Barriers and facilitators of deprescribing for older adults with cancer and polypharmacy

Abstract

Introduction

Polypharmacy affects up to 93% of older adults with cancer and increases risks of treatment toxicity, drug interactions, and adverse outcomes. Deprescribing, the planned discontinuation of potentially inappropriate medications, can mitigate these risks. However, deprescribing interventions in oncology clinics remain understudied outside palliative care settings. This study aimed to identify barriers and facilitators to deprescribing in the oncology clinic across multiple stakeholder groups.

Materials and methods

Between November 2020 and August 2021, virtual focus groups were conducted with five key informant groups: patients (n = 9), primary care physicians (n = 7), oncology pharmacists (n = 7), oncology nurses (n = 7), and oncologists (n = 6). Participants were recruited from the University of Rochester Wilmot Cancer Institute, affiliated sites, and a patient advisory board. Semi-structured interview guides explored topics including polypharmacy definitions, medication communication, workflows, and deprescribing strategies. Sessions were audio-recorded, transcribed verbatim, and analyzed using inductive content analysis with MAXQDA software. Two coders performed open coding and developed themes categorized at patient, healthcare provider, and system levels.

Results

At the patient level, barriers included resistance to change, lack of awareness, mistrust, and health complexity, while facilitators included education/empowerment, effective communication, and caregiver involvement. At the provider level, barriers encompassed knowledge gaps, scope of practice concerns, and time limitations, with facilitators including inter-provider communication, education, longitudinal approaches, and provider maturity. System-level barriers included care fragmentation, electronic health record limitations, and automated workflows, while facilitators emphasized team-based care, decision support tools, and pharmacist integration. Notably, all groups expressed consistent enthusiasm for pharmacist involvement in deprescribing interventions.

Discussion

This analysis revealed multilevel barriers and facilitators to deprescribing in older adults with cancer. Mismatches between provider perceptions and patient attitudes suggest opportunities for improved communication. Time constraints and scope of practice concerns were prominent provider barriers, addressable through longitudinal approaches and team-based models. The consistent enthusiasm across all stakeholder groups for pharmacist-led interventions informed the design of a subsequent cluster-randomized trial. These findings suggest scalable interventions leveraging pharmacist expertise and decision support tools to address polypharmacy in this vulnerable population.