Initiation and adherence to adjuvant endocrine therapy among urban, insured American Indian/Alaska Native breast cancer survivors

Concurrent factors associated with adherence to adjuvant endocrine therapy among women with non-metastatic breast cancer

PURPOSE

Adjuvant endocrine therapy (AET) reduces breast cancer morbidity and mortality, yet women often report suboptimal adherence. Though correlates of AET adherence are well-documented, few studies examine the relative importance of multi-level factors associated with adherence. The aim of this study was to identify factors most strongly associated with AET adherence in women with breast cancer.

METHODS

Between 10/2019 and 6/2021, women (N = 100) with non-metastatic, hormone receptor-positive breast cancer, taking AET who reported AET-related distress enrolled into a clinical trial. Participants completed baseline measures, including the Medication Adherence Rating Scale-5, sociodemographics, and validated measures of anxiety, depression, medication-taking self-efficacy, social support, and treatment satisfaction. We created a latent factor and tested associations between sociodemographic, medical, and psychosocial characteristics and adherence. Associated predictors (p < .10) were entered into a structural model, which was corroborated via multivariate regression modeling.

RESULTS

A four-indicator latent adherence factor demonstrated good model fit. Participants (Mage = 56.1 years, 91% White) who were unemployed (B = 0.27, SE = 0.13, p = .046) and reported greater treatment convenience (B = 0.01, SE = 0.01, p = .046) reported greater adherence. Scores of participants who reported greater medication-taking self-efficacy (p = .097) and social support (p = .062) approached better adherence. Greater medication-taking self-efficacy (B = 0.08, SE = 0.02, p < .001) and being unemployed (B = 0.28, SE = .14, p = .042) were most strongly associated with greater adherence, independent of other predictors. Multivariate modeling confirmed similar findings.

CONCLUSIONS

Medication-taking self-efficacy and employment status were associated with AET adherence above other related factors.

IMPLICATIONS FOR CANCER SURVIVORS

Enhancing patients' confidence in their ability to take AET for breast cancer may represent an important intervention target to boost adherence.

Racial Disparities in Breast Cancer: from Detection to Treatment

PURPOSE OF REVIEW

Update on current racial disparities in the detection and treatment of breast cancer.

RECENT FINDINGS

Breast cancer remains the leading cause of cancer death among Black and Hispanic women. Mammography rates among Black and Hispanic women have surpassed those among White women, with studies now advocating for earlier initiation of breast cancer screening in Black women. Black, Hispanic, Asian, and American Indian and Alaskan Native women continue to experience delays in diagnosis and time to treatment. Further, racial discrepancies in receipt of guideline-concordant care, access to genetic testing and surgical reconstruction persist. Disparities in the initiation, completion, toxicity, and efficacy of chemotherapy, endocrine therapy, and targeted drug therapy remain for racially marginalized women. Efforts to evaluate the impact of race and ethnicity across the breast cancer spectrum are increasing, but knowledge gaps remain and further research is necessary to reduce the disparity gap.

Use of endocrine therapy for estrogen receptor-positive breast cancer among American Indians and Alaska natives

BACKGROUND

American Indian/Alaska Native (AI/AN) women with estrogen receptor-positive (ER +) breast cancer have higher mortality compared to non-Hispanic whites (NHW). The purpose of this study is to compare rates of initiation of endocrine therapy (ET) between AI/AN and NHW and further determine survival outcomes for ER + breast cancer.

METHODS

We used the National Cancer Database to identify patients diagnosed with ER + breast cancer, stage I-III, between 2004 and 2017. Multivariable logistic regression was performed to determine factors associated with initiation of adjuvant ET. Overall survival was estimated using the Kaplan-Meier analysis and Cox proportional hazards modeling.

RESULTS

We identified a total of 771,619 patients (AI/AN, n = 2473; NHW, n = 769,146). Compared to NHW, AI/AN patients were more likely to live in rural areas, be younger, and have tumors that were higher grade, node positive, and larger. Initiation of adjuvant ET was high in both groups and not significantly different between AI/AN and NHW. Independent predictors of ET initiation included rural location, age, higher tumor grade, node-positive disease, larger tumor size, and progesterone receptor-positive status. Initiation of ET was significantly associated with improved overall survival among all patients. Overall survival was significantly worse among the AI/AN population.

CONCLUSION

AI/AN race was significantly and independently associated with worse overall survival after diagnosis of ER + breast cancer. We did not find a significant difference in the initiation of adjuvant ET between AI/AN and NHW. Exact reasons why AI/AN women with ER + breast cancer have higher mortality rates remain elusive but are probably multifactorial.

Geographic Variations and the Associated Factors in Adherence to and Persistence with Adjuvant Hormonal Therapy for the Privately Insured women Aged 18–64 with Breast Cancer in Texas

The purpose of this study is to examine the geographical patterns of adjuvant hormonal therapy adherence and persistence and the associated factors in insured Texan women aged 18–64 with early breast cancer. A retrospective cohort study was conducted using 5-year claims data for the population insured by the Blue Cross Blue Shield of Texas (BCBSTX). Women diagnosed with early breast cancer who were taking tamoxifen or aromatase inhibitors (AIs) for adjuvant hormonal therapy with at least one prescription claim were identified. Adherence to adjuvant hormonal therapy and persistence with adjuvant hormonal therapy were calculated as outcome measures. Women without a gap between two consecutively dispensed prescriptions of at least 90 days were considered to be persistently taking the medications. Patient-level multivariate logistic regression models with repeated regional-level adjustments and a Cox proportional hazards model with mixed effects were used to determine the geographical variations and patient-, provider-, and area-level factors that were associated with adjuvant hormonal therapy adherence and persistence. Of the 938 women in the cohort, 627 (66.8%) initiated adjuvant hormonal therapy. Most of the smaller HRRs have significantly higher or lower rates of treatment adherence and persistence rates relative to the median regions. The use of AHT varies substantially from one geographical area to another, especially for adherence, with an approximately two-fold difference between the lowest and highest areas, and area-level factors were found to be significantly associated with the compliance of AHT. There are geographical variations in AHT adherence and persistence in Texas. Patient-level and area-level factors have significant associations explaining these patterns.

Cancer statistics for American Indian and Alaska Native individuals, 2022: Including increasing disparities in early onset colorectal cancer

American Indian and Alaska Native (AIAN) individuals are diverse culturally and geographically but share a high prevalence of chronic illness, largely because of obstacles to high-quality health care. The authors comprehensively examined cancer incidence and mortality among non-Hispanic AIAN individuals, compared with non-Hispanic White individuals for context, using population-based data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. Overall cancer rates among AIAN individuals were 2% higher than among White individuals for incidence (2014 through 2018, confined to Purchased/Referred Care Delivery Area counties to reduce racial misclassification) but 18% higher for mortality (2015 through 2019). However, disparities varied widely by cancer type and geographic region. For example, breast and prostate cancer mortality rates are 8% and 31% higher, respectively, in AIAN individuals than in White individuals despite lower incidence and the availability of early detection tests for these cancers. The burden among AIAN individuals is highest for infection-related cancers (liver, stomach, and cervix), for kidney cancer, and for colorectal cancer among indigenous Alaskans (91.3 vs. 35.5 cases per 100,000 for White Alaskans), who have the highest rates in the world. Steep increases for early onset colorectal cancer, from 18.8 cases per 100,000 Native Alaskans aged 20-49 years during 1998 through 2002 to 34.8 cases per 100,000 during 2014 through 2018, exacerbated this disparity. Death rates for infection-related cancers (liver, stomach, and cervix), as well as kidney cancer, were approximately two-fold higher among AIAN individuals compared with White individuals. These findings highlight the need for more effective strategies to reduce the prevalence of chronic oncogenic infections and improve access to high-quality cancer screening and treatment for AIAN individuals. Mitigating the disparate burden will require expanded financial support of tribal health care as well as increased collaboration and engagement with this marginalized population.

Breast Cancer Screening and Outcomes Disparities Persist for Native American Women

Over the past three decades, mortality rates from breast cancer have decreased for multiple racial groups but have remained constant for American Indian and Alaskan Native (AI/AN) women. Additionally, AI/AN women are less likely to receive timely breast cancer screening and are more likely to be diagnosed with advanced stage breast cancer at younger ages than their White counterparts. These disparities can be explained, in part, by the unique barriers to accessing care faced by AI/AN women. The Indian Health Service provides care to many AI/AN patients; however, their scope of practice is limited, and the service is chronically underfunded, leaving many women without appropriate and timely care. Additionally, geographic access to care is limited because of the sparsity of clinics and limited transportation resources. American Indian and Alaskan Native patients also harbor a history of mistrust in health care systems, and there is a paucity of culturally sensitive education regarding the importance of screening. There have been some grassroots efforts to address these barriers; however, large-scale coordinated efforts are lacking. In order to provide equitable breast health care, more awareness and widescale initiatives are needed and can be championed by breast radiologists.

Predictors of adherence and the role of primary non-adherence in antihormonal treatment of breast cancer

BACKGROUND

Antihormonal treatment for hormone receptor (HR) positive breast cancer has highly beneficial effects on both recurrence rates and survival. We investigate adherence and persistence in this group of patients.

METHODS

The study population comprised 1192 patients with HR-positive breast cancer who were prescribed adjuvant antihormonal treatment from 2004 to 2013. Adherence was defined as a medical possession ratio (MPR) of ≥80.

RESULTS

Of the 1192 included patients, 903 (75.8%) were adherent and 289 (24.2%) were non-adherent. Primary non-adherence was seen in 101 (8.5%) patients. The extremes of age (< 40 and ≥ 80 years) were associated with poor adherence. Patients with metastasis to axillary lymph nodes and those who received radiotherapy and/or chemotherapy were more likely to be adherent. Better adherence was also shown for those who switched medication at 2 years after diagnosis. Primary non-adherence seems to be associated with cancers with a good prognosis.

CONCLUSION

Adherence to antihormonal therapy for breast cancer is suboptimal. Primary non-adherence occurs among patients with a relatively good prognosis. Non-adherent patients tend to terminate their antihormonal therapy in the initial part of the treatment period. Targeted interventions to improve adherence should be focused on the first part of the treatment period.

Factors influencing five-year adherence to adjuvant endocrine therapy in breast cancer patients: A systematic review

Purpose

This systematic review aimed to determine the rate and identify correlates of adherence and persistence over five years of treatment with adjuvant endocrine therapy in female breast cancer patients.

Methods

Relevant articles were identified from Medline, Embase, AMED, PsycINFO, International Pharmaceutical Abstracts, and APA PsycArticles. Studies that measured patient adherence in the implementation or persistence phase for a period of at least five years using objective or multiple measures of adherence and investigated correlates of adherence were included. The titles, abstracts and full articles were screened and reviewed by two authors and any discrepancies were discussed with a third author.

Results

Twenty-six studies were included. Mean rate of adherence at five-year for implementation phase was 66.2% (SD = 17.3%), and mean persistence was 66.8% (SD = 14.5%). On average, adherence decreased by 25.5% (SD = 9.3%) from the first to fifth year. Higher rate of adherence was observed through self-report in comparison to database or medical record. Older age, younger age, higher comorbidity index, depression and adverse effects were associated with lower adherence. Treatment with aromatase inhibitors, received chemotherapy, and prior medication use were associated with improved adherence.

Conclusion

Adherence to adjuvant endocrine therapy decreased from the first to fifth year of treatment. On average, one-third of patients were not adherent to treatment by the fifth year. Nineteen recurring factors were found to be significantly associated with long-term adherence in multiple studies. Further research using objective or multiple measures of adherence are needed to improve validity of results.

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On average, adherence fell by 25.5% from the first to the fifth year of treatment.

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Self-reported adherence may overestimate patient adherence.

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Nineteen recurring factors were associated with adherence.

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Having adverse effects was negatively associated with adherence.