Non-initiation of adjuvant hormonal therapy in women with hormone receptor-positive breast cancer: The Breast Cancer Quality of Care Study (BQUAL)

Factors and Beliefs Affecting Women Diagnosed With Breast Cancer to Initiate Cancer Treatment: A Systematic Review

BACKGROUND

Initiating treatment within the optimal time is critical for women with breast cancer. A delay in cancer treatment initiation can result in increased morbidity and mortality and decreased overall survival.

OBJECTIVE

This systematic review aims to investigate the literature for the factors and beliefs affecting women diagnosed with breast cancer with regard to initiating cancer treatment.

METHODS

The PubMed, CINAHL, and PsycINFO databases were searched using the terms of breast cancer, initiating or seeking treatment, and beliefs. The Johns Hopkins Evidence-Based Practice Research Evidence Appraisal Tool was used to evaluate the included articles.

RESULTS

Sixteen articles were included in this review. The addressed factors were classified as (1) patient-related factors, (2) disease-related factors, (3) provider-related factors, and (4) system-related factors. The identified beliefs were cultural beliefs and perceived barriers to initiating treatment.

CONCLUSION

Although the literature reported multiple factors and beliefs that impact the time of initiating treatment among women with breast cancer, more research is needed to fully understand the beliefs influencing treatment initiation. It is essential to address and screen the factors and beliefs identified for women diagnosed with breast cancer to enhance treatment initiation early and prevent any possible delay. Interventions can be developed to overcome the factors and beliefs that may lead to late treatment initiation. Advocacy for new policies should be in action to reduce the disparities associated with treatment initiation among women with breast cancer.

Associations between HIV infection status, psychosocial factors, and adjuvant endocrine therapy adherence among South African women with early-stage breast cancer

Purpose

We aimed to evaluate for associations between HIV status, psychosocial factors, and adjuvant endocrine therapy (AET) adherence in South African (SA) women with estrogen receptor positive (ER+) breast cancer (BC).

Methods

We enrolled South African women with early-stage ER + BC in remission and prescribed tamoxifen or an aromatase inhibitor to the prospective observational study. We performed AET pill counts at enrollment, 12 weeks, and 24 weeks, and calculated adherence ratios of pills consumed between visits to days between visits. Women completed questionnaires on social support, attitude towards medication, health literacy, self-efficacy, mental health, and AET toxicity. We collected household wealth data. We used hierarchical linear (HLM) and structural equation modelling (SEM) to compare adherence ratios between women with and without HIV while adjusting for psychosocial factors.

Results

We collected adherence data from 239 women, 63 (26.4%) with co-morbid HIV. Comparing women with and without HIV, median AET adherence ratio was 0.88 vs 0.89, respectively (HLM p = 0.31). In our SEM model for the full cohort, mental health, healthcare savvy, and side effect burden latent variables were not significantly associated with adherence. In the subgroup of women living with HIV, lower SES quintile (β 0.04, SE 0.02, p = 0.08) and poorer mental health (β -0.02, SE 0.01, p = 0.10) showed trends toward association with adherence.

Conclusions

HIV status is not predictive of AET adherence among SA women with ER + BC, though decreasing SES status and increasing mental health symptoms are marginally associated with adherence in women with BC and HIV.

The lived experience of patients with breast cancer on adjuvant endocrine therapy: side effects and coping strategies during the first year of medication initiation

PURPOSE

Adjuvant endocrine therapy (AET) is pivotal for hormone receptor-positive breast cancer patients, significantly enhancing survival rates. Yet, adherence to AET remains challenging due to side effects. This study delves into the lived experience of breast cancer survivors concerning AET-induced side effects and examines differences in symptom profiles between Tamoxifen and aromatase inhibitors (AIs).

METHODS

We interviewed 35 breast cancer survivors on AET, conducting qualitative iterative analysis using grounded theory. A codebook was developed to aid data coding and interpretation. NVIVO software facilitated comprehensive transcript analysis.

RESULTS

Survivors reported a spectrum of side effects like hot flashes, sexual issues, joint pain, stiffness, mood swings, and fertility concerns. Symptom profiles differed based on AET type. Tamoxifen users experienced more frequent sexual side effects and mood swings, while AIs were linked to joint pain, stiffness, and bone health worries. Those on AET for over 6 months expressed heightened concerns about side effects.

CONCLUSION

Tailored patient education, aligned with AET type, empowers survivors to manage side effects using self-regulatory strategies. Acknowledging distinct symptom profiles enables informed decisions, improving adherence and quality of life.

IMPLICATIONS

This study underscores tailored survivorship support, equipping patients with tools to manage side effects, enhancing adherence, and long-term outcomes. The findings inform the integration of comprehensive survivorship programs, emphasizing individualized strategies for managing side effects and promoting better adherence and improved quality of life.

Resistance to Resilience: Understanding Post-surgical Hormone Therapy in Breast Cancer Care

Breast cancer is one of the most common types of cancer affecting women worldwide. Over the years, breast cancer has become a major public health concern, and its incidence is rising globally. The treatment of breast cancer does not stop with surgical intervention, but adjuvant therapies are administered to improve patient outcomes post-surgery based on the type of breast cancer diagnosed. This review focuses on the value of hormone therapy (HT) in improving the prognosis of breast cancer patients and why adhering to adjuvant treatment post-surgery is difficult for patients. HT aims to reduce the chances of breast cancer recurrence after surgical treatment. Even though HT is life-saving, patients tend to not adhere to the therapy due to various factors such as side effects, age-related issues, and socioeconomic status. Most patients stop adhering to the therapy as the duration can be as long as 5-10 years, and the quality of life is greatly impacted due to the side effects of the treatment. This review examines the possible factors leading to non-adherence to HT and tries to propose possible interventions that might improve patient compliance with the treatment. This article not only focuses on the impact of side effects of HT on patients' quality of life but also tries to understand the problems faced by breast cancer patients in adhering to HT.

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.

Preventing metastatic recurrence in low-risk ER/PR + breast cancer patients-a retrospective clinical study exploring the evolving challenge of persistence with adjuvant endocrine therapy

PURPOSE

In the genomic era, more women with low-risk breast cancer will forego chemotherapy and rely on adjuvant endocrine therapy (AET) to prevent metastatic recurrence. However, some of these patients will unfortunately relapse. We sought to understand this outcome. Preliminary work suggested that early discontinuation of AET, also known as non-persistence, may play an important role. A retrospective analysis exploring factors related to our breast cancer patients' non-persistence with AET was performed.

METHODS

Women who underwent Oncotype-DX® testing between 2011 and 2014 with minimum 5 years follow-up were included. 'Low risk' was defined as Oncotype score < 26. Outcomes of recurrence and persistence were determined by chart review. Patient, tumor and treatment factors were collected, and persistent versus non-persistent groups compared using multivariable ANOVA and Fisher Chi square exact test.

RESULTS

We identified six cases of distant recurrence among low-risk patients with a median follow-up of 7.7 years. Among them, five of six patients (83%) were non-persistent with AET. The non-persistence rate in our cohort regardless of recurrence was 57/228 (25%). Non-persistent patients reported more severe side effects compared with persistent patients (p = 0.002) and were more likely to be offered a switch in endocrine therapy, rather than symptom-relief (p = 0.006). In contrast, persistent patients were 10.3 times more likely to have been offered symptom-alleviating medications compared with non-persistent patients (p < 0.001). A subset analysis revealed that patients who persisted with therapy had a higher Oncotype-DX® score than patients who discontinued early (p = 0.028).

CONCLUSION

Metastatic recurrence in low-risk breast cancer patients may be primarily due to non-persistence with endocrine therapy. Further work is needed to optimize care for patients who struggle with side effects. To our knowledge, these are the first published data suggesting that Oncotype-DX® score may influence persistence with AET.

Adjuvant endocrine therapy non-initiation and non-persistence in young women with early-stage breast cancer

PURPOSE

Characterizing oral adjuvant endocrine therapy (ET) non-initiation and non-persistence in young women with breast cancer can inform strategies to improve overall adherence in this population.

METHODS

We identified 693 women with hormone receptor-positive, stage I-III breast cancer enrolled in a cohort of women diagnosed with breast cancer at age ≤ 40 years. Women were classified as non-initiators if they did not report taking ET in the 18 months after diagnosis. Women who initiated but did not report taking ET subsequently (through 5-year post-diagnosis) were categorized as non-persistent. We assessed ET decision-making and used logistic regression to identify factors associated with non-initiation/non-persistence and to evaluate the association between non-persistence and recurrence.

RESULTS

By 18 months, 9% had not initiated ET. Black women had higher odds and women with a college degree had lower odds of non-initiation. Among 607 women who initiated, 20% were non-persistent. Younger age, being married/partnered, and reporting more weight problems were associated with higher odds of non-persistence; receipt of chemotherapy and greater hot flash and vaginal symptom burden were associated with lower odds of non-persistence. Adjusting for age and clinical characteristics, non-persistence was associated with lower odds of recurrence. Women who initiated were more likely to report shared decision-making than non-initiators (57% vs. 38%, p = 0.049), while women who were non-persistent were less likely to indicate high confidence with the decision than women who were persistent (40% vs. 63%, p < 0.001).

CONCLUSION

Interventions to improve ET decision-making may facilitate initiation and address barriers to adherence in young breast cancer survivors.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov , NCT01468246.

Patient experiences and views on pharmaceutical care during adjuvant endocrine therapy for breast cancer: A qualitative study

OBJECTIVE

The use of adjuvant endocrine therapy (AET) after primary treatment of hormone receptor-positive breast cancer reduces the risk of recurrence and mortality. However, non-adherence is still common. Limited consideration has been given to how users deal with AET and the role of pharmaceutical care. Therefore, this study aims to obtain insight into the needs and wishes of women using AET regarding pharmaceutical care and eHealth.

METHODS

This is a qualitative explorative study comprising semi-structured interviews (n = 16) and a focus group (n = 5) among women who use or used AET after primary early-stage breast cancer (EBC) treatment using a thematic analysis approach.

RESULTS

Three themes emerged from the interviews and focus group: (1) experiences with AET use, (2) experiences with provided information and (3) needs and wishes regarding pharmaceutical care. Most women were highly motivated to use AET and indicated to have received useful information on AET. However, many expressed a strong need for more elaborate tailored and timely provided information on AET. They acknowledged the accessibility of pharmacists but reported that currently, pharmacists are hardly involved in AET care. Several women considered eHealth useful to obtain counselling and reliable information.

CONCLUSION

Women need more comprehensive information and follow-up in primary setting after initial cancer treatments. A more elaborate role for the pharmacy and eHealth/mHealth, especially with regard to counselling on side effects and side effect management, could potentially improve pharmaceutical care.

Breast cancer knowledge and understanding treatment rationales among diverse breast cancer survivors

Purpose

The degree to which breast cancer survivors know about their tumors and understand treatment rationales is not well understood. We sought to identify information gaps within a diverse sample and explore whether knowledge about breast cancer and treatment may impact care.

Methods

We conducted a one-time, interviewer-administered survey of women who were diagnosed with breast cancer during 2013–2017 and received care at one of three centers in Boston, MA, and New York, NY. We examined knowledge of breast cancer and treatment rationales, information preferences, and treatment receipt.

Results

During 2018–2020, we interviewed 313 women (American Association for Public Opinion Research Cooperation Rates 58.4–76.5% across centers) who were 56.9% White, 23.6% Black, 14.1% Hispanic, and 5.4% other. Among the 296 included in analyses, we observed high variability in knowledge of breast cancer and treatment rationales, with a substantial number demonstrating limited knowledge despite feeling highly informed; > 25% actively avoided information. Black and Hispanic (vs. White) women consistently knew less about their cancers. Lack of understanding of treatment rationales for chemotherapy, radiation, and hormonal therapy was common but not consistently different by race and ethnicity. Understanding treatment rationale (but not cancer knowledge) was associated with treatment initiation, but small sample sizes limited in-depth examination.

Conclusions

Our study highlights the need for enhanced informational support for breast cancer survivors, who are challenged with complex information during the decision-making process and beyond. More research is needed to understand how to further educate and empower diverse populations of patients with breast cancer.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06752-8.

Factors Associated With Patients Not Receiving Oral Anticancer Drugs

IMPORTANCE

Oral anticancer drugs (OACDs) are increasingly prescribed for cancer treatment and require significant coordination of care. Retrospective studies suggest that 10% to 20% of OACD prescriptions are never received by the patients, but the reasons behind this are poorly understood.

OBJECTIVES

To estimate the rate of failure to receive OACD prescriptions among patients with cancer and to examine the underlying reasons for this failure.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study was conducted among patients with cancer who were prescribed a new OACD from January 1, 2018, to December 31, 2019, at an urban academic medical center. Data analysis was conducted between 2021 and 2022.

MAIN OUTCOMES AND MEASURES

Patient demographic, clinical, and insurance data and OACD delivery dates were collected. The reasons for a failure to receive a prescribed OACD within 3 months were confirmed by manual review of medical records and were classified into 7 categories: clinical deterioration, financial access, clinician-directed change in decision-making, patient-directed change in decision-making, transfer of care, loss to follow-up, and unknown or other. A multivariable random-effects model was developed to identify factors associated with failure to receive a prescribed OACD.

RESULTS

The cohort included 1024 patients (538 men [53%]; mean [SD] age, 66.2 [13.9] years; 463 non-Hispanic White patients [45%], 140 non-Hispanic Black patients [14%], and 300 Hispanic patients [29%]), representing 1197 new OACD prescriptions. Of the 1197 prescriptions, 158 (13%) were categorized as having not been received by the patient. The most common reason for the failure to receive a prescribed OACD was due to patient and clinician decision-making (73 of 158 [46%]), and 20 cases (13%) in which prescriptions were not received were associated with financial access issues. In multivariable analysis, patients with a nonmetastatic solid malignant neoplasm were significantly less likely to not receive their OACDs than those with a hematologic malignant neoplasm (odds ratio, 0.57 [95% CI, 0.33-1.00]; P = .048).

CONCLUSIONS AND RELEVANCE

This cohort study of patients prescribed a new OACD found that 13% of prescriptions were not received. The failure to receive a prescribed OACD was most frequently due to a change in clinical decision-making or patient choice. Ultimately, the reasons for the failure to receive a prescribed OACD were multifactorial and may have been appropriate in some cases.

The lived experience during the peri-diagnostic period of breast cancer: A scoping review

OBJECTIVES

The aim of this scoping review is to provide an overview of the existing research that investigates the lived experience during the peri-diagnostic period of breast cancer.

METHODS

Nine databases were searched for relevant literature between January 2007 and April 2019. Data were extracted and categorized using deductive and inductive approaches.

RESULTS

A majority of the 66 studies included used qualitative methods to retrospectively explore the treatment decision making process of female breast cancer patients. Patients experienced uncertainty, emotional distress, and a need for more information from providers and relied on social support and family guidance during this period.

CONCLUSIONS

The results of this review show that the burdens experienced during the peri-diagnostic period parallel those in later periods of cancer care. However, these burdens are prompted by different circumstances. More research is needed to explore the lived experience during this period through the use of mixed-methods and by recruiting a diverse sample with regards to role in the breast cancer experience, age, gender, race, and ethnicity.

PRACTICE IMPLICATIONS

Interventions positioned at earlier points in the breast cancer experience should provide informational support, which could be delivered through shared decision making models. Additional support could be facilitated by patient navigation programs and health information technology.

Five-Year Adjuvant Endocrine Therapy Adherence Trajectories Among Women With Breast Cancer: A Nationwide French Study Using Administrative Data

BACKGROUND

Adjuvant endocrine therapy (AET) improves long-term survival of breast cancer patients, yet many women are nonadherent or discontinue this treatment. In this study we aimed to describe AET adherence trajectories over 5 years after treatment initiation and to identify factors associated with these trajectories, in a nationwide French cohort of breast cancer survivors.

PATIENTS AND METHODS

Every woman diagnosed with a first nonmetastatic breast cancer in 2011 in France who initiated AET in the 12 months after surgery was included from the French cancer cohort. We identified all reimbursements for AET from national health administrative data sets and modeled AET adherence trajectories over 5 years, using group-based trajectory modeling on the basis of the monthly proportion of days covered by AET. Associated factors were identified using multinomial logistic regressions.

RESULTS

We included 33,260 women. A 6-trajectory model was selected: 1, immediate discontinuation (6.6%); 2, continuous suboptimal adherence (4.3%); 3, progressive nonadherence then discontinuation (6.3%); 4, early nonadherence then discontinuation (5.7%); 5, continuous optimal adherence (68.8%); and 6, late nonadherence then discontinuation (8.3%). The main factors associated with nonadherence trajectories were extreme age (younger than 50 and older than 70 years) and switching AET.

CONCLUSION

Approximately 70% of women had optimal adherence over all 5 years. The original nationwide approach enabled us to identify the "continuous suboptimal adherence trajectory" never previously described.

Assessing Predictors of Tamoxifen Nonadherence in Patients with Early Breast Cancer

Adjuvant endocrine therapy (AET) is generally proposed to all patients with hormone receptor-positive breast cancer to reduce the risk of recurrence and death. Adherence to therapy is crucial. However, non-adherence to AET is common, with estimates of up to 50% of patients not successfully completing a five-year course of treatment, and it is significantly associated with lower survival rates and a higher risk of recurrence. Currently, no gold standard is available to assess adherence. Several studies, most of them retrospective in nature, have used both direct and indirect methods to monitor the adherence to therapy in breast cancer. The indirect method is more widely used, and it is based on pharmacy prescription refills and patient administered questionnaires. On the other hand, direct methods such as a measurement of the level of the drug or its metabolites in blood or urine are much more precise, but more expensive and not routinely implemented. In this review, we analyzed the results of the major studies focused on the adherence to tamoxifen in breast cancer patients. We identified several factors associated with poor adherence, such as the side effects of therapy, the lack of shared decision-making between the physician and patient, the context in which the discussion takes place, and whether the patients are enrolled in a clinical trial. Moreover, we discussed possible methods to improve adherence to adjuvant therapy in breast cancer.

Improving Adherence to Adjuvant Hormonal Therapy Among Disadvantaged Women Diagnosed with Breast Cancer in South Carolina: Proposal for a Multimethod Study

BACKGROUND

Current clinical guidelines recommend that hormone receptor-positive breast cancer survivors take adjuvant hormonal therapy (AHT) for 5 to 10 years, following the end of definitive treatment. However, fewer than half of patients adhere to the guidelines, and suboptimal adherence to AHT is associated with an increased risk of breast cancer mortality. Research has extensively documented sociodemographic and disease-specific factors associated with adherence to AHT, but very little evidence exists on behavioral factors (eg, knowledge, patient-provider communication) that can be modified and targeted by interventions.

OBJECTIVE

The goal of this study is to develop and test a theory-based, multilevel intervention to improve adherence to AHT among breast cancer survivors from racially and socioeconomically disadvantaged backgrounds (eg, Medicaid-insured). The specific aims are to (1) explore multilevel (eg, patient, health care system) factors that influence adherence to AHT; (2) develop a theory-based, multilevel intervention to improve adherence to AHT; and (3) pilot test and evaluate the intervention developed in Aim 2.

METHODS

For Aim 1, we will recruit breast cancer survivors and health care professionals to participate in semistructured interviews to gain their perspectives about barriers and facilitators to AHT use. We will conduct a directed content analysis of the Aim 1 qualitative interview data. For Aim 2, we will integrate Aim 1 findings and current literature into the design of a multilevel intervention using an Intervention Mapping approach. For Aim 3, we will recruit Medicaid-insured breast cancer survivors to assess the feasibility of the pilot intervention.

RESULTS

From May 2016 to July 2018, we completed interviews with 19 breast cancer survivors and 23 health care professionals in South Carolina. We will conduct a directed content analysis of the qualitative interview data. Results from this analysis will be used, in combination with current literature, to design (Aim 2) and pilot test a theory-based multilevel intervention (Aim 3) in Summer 2021. Results of the pilot are expected for Fall 2021.

CONCLUSIONS

This study will provide a deeper understanding of how to improve adherence to AHT, using a novel and multilevel approach, among socioeconomically disadvantaged breast cancer survivors who often experience disproportionate breast cancer mortality.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17742.

Endocrine treatment and incidence of relapse in women with oestrogen receptor-positive breast cancer in Europe: a population-based study

PURPOSE

Endocrine therapy (ET) is the mainstream adjuvant treatment for ER-positive breast cancer (BC). We analysed 9293 ER-positive BC patients diagnosed in nine European countries in 2009-2013 to investigate how comorbidities at diagnosis, age, stage and subtype affected ET use over time, and relapse.

METHODS

Adjusted odds ratios (ORs) and 95% confidence intervals (95%CIs) of receiving ET were estimated according to Charlson comorbidity, age, stage and subtype using logistic regression. The 2-year cumulative incidence and adjusted sub-hazard ratios (SHRs) of relapse were estimated using competing risk analysis, with all-cause death as the competing event. The z-test was used to assess differences in the proportion of patients receiving ET in 1996-1998 and 2009-2013.

RESULTS

Ninety percent of the patients started adjuvant ET, range 96% (Belgium, Estonia, Slovenia, Spain)-75% (Switzerland). ORs of starting ET were lower for women aged > 75 years, with severe comorbidities, or luminal B HER2-positive cancer. The factors independently increasing the risk of relapse were: not receiving ET (SHR 2.26, 95%CI 1.02-5.03); severe comorbidity (SHR 1.94, 95%CI 1.06-3.55); luminal B, either HER2 negative (SHR 3.06, 95%CI 1.61-5.79) or positive (SHR 3.10, 95%CI 1.36-7.07); stage II (SHR 3.20, 95%CI 1.56-6.57) or stage III (SHR 7.41, 95%CI 3.48-15.73). ET use increased significantly but differently across countries from 51-85% in 1996-1998 to 86-96% in 2009-2013.

CONCLUSIONS

ER-positive BC patients in Europe are increasingly prescribed ET but between-country disparities persist. Older women and women with severe comorbidity less frequently receive ET. ET omission and severe comorbidity independently predict early disease relapse.

Increasing Adherence to Adjuvant Hormone Therapy Among Patients With Breast Cancer: A Smart Phone App-Based Pilot Study

PURPOSE

This study tested the feasibility and efficacy of using a text-based intervention to increase initiation, decrease discontinuation, and improve adherence as prescribed to adjuvant hormone therapy (AHT) among hyphenate post-menopausal breast cancer survivors.

METHODS

The 3-month intervention consisted of daily text message reminders to take medication, coupled with a dynamic (eg, feedback on progress) tailored intervention using weekly interactive surveys delivered by a smartphone app. Five clinic sites within the Alliance for Clinical Trials in Oncology participated. Hormone levels were measured prior to AHT initiation and at study exit.

RESULTS

Of the 39 patients recruited to the pilot study, 27 (69.2%) completed all study requirements (completed both the baseline and the exit surveys, both blood draws, and did not miss more than 2 weekly surveys). Significant improvements were observed pre- to postintervention for self-reported medication adherence (P = .015), mental health functioning (P = .007), and perceived stress (P = .04). Significant decreases in estradiol, estrogen, and estrone hormone levels were observed from baseline to study exit (P < .001), indicating the accuracy of self-reported AHT adherence. Participants (91.9%) and physicians (100%) agreed that participant participation in the intervention was beneficial.

CONCLUSIONS

The results of this pilot study established the general feasibility and efficacy of an app-based intervention to support patient AHT adherence. Larger controlled, randomized trials are needed to examine the effectiveness of the app-based intervention in improving AHT and quality of life among breast cancer survivors.

Providers' Perspectives on Adherence to Hormonal Therapy in Breast Cancer Survivors. Is there a Role for the Digital Health Feedback System?

Objective

Despite the benefits of hormonal therapy (HT) adherence remains suboptimal in ER positive breast cancer patients. Medication adherence is challenging to assess and tends to be overestimated. The Digital Health Feedback System (DHFS) consists of an ingestible sensor attached to a pill that sends intake date and time to a smart phone or computer. Patients can share this information with health care providers and other persons. The DHFS can also send reminders. This mixed methods study examined providers' perceptions of HT medication adherence. The potential role of the DHFS in enhancing medication tracking and adherence was also explored.

Methods

We conducted semi-structured interviews with key informants (N=10). Questions examined perceptions about adherence barriers and facilitators, challenges tracking adherence, and views on the DHFS. Findings informed the development of a survey that was administered online (N=19).

Results

Providers emphasized the importance of fostering open and trustful communication around adherence. The most mentioned challenges to assessing adherence were the patient not disclosing discontinuation immediately (78.9%) and over-reporting adherence (57.9%). The perceived potential benefits of DHFS were the ability to track adherence better (94.7%) and reminders to take the medication (68.4%). Safety to ingest a sensor was as a major perceived barrier (8 4.2%).

Conclusion

Interventions that target providers and doctor-patient communication are warranted to enhance adherence and reduce communication delays around HT discontinuation.

Practice Implications

DHFS has the potential to enhance HT adherence by directly targeting barriers. Future studies should also examine the feasibility of adopting the DHFS with cancer patients.

Endocrine Therapy Nonadherence and Discontinuation in Black and White Women

BACKGROUND

Differential use of endocrine therapy (ET) by race may contribute to breast cancer outcome disparities, but racial differences in ET behaviors are poorly understood.

METHODS

Women aged 20-74 years with a first primary, stage I-III, hormone receptor-positive (HR+) breast cancer were included. At 2 years postdiagnosis, we assessed nonadherence, defined as not taking ET every day or missing more than two pills in the past 14 days, discontinuation, and a composite measure of underuse, defined as either missing pills or discontinuing completely. Using logistic regression, we evaluated the relationship between race and nonadherence, discontinuation, and overall underuse in unadjusted, clinically adjusted, and socioeconomically adjusted models.

RESULTS

A total of 1280 women were included; 43.2% self-identified as black. Compared to white women, black women more often reported nonadherence (13.7% vs 5.2%) but not discontinuation (10.0% vs 10.7%). Black women also more often reported the following: hot flashes, night sweats, breast sensitivity, and joint pain; believing that their recurrence risk would not change if they stopped ET; forgetting to take ET; and cost-related barriers. In multivariable analysis, black race remained statistically significantly associated with nonadherence after adjusting for clinical characteristics (adjusted odds ratio = 2.72, 95% confidence interval = 1.75 to 4.24) and after adding socioeconomic to clinical characteristics (adjusted odds ratio = 2.44, 95% confidence interval = 1.50 to 3.97) but was not independently associated with discontinuation after adjustment. Low recurrence risk perception and lack of a shared decision making were strongly predictive of ET underuse across races.

CONCLUSIONS

Our results highlight important racial differences in ET-adherence behaviors, perceptions of benefits/harms, and shared decision making that may be targeted with culturally tailored interventions.

Opportunities for personalised follow-up care among patients with breast cancer: A scoping review to identify preference-sensitive decisions

INTRODUCTION

Current follow-up arrangements for breast cancer do not optimally meet the needs of individual patients. We therefore reviewed the evidence on preferences and patient involvement in decisions about breast cancer follow-up to explore the potential for personalised care.

METHODS

Studies published between 2008 and 2017 were extracted from MEDLINE, PsycINFO and EMBASE. We then identified decision categories related to content and form of follow-up. Criteria for preference sensitiveness and patient involvement were compiled and applied to determine the extent to which decisions were sensitive to patient preferences and patients were involved.

RESULTS

Forty-one studies were included in the full-text analysis. Four decision categories were identified: "surveillance for recurrent/secondary breast cancer; consultations for physical and psychosocial effects; recurrence-risk reduction by anti-hormonal treatment; and improving quality of life after breast cancer." There was little evidence that physicians treated decisions about anti-hormonal treatment, menopausal symptoms, and follow-up consultations as sensitive to patient preferences. Decisions about breast reconstruction were considered as very sensitive to patient preferences, and patients were usually involved.

CONCLUSION

Patients are currently not involved in all decisions that affect them during follow-up, indicating a need for improvements. Personalised follow-up care could improve resource allocation and the value of care for patients.

Association between financial burden and adjuvant hormonal therapy adherence and persistent use for privately insured women aged 18-64 years in BCBS of Texas

PURPOSE

The objective of this study is to understand an impact of financial burden on the adjuvant hormonal therapy (AHT) adherence and persistence for insured women aged 18-64 with early breast cancer in Texas.

METHODS

We conducted a retrospective cohort study using claims data for population insured by Blue Cross Blue Shield of Texas from the year 2008 to 2013. Outcomes include adherence to adjuvant hormonal therapy, which was measured by medication possession ratio and persistence on AHT, which is the duration of time from initiation to discontinuation of therapy. Multivariate logistic regression models with repeated regional-level adjustments were used to explore the odds of AHT adherence. Cox proportional hazards model was conducted to assess time to the first 90+-day gap for persistence and a Kaplan-Meier curve were used to estimate probabilities to calculate the percentages of women who experienced 90+-day gaps in AHT.

RESULTS

Of the 938 women in the cohort, 627 (66.8%) initiated the treatment. By year 1, 66.9% of women were adherent to the therapy, and by year 5, only 29% of those were adherent. The percentage of women with no gap in therapy greater than 90 days was 80.8%. Both higher out-of-pocket costs spent on all prescription drugs except AHT and AHT-specific out-of-pocket costs were negatively associated with adherence to AHT as well as continuing AHT as recommended.

CONCLUSIONS

Financial burdens including both non-AHT medication and AHT-specific out-of-pocket costs were significantly associated with adherence and persistence to the therapy.

Initiation of Adjuvant Endocrine Therapy in Black and White Women With Breast Cancer

BACKGROUND

Adjuvant endocrine therapy reduces risk of recurrence and mortality in women with hormone receptor-positive breast cancer, yet many women never initiate it. We examined the influence of race, sociocultural factors, and process-of-care factors on initiation of adjuvant endocrine therapy in a racially diverse sample.

PATIENTS AND METHODS

Eligible women were originally recruited for the Narrowing the Gaps in Adjuvant Therapy Study (2006-2011). Sociocultural and process-of-care factors were collected via telephone surveys before adjuvant therapy. Clinical factors were abstracted from charts. Penalized LASSO (least absolute shrinkage and selection operator) logistic regression model was used to identify variables associated with initiation.

RESULTS

Of the 270 women, 55.6% were black and the rest were white. Most women (74.8%) initiated therapy. A significant interaction (P = .008) was found between race and age. Black women aged ≤ 50 years had the lowest initiation (59.7%) compared to black women > 50 years (87.1%), white women ≤ 50 years (73.7%), or white women > 50 years (72.0%). Multivariate analysis found that younger black women exhibited a marginally higher risk of noninitiation compared to older black women. Additionally, ratings of financial access, presence of comorbidities, and levels of communication were all associated with endocrine therapy initiation.

CONCLUSION

Black women ≤ 50 years of age and women with financial constraints may be important subgroups for interventions. Patient-provider communication appears to be an important leverage point to foster therapy uptake.

Impact of persistence on survival of patients with breast cancer treated with endocrine therapy in Northeast China: a prospective study

The purpose of this prospective study is to investigate the impact of endocrine treatment persistence on the survival of patients with estrogen receptor-positive breast cancer treated with endocrine therapy and identify the risk factors influencing the treatment persistence. We enrolled 1085 patients from Northeast China who were diagnosed as stage I–III, estrogen receptor-positive breast cancer between January 2007 and December 2010. The prognostic factors for disease-free survival (DFS) and overall survival (OS) of patients were identified using univariate and multivariate Cox proportional hazards regression models. Multiple logistic regression analysis was done to determine the possible risk factors for non-endocrine treatment and treatment discontinuation. Among the patients enrolled, 598 (55.1%) underwent 5 years of endocrine therapy, 278 (25.6%) less than 5 years, and 209 (19.3%) non-endocrine therapy. OS rates in the continuation, discontinuation, and non-endocrine treatment groups were 97.8%, 92.6% and 74.3%, and DFS 97.5%, 86.2% and 69.9%, respectively. After adjusting for pathological and socioeconomic factors, non-endocrine therapy and discontinuation were independent predictors for DFS and OS. Elderly patients (≥ 65 years), those living in suburban and rural areas, locally advanced patients, and receiving no radiotherapy and/or chemotherapy were more likely to receive non-endocrine therapy and discontinue endocrine treatment. In conclusion, the prospective study demonstrate that the persistence of endocrine treatment is low in estrogen receptor-positive breast cancer patients in Northeast China. Non-endocrine treatment and early discontinuation serve as independent prognostic factors for both DFS and OS of breast cancer patients treated with endocrine therapy.

Bidirectional Text Messaging to Monitor Endocrine Therapy Adherence and Patient-Reported Outcomes in Breast Cancer

Introduction

Up to 40% of patients with breast cancer may not adhere to adjuvant endocrine therapy. Therapy-related adverse effects (AEs) are important contributors to nonadherence. We developed a bidirectional text-message application, BETA-Text, that simultaneously tracks adherence, records symptoms, and alerts the clinical team.

Patients and Methods

We piloted our intervention in 100 patients. The intervention consisted of text messages to which patients responded for 3 months: daily, evaluating adherence; weekly, evaluating medication-related AEs; and monthly, regarding barriers to adherence. Concerning responses prompted a telephone call from a clinic nurse. The primary objective was to assess patient acceptance of this intervention using self-reported surveys. To compare participants with the general population at our institution, we assessed 100 consecutively treated patients as historical controls using medical record review.

Results

We approached 141 consecutive patients, 100 (71%) of whom agreed to participate and 89 of whom completed the intervention. A majority of patients reported that the intervention was easy to use (98%) and helpful in taking their medication (96%). Four patients discontinued therapy before 3 months, and 93% of patients who continued therapy took ≥ 80% of their medication. The frequency of AEs reported by participants via text was higher than that reported in clinical trials: hot flashes (72%), arthralgias (53%), and vaginal symptoms (35%). Approximately 39% of patients reported one or more severe AE that prompted an alert to the provider team to call the patient.

Conclusion

A daily bidirectional text-messaging system can monitor adherence and identify AEs and other barriers to adherence in real time without inconveniencing patients. AEs of endocrine therapy, as detected using this texting approach, are more prevalent than reported in clinical trials.

Healthcare System Distrust, Physician Trust, and Patient Discordance with Adjuvant Breast Cancer Treatment Recommendations

Background: Adjuvant therapy after breast cancer surgery decreases recurrence and increases survival, yet not all women receive and complete it. Previous research has suggested that distrust in medical institutions plays a role in who initiates adjuvant treatment, but has not assessed treatment completion, nor the potential mediating role of physician distrust.Methods: Women listed in Pennsylvania and Florida cancer registries, who were under the age of 65 when diagnosed with localized invasive breast cancer between 2005 and 2007, were surveyed by mail in 2007 to 2009. Survey participants self-reported demographics, cancer stage and treatments, treatment discordance (as defined by not following their surgeon or oncologist treatment recommendation), healthcare system distrust, and physician trust. Age and cancer stage were verified against cancer registry records. Logistic regression assessed the relationship between highest and lowest tertiles of healthcare system distrust and the dichotomous outcome of treatment discordance, controlling for demographics and clinical treatment factors, and testing for mediation by physician trust.Results: Of the 2,754 participants, 30.2% (n = 832) reported not pursing at least one recommended treatment. The mean age was 52. Patients in the highest tertile of healthcare system distrust were 22% more likely to report treatment discordance than the lowest tertile; physician trust did not mediate the association between healthcare system distrust and treatment discordance.Conclusions: Healthcare system distrust is positively associated with treatment discordance, defined as failure to initiate or complete physician-recommended adjuvant treatment after breast cancer.Impact: Interventions should test whether or not resolving institutional distrust reduces treatment discordance. Cancer Epidemiol Biomarkers Prev; 26(12); 1745-52. ©2017 AACR.

Evaluation of the Quality of Adjuvant Endocrine Therapy Delivery for Breast Cancer Care in the United States

Importance

Randomized trials in breast cancer have demonstrated the clinical benefits of adjuvant endocrine therapy (AET) in preventing recurrence and death. The examination of concordance with AET guidelines at a national level as a measure of quality of care is important.

Objective

To investigate temporal trends and factors related to receipt of AET for breast cancer.

Design, Setting, and Participants

This retrospective cohort study included 981 729 women with breast cancer in the National Cancer Database from January 1, 2004, to December 31, 2013. Women with stages I to III breast cancer who received all or part of their treatment at the reporting institution were included in the analysis.

Main Outcomes and Measures

Temporal changes in AET receipt (estimating the annual percentage change) and AET practice patterns (using logistic regression) and the effect of AET guideline concordance on survival of women with hormone receptor-positive (HR+) breast cancer (using the multivariable Cox proportional hazards model).

Results

Of the 981 729 eligible patients (mean [SD] age, 60.8 [13.3] years), 818 435 had HR+ and 163 294 had HR-negative (HR-) cancer. Among the patients with HR+ cancer, receipt of AET increased over time, from 69.8% in 2004 to 82.4% in 2013. Among patients with HR- cancer, receipt decreased from 5.2% in 2004 to 3.4% in 2013. Hospital-level adherence (≥80% of patients with HR+ cancer received AET) increased from 40.2% in 2004 to 69.2% in 2013. Receipt of AET varied significantly by age (lower in patients ≥80 years), race (lower in African American and Hispanic participants), geographic location (lower in West South Central, Mountain, and Pacific census regions), and receptor status (lower in patients with estrogen receptor-negative and progesterone receptor-positive cancer). Surgery and radiotherapy were the factors most significantly associated with appropriate AET receipt (only 45.0% in patients who received lumpectomy without radiotherapy). Receipt of AET was associated with a 29% relative risk reduction in mortality. Based on this effectiveness estimate, if all patients with HR+ cancer received AET, approximately 14 630 lives would have been saved over 10 years.

Conclusions and Relevance

From 2004 to 2013, underuse and misuse of AET have decreased for patients with breast cancer, but optimal use has not been achieved, and significant variation in care remains. The involvement of surgery and radiotherapy were among the most significant factors associated with optimal use, which underscores the benefits of team-based care to support guideline-concordant therapy.

Endocrine therapy initiation, discontinuation and adherence and breast imaging among 21-gene recurrence score assay-eligible women under age 65

BACKGROUND

Aside from chemotherapy utilization, limited data are available on the relationship between gene expression profiling (GEP) testing and breast cancer care. We assessed the relationship between GEP testing and additional variables and the outcomes of endocrine therapy initiation, discontinuation and adherence, and breast imaging exams in women under age 65 years.

METHODS

Data from five state cancer registries were linked with claims data and GEP results. We assessed variables associated with survivorship care outcomes in an incident cohort of 5014 commercially insured women under age 65 years, newly diagnosed with stage I or II hormone-receptor-positive, human epidermal growth factor receptor 2 (HER2) non-positive breast cancer from 2006 to 2010.

RESULTS

Among tested women, those with high Oncotype DX® Breast Recurrence Score® (RS) were significantly less likely to initiate endocrine therapy than women with low RS tumors (OR 0.40 (95% CI 0.20 to 0.81); P = 0.01). Among all test-eligible women, receipt of Oncotype DX testing was associated with a greater likelihood of endocrine therapy initiation (OR 2.48 (95% CI 2.03 to 3.04); P <0.0001). The odds of initiation were also significantly higher for tested vs. untested women among women who did not initiate chemotherapy within six months of diagnosis (OR 3.25 (95% CI 2.53 to 4.16)), with no effect in women who received chemotherapy. Discontinuation and adherence and breast imaging exams were unrelated to tested status or RS.

CONCLUSIONS

Lower endocrine therapy initiation rates among women with high RS tumors and among untested women not receiving chemotherapy are concerning, given its established efficacy. Additional research is needed to suggest mechanisms to close this gap.

High Initiation of Adjuvant Hormonal Therapy Among Uninsured Stages I-III Breast Cancer Patients Treated in a Safety-Net Healthcare System

OBJECTIVE

Despite benefits of adjuvant hormonal therapy (AHT), many eligible breast cancer patients do not complete therapy as recommended. Patterns of AHT use have not been well studied among uninsured breast cancer patients who fall into coverage gaps or are ineligible for public insurance programs.

METHODS

We identified 291 patients newly diagnosed with stages I-III hormone receptor-positive breast cancer from January 2008 to December 2012. All patients were treated at a safety-net healthcare system and enrolled in an income-based medical assistance program that fills AHT prescriptions at low cost. We extracted and linked cancer registry, pharmacy claims, and medical record data to assess AHT initiation (defined as a new AHT prescription ≤18 months since diagnosis) and sociodemographic and healthcare utilization variables. Log-binomial regression was used to identify correlates of initiation.

RESULTS

Overall, 239 (82%) patients initiated AHT. Tamoxifen (42%) and anastrozole (55%) were most commonly prescribed. The mean copay was $4.90 for tamoxifen and $6.00 for anastrozole. Although crude analyses revealed small, statistically significant prevalence ratios for race/ethnicity (Hispanic vs. white, other vs. white), year of diagnosis (2008 vs. 2012), primary care visit before diagnosis (any vs. none), and smoking status (current vs. never), there were no significant correlates of initiation in the adjusted model.

CONCLUSION

Safety-net healthcare systems providing access to AHT (i.e., through reduced copays) could improve the number of eligible patients initiating therapy. Continuity and integration of care in these settings may reduce disparities frequently observed in uninsured, low-income breast cancer populations.

Investigating Associations Between Health-Related Quality of Life and Endocrine Therapy Underuse in Women With Early-Stage Breast Cancer

PURPOSE

Endocrine therapy (ET) underuse puts women at increased risk for breast cancer (BC) recurrence. Our objective was to determine if health-related quality of life (HRQOL) subgroups were associated with underuse.

METHODS

Data came from the third phase of the Carolina Breast Cancer Study. We included 1,599 women with hormone receptor-positive BC age 20 to 74 years. HRQOL was measured, on average, 5 months postdiagnosis. Subgroups were derived using latent profile (LP) analysis. Underuse was defined as not initiating or adhering to ET by 36 months postdiagnosis. Multivariable logistic regression models estimated adjusted odds ratios (ORs) between HRQOL LPs and underuse. The best HRQOL LP was the reference. Chemotherapy- and race-stratified models were estimated, separately.

RESULTS

Initiation analyses included 953 women who had not begun ET by their 5-month survey. Of these, 154 never initiated ET. Adherence analyses included 1,114 ET initiators, of whom 211 were nonadherent. HRQOL was not significantly associated with noninitiation, except among nonchemotherapy users, with membership in the poorest LP associated with increased odds of noninitiation (adjusted OR, 5.5; 95% CI, 1.7 to 17.4). Membership in the poorest LPs was associated with nonadherence (LP1: adjusted OR, 2.2; 95% CI, 1.2 to 4.0 and LP2: adjusted OR,1.9; 95% CI, 1.1 to 3.6). Membership in the poorest LP was associated with nonadherence among nonchemotherapy users (adjusted OR, 2.1; 95% CI, 1.2 to 5.1).

CONCLUSION

Our results suggest women with poor HRQOL during active treatment may be at increased risk for ET underuse. Focusing on HRQOL, a modifiable factor, may improve targeting of future interventions early in the BC continuum to improve ET initiation and adherence and prevent BC recurrence.

Opportunities and challenges of long term anti-estrogenic adjuvant therapy: treatment forever or intermittently?

INTRODUCTION

Extended adjuvant (5-10 years) therapy targeted to the estrogen receptor (ER) has significantly decreased mortality from breast cancer (BC). Areas covered: Translational research advanced clinical testing of extended adjuvant therapy with tamoxifen or aromatase inhibitors (AIs). Short term therapy or non-compliance increase recurrence, but surprisingly recurrence and death does not increase dramatically after 5 years of adjuvant therapy stops. Expert commentary: Compliance ensures optimal benefit from extended antihormone adjuvant therapy.Retarding acquired resistance using CDK4/6 or mTOR inhibitors is discussed. Preventing acquired resistance from mutations of ER could be achieved with Selective ER Downregulators (SERDs), eg fulvestrant. Fulvestrant is a depot injectable so oral SERDs are sought for extended use. In reality, a 'super SERD' which destroys ER but improves women's health like a Selective ER Modulator (SERM), would aid compliance to prevent recurrence and death. Estrogen-induced apoptosis occurs in 30% of BC with antihormone resistance. The 'one in three' rule that dictates that one in three unselected patients respond to either hormonal or antihormonal therapy in BC occurs with estrogen or antiestrogen therapy and must be improved. The goal is to maintain patients for their natural lives by blocking cancer cell survival through precision medicine using short cycles of estrogen apoptotic salvage therapy, and further extended antihormone maintenance.

Using Technology to Improve Cancer Care: Social Media, Wearables, and Electronic Health Records

Digital engagement has become pervasive in the delivery of cancer care. Internet- and cellular phone-based tools and systems are allowing large groups of people to engage with each other and share information. Health systems and individual health professionals are adapting to this revolution in consumer and patient behavior by developing ways to incorporate the benefits of technology for the purpose of improving the quality of medical care. One example is the use of social media platforms by oncologists to foster interaction with each other and to participate with the lay public in dialogue about science, medicine, and cancer care. In addition, consumer devices and sensors (wearables) have provided a new, growing dimension of digital engagement and another layer of patient-generated health data to foster better care and research. Finally, electronic health records have become the new standard for oncology care delivery, bringing new opportunities to measure quality in real time and follow practice patterns, as well as new challenges as providers and patients seek ways to integrate this technology along with other forms of digital engagement to produce more satisfaction in the process of care along with measurably better outcomes.

Correlates of Triple Negative Breast Cancer and Chemotherapy Patterns in Black and White Women With Breast Cancer

BACKGROUND

Triple negative breast cancer (TNBC) tumors are estrogen receptor-negative, progesterone receptor-negative, and human epidermal growth factor-negative. TNBC is responsive to chemotherapy, but chemotherapy might be underused in some patient subgroups. The goal of the present study was to characterize the patterns of chemotherapy use (uptake and completion) in TNBC patients.

PATIENTS AND METHODS

Women with primary invasive, nonmetastatic breast cancer were recruited in Washington, DC, and Detroit. Data were collected using a standardized telephone survey that captured sociocultural and health care process factors. Clinical data were abstracted from the medical records. We used χ² tests to access the association between the receipt of chemotherapy use (initiation and completion) and categorical variables, and t tests were used for continuous variables. Logistic regression models were used to evaluate the factors associated with chemotherapy uptake.

RESULTS

Women with TNBC (16% of sample) were more likely to be black than white (68% vs. 32%; P < .05). Among women with TNBC, 60% underwent chemotherapy. Chemotherapy uptake was greater for black than for white women (48.3% vs. 11.7%; P = .01) and in women without (vs. with) healthcare discrimination (35% vs. 25%; P = .04). In multivariable models, only race was associated with the receipt of chemotherapy. Black women were more likely to receive chemotherapy than were white women. The odds ratio of receiving chemotherapy by race was 4.1 (95% confidence interval, 1.3-13.1). Each 1-year increase in age was associated with a lower likelihood of chemotherapy completion (odds ratio, 0.9; 95% confidence interval, 0.826-0.981; P = .02). Women with at least some college were less likely to complete chemotherapy than were those with other education levels (P = .02).

CONCLUSION

A substantial number of TNBC patients failed to receive and/or complete chemotherapy. Differences in chemotherapy uptake by race and sociocultural factors diminished in multivariable models but age and stage remained significant. Suboptimal treatment among women with TNBC could contribute to adverse outcomes. Future investigations are necessary to assess whether the noninitiation and/or noncompletion of chemotherapy is clinically warranted.

Disparities and challenges in adherence to oral antineoplastic agents

The issue of medication noncompliance is becoming increasingly important in oncology as more cancer therapies are delivered orally. Medication adherence is difficult to assess and there is no gold standard of measurement. The act of measuring adherence can affect outcomes. Medication noncompliance is common, and is estimated to be 50% in treatment of chronic diseases. Studies have shown that women initiate adjuvant hormonal therapy for breast cancer 64% to 88% of the time when prescribed. Of those who initiate therapy, 50% to 80% are adherent for the prescribed duration, depending on the study. Patients noncompliant with adjuvant hormonal therapy for breast cancer have worse overall survival than their counterparts. Suboptimal treatment responses in chronic myeloid leukemia (CML) are also associated with medication noncompliance. Poor adherence can also affect clinical trial results, leading to inaccuracies of treatment efficacy. Barriers to compliance can occur on the individual, cultural, or system level. Examples of specific barriers are side effects, cost and access to medication, and individual health beliefs. Specific populations, including racial minorities, elderly patients, and very young patients, may be at higher risk for medication noncompliance. Strategies to improve compliance are multifactorial and include improvement of patient education, reduction of treatment side effects, interventions to alter behavior, and changes in public policy to improve financial barriers to treatment. Technology has been an effective tool in improving compliance in noncancer-related illness, and ongoing studies are evaluating its role in the oncology population.

Psychosocial factors related to non-persistence with adjuvant endocrine therapy among women with breast cancer: the Breast Cancer Quality of Care Study (BQUAL)

Non-adherence to adjuvant endocrine therapy (ET) for breast cancer (BC) is common. Our goal was to determine the associations between psychosocial factors and ET non-persistence. We recruited women with BC receiving care in an integrated healthcare system between 2006 and 2010. Using a subset of patients treated with ET, we investigated factors related to ET non-persistence (discontinuation) based on pharmacy records (≥90 days gap). Serial interviews were conducted at baseline and every 6 months. The Functional Assessment of Cancer Therapy (FACT), Medical Outcomes Survey, Treatment Satisfaction Questionnaire (TSQM), Impact of Events Scale (IES), Interpersonal Processes of Care measure, and Decision-making beliefs and concerns were measured. Multivariate models assessed factors associated with non-persistence. Of the 523 women in our final cohort who initiated ET and had a subsequent evaluation, 94 (18 %) were non-persistent over a 2-year follow-up. The cohort was primarily white (74.4 %), stage 1 (60.6 %), and on an aromatase inhibitor (68.1 %). Women in the highest income category had a lower odds of being non-persistent (OR 0.43, 95 % CI 0.23-0.81). Quality of life and attitudes toward ET at baseline were associated with non-persistence. At follow-up, the FACT, TSQM, and IES were associated with non-persistence (p < 0.001). Most women continued ET. Women who reported a better attitude toward ET, better quality of life, and more treatment satisfaction, were less likely to be non-persistent and those who reported intrusive/avoidant thoughts were more likely to be non-persistent. Interventions to enhance the psychosocial well-being of patients should be evaluated to increase adherence.

Age-related differences in persistence in women with breast cancer treated with tamoxifen or aromatase inhibitors in Germany

AIMS

To study age-related persistence in postmenopausal women with endocrine-responsive breast cancer treated with tamoxifen (TAM) and aromatase inhibitors (AI).

METHODS

Data on 29,245 patients diagnosed with metastatic or non-metastatic breast cancer (BC) and initially treated with TAM or AI between 2004 and 2013 were included. The primary outcome measure was the age-dependent rate of discontinuation of endocrine treatment within 5years after initiation. Discontinuation of therapy was defined as a period of at least 90days without treatment. A multivariate Cox regression model was created to determine the influence of age on the risk of discontinuation. Health insurance type (private/statutory), type of care (gynecological/general), region (West/East Germany), concomitant diagnoses (depression, osteoporosis, and diabetes), and Charlson Comorbidity Score were included as covariates.

RESULTS

The mean ages of the women in the <70 and ≥70 groups were 55.9 (SD: 9.7) and 77.4 (SD: 5.4) years, respectively. Within 5years after treatment initiation, 88.8% of women <70 of age and 82% of women ≥70 years of age had terminated treatment (p-value<0.001). Patients aged ≥70 exhibited a lower risk of treatment discontinuation than patients aged <70 (HR=0.75, 95% CI: 0.66-0.85). Furthermore, gynecological practices, disease management programs, and high Charlson scores increased persistence.

CONCLUSIONS

Overall, the present study indicates that persistence rates are low in both women with BC aged <70 and those aged ≥70 years. We also found that younger women with BC are at a higher risk of treatment discontinuation than older women.

Behavioral Interventions to Enhance Adherence to Hormone Therapy in Breast Cancer Survivors: A Systematic Literature Review

Adjuvant hormone therapy contributes to reductions in recurrence and mortality for women with hormone receptor-positive breast cancer. However, adherence to hormone therapy is suboptimal. This is the first systematic literature review examining interventions aimed at improving hormone therapy adherence. Researchers followed the PRISMA guidelines. PubMed-Medline, CINAHL, PsychInfo, Ovid-Medline, and EMBASE were searched for behavioral interventions that aimed to enhance adherence to adjuvant hormone therapy in breast cancer survivors. A total of 376 articles were screened for eligibility. Five articles met the study criteria. All interventions presented adherence outcomes after 1-year follow-up. None significantly enhanced adherence compared to the usual care in the primary analysis (odds ratios ranged from 1.03 to 2.06 for adherence and from 1.11 to 1.18 for persistence). All studies targeted patients, and only 3 studies included postmenopausal breast cancer patients. Three tested the same intervention consisting of educational materials. Only one was conducted in the United States. Only one reported participants' ethnicity. Overall, it was unclear whether the studies contained bias. The use of different terminology and operationalization of adherence made comparisons challenging. Interventions to improve adherence to adjuvant hormone therapy in US breast cancer populations that include survivors who are ethnically diverse, premenopausal, and receiving tamoxifen therapy are necessary to inform future interventions. Adoption of consistent adherence definitions/measurements will provide a clearer framework to consolidate aggregate findings. Given the limited efficacy of tested interventions, it is important to engage oncologists and researchers to develop approaches that target different components associated with hormone therapy adherence, such as doctor-patient communication or social support.

Age-related differences in persistence with bisphosphonates in women with metastatic breast cancer

Aims

To investigate age-related persistence with bisphosphonates (BIS) in women with breast cancer (BC) and bone metastases.

Methods

We included a dataset of 1541 patients diagnosed with BC and bone metastases and initially treated with BIS between 1994 and 2013. The primary outcome measure was the age-related rate of BIS discontinuation within 12 months after treatment initiation. Therapy discontinuation was defined as a period of at least 90 days without treatment. A multivariate Cox regression model was created to determine the influence of age on the risk of discontinuation. Health insurance coverage (private/statutory), type of care (gynecological/general), region (West/East Germany), depression, chemotherapy, hormone therapy, pain medication, antidepressants, and the number of co-medications were included as covariates.

Results

The mean ages in the group of women <70 and that of women ≥70 years of age were 55.7 (SD: 9.8) and 76.7 (SD: 5.1) years respectively. Within 12 months after treatment initiation, 44.3% of women <70 and 34.8% of women ≥70 had terminated treatment (p-value<0.001). Patients aged ≥70 were at a lower risk of treatment discontinuation than patients <70 (HR=0.78, 95% CI: 0.67–0.91). Furthermore, treatment in gynecological practices, chemotherapy, hormone therapy, pain medication, and number of co-medications decreased the risk of discontinuation. By contrast, residing in West Germany and private health insurance coverage increased discontinuation risk.

Conclusions

Women with metastatic BC aged ≥70 are at a lower risk of BIS treatment discontinuation than younger women.

Racial/Ethnic and socioeconomic disparities in endocrine therapy adherence in breast cancer: a systematic review

We examined the current literature to understand factors that influence endocrine therapy (ET) adherence among racial/ethnic and socioeconomic subpopulations of breast cancer patients. We searched PubMed and PsycINFO databases for studies from January 1, 1978, to June 20, 2014, and January 1, 1991, to June 20, 2014, respectively, and hand-searched articles from relevant literature reviews. We abstracted and synthesized results within a social ecological framework. Fourteen articles met all inclusion criteria. The majority of included articles reported significant underuse of ET among minority and low-income women. Modifiable intrapersonal, interpersonal, and community-level factors are associated with ET use, and these factors vary across subgroups. Both race/ethnicity and socioeconomic status are associated with ET use in most settings. Variation in factors associated with ET use across subgroups indicates the need for more nuanced research and targeted interventions among breast cancer patients.

Symptoms of hormonal therapy and social support: Is there a connection? Comparison of symptom severity, symptom interference and social support among breast cancer patients receiving and not receiving adjuvant hormonal treatment

BACKGROUND

Although there has been a significant reduction in mortality, breast cancer is the most frequent cancer among women worldwide. This decline in mortality has created a significant survivor population that must manage the post curative treatment phase, in order to have an increased quality of life and well-being. This study examined the relationship between symptom interference and severity with the perception of social support in the lives of women receiving or not receiving, hormonal therapy after initial treatment.

METHODS AND SAMPLE

Participants completed symptom severity and interference questionnaires, (MDASI and BCPT), a social support survey (MSPSS) and demographic and comorbidity questionnaires.

RESULTS

Of the 210 women participants, higher symptom severity correlated with unemployment, living alone or being religious. Participants who were currently taking hormonal treatment (n = 84), reported a significant negative correlation between symptom severity, measured by MDASI, and social support (p = 0.006). Consequently, as symptom severity increased, perceived social support decreased. In the BCPT assessment, decreased cognitive functioning (p < 0.05), pain (p < 0.05), bladder dysfunction (p = 0.001), and reduced self-image (p < 0.01) were significantly negatively correlated with social support for those participants currently taking hormonal therapy. Participants who had not previously received hormonal therapy (n = 64), cognitive dysfunction and bladder dysfunction were negatively correlated with social support. Women with preexisting heart or pulmonary dysfunction and arthritis reported statistically significant higher levels of symptom severity and decreased perceptions of social support.

CONCLUSIONS

Identifying socio-demographic variables and comorbidities that affect hormonal therapy symptom burden is essential for offering adequate support for breast cancer survivors.

The change from brand-name to generic aromatase inhibitors and hormone therapy adherence for early-stage breast cancer

BACKGROUND

Nonadherence to hormonal therapy is common and is associated with increased copayment amount. We investigated the change in adherence after the introduction of generic aromatase inhibitors (AIs) in 2010.

METHODS

Using deidentified pharmacy and claims data from OptumInsight, we identified women older than 50 years on brand-name AIs (BAIs) and/or generic AIs (GAIs) for early breast cancer between January 1, 2007 and December 31, 2012. Clinical, demographic, and financial variables were evaluated. Adherence was defined as a medication possession ratio (MPR) 80% or greater.

RESULTS

We identified 5511 women, 2815 (51.1%) on BAI, 1411 (25.6%) on GAI, and 1285 (23.3%) who switched from BAI to GAI. The median 30-day copayment was higher for BAI ($33.3) than for GAI ($9.04). In a multivariable Cox-proportional hazard analysis, women who took GAI were less likely to discontinue therapy (hazard ratio [HR] = 0.69, 95% confidence interval [CI] = 0.57 to 0.84) compared with BAI. Discontinuation was positively associated with a higher monthly copayment of $15 to $30 (HR = 1.21, 95% CI = 1.01 to 1.44) and more than $30 (HR = 1.49, 95% CI = 1.23 to 1.80) compared with less than $15. In a multivariable logistic regression analysis, adherence (medication possession ratio ≥ 80%) was positively associated with GAI use (odds ratio = 1.53, 95% CI = 1.22 to 1.91) compared with BAI and inversely associated with increased monthly copayment. In addition, adherence was associated with a high annual income of more than $100k/year (odds ratio = 1.58, 95% CI = 1.17 to 2.11).

CONCLUSIONS

Higher prescription copayment amount was associated with nonadherence and discontinuation of AIs. After controlling for copayment, discontinuation was higher and adherence was lower with Brand AIs. Because nonadherence is associated with worse survival, efforts should be directed towards reducing out-of-pocket costs for these life-saving medications.

A Narrative Review of the Confluence of Breast Cancer and Low-wage Employment and Its Impact on Receipt of Guideline-recommended Treatment

Breast cancer is the leading cause of cancer among women in the United States, costing the healthcare system, employers, and society billions of dollars each year. Despite improvements in screening and treatment, significant breast cancer treatment and survivorship disparities exist among various groups of women. One variable that has not been explored extensively as a possible contributor to breast cancer treatment disparities is employment. This is concerning, given the changing economic and employment trends in the United States favoring low-wage employment. Currently, one-quarter to one-third of all US workers are considered to be working poor, and women are disproportionally represented in this group. Characteristics of low-wage work-limited paid time off, minimal health benefits, schedule inflexibility, and economic insecurity-may become even more significant in the event of a breast cancer diagnosis. To date, there has been limited research into how job conditions inherent to low-wage work may influence working poor survivors' receipt of guideline-recommended breast cancer treatment. Therefore, the purpose of this narrative review was to critically examine the current literature to further our understanding of how employment context may impact treatment decisions and adherence-and therefore receipt of guideline-recommended care-among newly diagnosed, working poor breast cancer survivors. After undertaking a comprehensive review, we failed to identify any published literature that explicitly addressed low-wage employment and receipt of guideline-recommended breast cancer treatment. Four articles reported circumstances where women delayed, missed, or quit treatments due to work interference, or alternatively, developed strategies that allowed them to continue to work and obtain their breast cancer treatment concurrent with medical and economic challenges. An additional five articles, while focused on other cancer and employment outcomes, described the need for increased patient-provider communication about the influence of work on treatment decisions and the development of alternative treatment plans. Due to the paucity of research in this area, future policy, practice, and research efforts should focus on the employment context of working poor breast cancer survivors as a potential contributor to cancer disparities. Engagement of women, employers, oncology providers, healthcare systems, and interdisciplinary researchers is warranted to improve cancer outcomes among this disparate population of working women.

Frailty and adherence to adjuvant hormonal therapy in older women with breast cancer: CALGB protocol 369901

PURPOSE

Most patients with breast cancer age ≥ 65 years (ie, older patients) are eligible for adjuvant hormonal therapy, but use is not universal. We examined the influence of frailty on hormonal therapy noninitiation and discontinuation.

PATIENTS AND METHODS

A prospective cohort of 1,288 older women diagnosed with invasive, nonmetastatic breast cancer recruited from 78 sites from 2004 to 2011 were included (1,062 had estrogen receptor-positive tumors). Interviews were conducted at baseline, 6 months, and annually for up to 7 years to collect sociodemographic, health care, and psychosocial data. Hormonal initiation was defined from records and discontinuation from self-report. Baseline frailty was measured using a previously validated 35-item scale and grouped as prefrail or frail versus robust. Logistic regression and proportional hazards models were used to assess factors associated with noninitiation and discontinuation, respectively.

RESULTS

Most women (76.4%) were robust. Noninitiation of hormonal therapy was low (14%), but in prefrail or frail (v robust) women the odds of noninitiation were 1.63 times as high (95% CI, 1.11 to 2.40; P = .013) after covariate adjustment. Nonwhites (v whites) had higher odds of noninitiation (odds ratio, 1.71; 95% CI, 1.04 to 2.80; P = .033) after covariate adjustment. Among initiators, the 5-year continuation probability was 48.5%. After adjustment, the risk of discontinuation was higher with increasing age (P = .005) and lower for stage ≥ IIB (v stage I) disease (P = .003).

CONCLUSION

Frailty is associated with noninitiation of hormonal therapy, but it does not seem to be a major predictor of early discontinuation in older patients.

Non-initiation and early discontinuation of adjuvant trastuzumab in women with localized HER2-positive breast cancer

One year of trastuzumab therapy is recommended for women with HER2-positive breast cancer ≥ 1.0 cm in size to increase survival and is considered for women with tumors 0.5-0.9 cm in size. We analyzed compliance with trastuzumab among women with HER2-positive breast cancer in a prospective cohort study. Of 1145 recruited patients with breast cancer, 152 were HER2-positive (13.2 %), of whom 126 had tumors ≥ 1.0 cm; 110/126 (87.3 %) of these initiated trastuzumab. Non-receipt was associated with older age, better prognosis tumors, and with non-receipt of adjuvant chemotherapy. Of the 110 who initiated treatment, 18 (15 %) did not complete treatment, 15 (83 %) of them because of cardiotoxicity. Of 20 women with tumors 0.5-0.9 cm, 5 (25 %) initiated trastuzumab. Compliance with trastuzumab was very high among those with HER2-positive breast cancer, as was the completion of the recommended therapy.

Optimizing expectations to prevent side effects and enhance quality of life in breast cancer patients undergoing endocrine therapy: study protocol of a randomized controlled trial

BACKGROUND

Adjuvant endocrine therapy can improve disease-free survival and time before recurrence in breast cancer patients. However, it is associated with considerable side effects that negatively affect patients' quality of life and cause non-adherence. The recently demonstrated effect of individual expectations on side-effect development (nocebo effect) suggests that psychological factors play a role in the prevention of side effects. The aim of this study is to evaluate cognitive-behavioral side-effect prevention training (SEPT) for breast cancer patients. This article describes the study protocol and applied research methods.

METHODS/DESIGN

In a randomized controlled trial, 184 female breast cancer patients are assigned to receive either SEPT, standard medical care or a manualized supportive therapy at the start of adjuvant endocrine treatment. SEPT consists of three sessions of cognitive-behavioral training including psychoeducation to provide a realistic view of endocrine therapy, imagination-training to integrate positive aspects of medication into daily life, and side-effect management to enhance expectations about coping ability. Side effects three months after the start of endocrine therapy serve as primary outcomes. Secondary outcomes include quality of life, coping ability and patients' medication adherence. Patients' expectations (i.e., expectations about side effects, coping ability, treatment and illness) are analyzed as mediators.

DISCUSSION

The optimization of expectations might be a potential pathway in health care to improve patients' quality of life during long-term medication intake. The results will provide implications for a possible integration of evidence-based prevention training into clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov, (NCT01741883).

Do community-based patient assistance programs affect the treatment and well-being of patients with breast cancer?

PURPOSE

Patients with breast cancer who need adjuvant treatments often fail to receive them. High-quality, community-based patient-assistance programs are an underused, inexpensive resource to help patients with cancer obtain needed therapy. We sought to determine whether connecting women to patient-assistance programs would reduce underuse of adjuvant therapies.

METHODS

We conducted a randomized trial of 374 women (190 assigned intervention [INT], 184 to usual care [UC]) with early-stage breast cancer who underwent surgery between October 2006 and August 2009. After initial needs assessment, individualized action plans were created to connect INT patients with targeted patient-assistance programs; UC patients received an informational pamphlet. Main outcome measures were receiving adjuvant treatment and obtaining help.

RESULTS

High rates of INT and UC patients received treatment: 87% INT versus 91% UC women who underwent lumpectomy received radiotherapy (P = .39); 93% INT versus 86% UC women with estrogen receptor (ER) -negative tumors ≥ 1 cm received chemotherapy (P = .42); 92% INT versus 93% UC women with ER-positive tumors ≥ 1 cm received hormonal therapy (P = .80). Many women reported needs: 63% had informational; 55%, psychosocial; and 53%, practical needs. High rates of INT patients with needs connected with a program within 2 weeks (92%). At 6 months, INT and UC women used patient-assistance programs at similar rates (75% v 76%; P = .54). Women with informational or psychosocial needs were more likely to receive help (relative risk [RR], 1.77; 95% CI, 1.51 to 1.90 and RR, 1.37; 95% CI, 1.06 to 1.61, respectively).

CONCLUSION

INT and UC patients received high rates of adjuvant treatment regardless of trial assignment. Patients with breast cancer who connect to relevant patient assistance programs receive useful informational and psychosocial but not practical help.

[The importance of individual beliefs about cancer treatments for therapeutic decisions]

Interest for representations about cancer treatments and their side effects is increasing because their central role has been proved in how patients cope with illness and symptoms and how they react emotionally. Through a synthesis of the literature, this paper has two objectives: firstly, to clarify the current state of knowledge in this field, and secondly to point out the manner that bringing out these individual representations during oncological consultations contributes to preventing difficulties and treatment discontinuation and facilitates medical decision processing.

Interpersonal influences and attitudes about adjuvant therapy treatment decisions among non-metastatic breast cancer patients: an examination of differences by age and race/ethnicity in the BQUAL study

Patients are increasingly involved in cancer treatment decisions and yet little research has explored factors that may affect patient attitudes and beliefs about their therapeutic choices. This paper examines psychosocial factors (e.g., attitudes, social support), provider-related factors (e.g., communication, trust), and treatment considerations in a prospective study of a sample of non-metastatic breast cancer patients eligible for chemotherapy and/or hormonal therapy (BQUAL cohort). The data come from a multisite cohort study of white, black, Hispanic, and Asian non-metastatic breast cancer patients recruited in New York City, Northern California, and Detroit, Michigan. Baseline surveys were conducted over the telephone between 2006 and 2010 among a total of 1,145 women. Most participants were white (69 %), had more than a high school education (76 %), and were diagnosed with stage I disease (51 %). The majority of women reported discussing chemotherapy and hormonal therapy with their doctor (90 and 83 %, respectively); these discussions primarily took place with medical oncologists. Nearly a quarter of women reported that the treatment decision was difficult, and the majority were accompanied to the doctor (76 %) and involved a friend or family member in making the decision (54 %). Positive considerations (e.g., beliefs about treatment reducing risk of recurrence) were important in making treatment decisions. Participants preferred a shared decision-making style, but results suggested that there is room for improvement in terms of actual patient's involvement in making the decision and provider communication, particularly among black patients. Patients 65 years and older reported fewer provider discussions of chemotherapy, poorer patient-provider communication, higher rates of being assisted by family members in making the decision, and more negative attitudes and beliefs toward treatment.

Noninitiation of adjuvant chemotherapy in women with localized breast cancer: the breast cancer quality of care study

PURPOSE

For some women, adjuvant chemotherapy for nonmetastatic breast cancer decreases recurrences and increases survival; however, patient-physician decisions regarding chemotherapy receipt can be influenced by medical and nonmedical factors.

PATIENTS AND METHODS

We used a prospective cohort design and multivariate modeling to investigate factors related to noninitiation of chemotherapy among women with newly diagnosed breast cancer recruited from three US sites. We interviewed patients at baseline and during treatment on sociodemographic, tumor, and treatment decision-making factors. Patients were categorized according to National Comprehensive Cancer Network guidelines as those for whom chemotherapy was definitely indicated, clinically discretionary, or discretionary based on age greater than 70 years.

RESULTS

Of 1,145 patients recruited, chemotherapy was clinically indicated for 392 patients, clinically discretionary for 459 patients, discretionary because of age for 169 patients, and not indicated for 93 patients; data were insufficient for 32 patients. Chemotherapy rates were 90% for those in whom chemotherapy was clinically indicated, 36% for those in whom it was discretionary because of clinical factors, and 19% for those in whom it was discretionary based on age greater than 70 years. Nonreceipt of chemotherapy was associated with older age, more negative beliefs about treatment efficacy, less positive beliefs about chemotherapy, and more concern about adverse effects. In the two discretionary groups, clinical predictors of worse outcome (greater tumor size, positive nodes, worse grade, and estrogen receptor- and progesterone receptor-negative status) were associated with increased chemotherapy initiation.

CONCLUSION

Utilization of adjuvant chemotherapy was most common among patients who, based on clinical criteria, would most likely benefit from it, patients with more positive than negative beliefs regarding treatment efficacy, and patients with few concerns about adverse effects.