cells have the ability to affect any part of the body and is characterized
by its uncontrollable and abnormal overgrowth pattern. It can rapidly create abnormal
cells that grow beyond their usual boundaries and then invade the adjoining
organs and distant parts as well (WHO, 2012). It begins to harm the body when
altered cells divide uncontrollably to form lumps or masses of tissue called
tumors that are malignant.

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is reported as a leading cause for morbidity and mortality worldwide. In 2013
there were 14.9 million cancer cases and 8.2 million deaths. It is the second
leading cause of death globally, and was responsible for 8.8 million deaths in
2015. Globally 1 in 6 deaths is due to cancer. Number of new cases are expected
to rise by about 70% over the next two decades. Africa, Asia, Central and South
America account for 60% of total new cancer cases and 70% of cancer deaths in
the world (WHO, 2012).


out of fifteen Asian countries consist of 3.6 million males and 4.0 million
females living with cancer (diagnosed within the past five years). Within the Asian
countries, colon and rectal cancers are most common among male cancer survivors
and breast cancer is the most prevalent among female survivors. Other most
common causes of death include lung, liver, stomach, breast, colorectal and esophageal
cancer (WHO, 2012).


is evident that cancer is a significant burden for many reasons. Not only it
have a great impact on the healthcare system, but it is also a financial
burden. Among the male population, prostate cancer has become more frequent
(1.4 million) while among the female population it’s breast cancer (1.8
million). Incidence rates have increased in most countries since 1990. This
trend is a particular threat to developing nations with health systems that are
ill-equipped to deal with complex and expensive treatments. Thus, effective
measures must be taken to reduce cancer morbidity and mortality (Oncol, 2015).


has shown that five leading behavioral and dietary risks including high body
mass index, low fruit and vegetable intake, lack of physical activity, tobacco
and alcohol use are responsible for around one third of cancer related deaths.
Most important risk factor among them is the tobacco use and it is accounted
for approximately 22% of deaths (WHO, 2012). The impact of one’s genetic makeup
along with exposure to carcinogens play a major role in this. There are other
risk factors such as age, hormones, infectious agents, radiation and sunlight which
also contribute to the development of this disease.


There are various
types of treatments available. The type of treatment depends on the type of
cancer and how advanced it is. Surgery, chemotherapy, radiation therapy, immunotherapy,
targeted therapy, hormone therapy and stem cell transplantation are the main
types of treatment. The main goals of treatment include definite cure,
prolongation of life and relief of suffering.


considering treatment options, priority is given for oral anti-cancer agents
(OACA) which is classified under chemotherapy. Oral chemotherapy is not
available for all types of cancers and it can be defined as any drug taken orally
to treat cancer by destruction of the malignant cells.  OACA are used as single agents or in
combinations and indicated for solid tumors and hematological malignancies
(Timmers et al, 2012). OACA have different modes of action and different
toxicity profiles.


Majority of
antineoplastic drugs act by interfering with cell growth. These drugs can be
used for cure, control or as palliative therapy. They have various mechanism of
actions. These include the interaction with the process of cell division of
cancer cells and DNA, RNA synthesis. Furthermore, they can also interfere with
various metabolic functions of cells disrupting normal cell function and altering
the hormonal environment of the cell.


OACA have
been used in multiple types of cancer such as lung cancer, colon cancer, along
with hematological and genitourinary cancers. Some commonly used oral
anti-cancer agents are Capecitabine, Cyclophosphamide, Vinorelbine, Temozolamide
and Mercaptopurine.


chemotherapy has many advantages like ease of administration and convenience
and the ability to reduce the need for invasive procedures. Oral therapy in
general is preferable in the patient population over parenteral therapy due to
its ease and comfort. In addition, it does not cause significant damage to
surrounding organs as radiotherapy. There are some challenges associated with
oral chemotherapy. For instance, adherence to medication, understanding complex
schedules and its different side effect profiles can be challenging. It can
also interact with food and other medications. 
There is always the risk of medication errors and the lack of safe
handling procedures (Mahay, 2009).


cancerous cells grow more rapidly than other cells. The drug can target other normal
dividing cells as well. As a result, antineoplastic drugs will affect hair
follicles, gonad organs, lymph tissues and bone marrow. Some of the common side
effects of these drugs are nausea, vomiting, diarrhea, loss of appetite, hair
loss, mouth sores and skin changes. These side effects of OACA negatively affect
the level of adherence.


oral chemotherapy requires a new model of patient education, monitoring and support
that would depend on integration and collaboration among physicians and pharmacists.
This is due to the fact that adherence is very important in oral chemotherapy. It
is more crucial for outpatients rather than for in-patients because in-patients
can be monitored daily by healthcare professionals. It is clear that it is one
of the most important factors that should be considered in oral chemotherapy.


is defined as the extent to which the patient’s history of therapeutic
drug-taking correlates with the prescribed treatment (WHO, 2015). It implies
that health professionals have a responsibility to form a relationship with
patients in order to encourage them to comply with recommended treatment
regimen.  Having a good professional
relationship between patients and healthcare providers can be beneficial when encouraging


to long term therapies in the general population is around 50% in developed
countries while it’s much lower in developing countries (WHO, 2013). A patient’s
level of

towards medication differs around the world based on numerous factors such as
economic status social support and level of education (Mathes et al,
2014). Due to financial circumstances, two million elderly Medicare
beneficiaries did not adhere to drug treatment regimens. In turn higher
hospitalizations and deterioration of their health were reported (Mojtabai et
al. 2003).


patients do not take their medications according to prescribed regimen, it is
known as non-adherence or poor adherence. Non-adherence to medications will have
a negative effect on their overall health. 
It will cause increased hospitalizations, difficulty in the management
of disease, resistance, poor health condition or even death. Non-adherence can occur
both intentionally and unintentionally. This will lead to either overuse or
underuse of prescribed medication. It may happen due to missed doses, delaying
or not filling a prescription at all. Some may even cease their medication prematurely.


is prevalent among long term therapies. Such as for the treatment of asthma, tobacco
smoking-cessation, hypertension, mental disorders, tuberculosis, epilepsy etc. It
is more common in cancer patients. However, it’s difficult to establish the
adherence with the nature of the disease because patients are reluctant to
adhere to treatment options due to their ideas on disease process and
prognosis. For instance, some have the presumption that their prognosis is poor
despite treatment. The word “cancer” alone is enough for patients to lose hope
and they cease their medications. They lack information regarding benefits of


to the life-threatening nature of the disease, non-adherence to self-administered
medication by outpatients can occur. Similarly, some may even alter the
prescribed therapy assuming that an increased dose for example may provide
better outcomes. In contrast, others may reduce the dose due to perceived
toxicity and side effects. The effect of medication may not be immediate and
this carries the risk of ceasing treatment prematurely. Without appropriate
monitoring in a home setting it is more likely that that the prescribed regimen
may not be followed adequately.


that can affect non-adherence for oral chemotherapy include lack of understanding
the benefit of the treatment, finances (poverty and travelling cost), complex
administration schedules and adverse effects of the medicine. It has been shown
that the presence of cognitive impairment due to psychological problems and
anti-drug attitude can also have a great impact (Amato, 2008).


should be avoided as much as possible in order to achieve an effective role from
oral chemotherapy. Therefore adherence needs to be improved in this type of
patients by reassuring that oral chemotherapy is effective. They will also
require regular follow up, education regarding the rationale for the treatment
and assurance that their health care professionals are there for ongoing


Anti-cancer medications are very expensive
and can be of great burden for the health care system. It’s very important to reap
maximum benefit of the medicines. It was estimated that 107 billion dollars are
spent annually for anti-cancer drug treatment. Although a large amount of money
is spent on cancer medications for a patient, most countries in the developed world
provide anti-cancer medications to patients free of charge. Therefore it’s extremely
important to find whether the patients are taking their medications as
indicated. If they are not taking medications properly, it is harmful and
non-beneficial for their disease. It is also a huge wastage of money. Therefore
it is clear that adherence to oral chemotherapy is essential to ensure that maximum
benefit is attained.

All of the above reasons mentioned prove that adherence
plays an important role in the effectiveness of oral chemotherapy in
outpatients. Adequate adherence can lead to effective treatment while
non-adherence will reduce the effectiveness of the treatment. This is more
relevant for outpatients who lack regular monitoring of their therapy. 

Conducting this study on the level of adherence further
demonstrates its importance. If they identified that their level of adherence
is low then they can aim to improve. If they stated their adherence is
sufficient, then they can continue in this manner. 

Even though this type of
studies had been conducted in foreign countries, there are no previous studies done
investigated adherence to oral chemotherapy for cancer outpatients in Sri Lanka.
This research study will play an important part in ongoing oral chemotherapy treatment.
Adherence levels can play a role in the overall health of the patient
population, including their quality of life. In summary, the healthcare system
depends on this type of studies to ensure that patients receive the best
quality of healthcare possible.