Barriers to and facilitative processes of endocrine therapy adherence among women with breast cancer

Effects of Adjuvant Endocrine Therapy-Specific Perceptions on Response to a Behavioral Intervention for Adjuvant Endocrine Therapy Adherence in Patients With Breast Cancer

PURPOSE

Adjuvant endocrine therapy (AET) is a life-saving medication for patients with hormone-sensitive breast cancer, yet many struggle with adherence, warranting behavioral intervention. In our recent trial, participation in a group cognitive behavioral intervention (STRIDE) for symptom management and adherence was associated with improvements in symptom distress, coping, quality of life, and mood. We now explore whether baseline patient- and medication-specific factors-which may be modifiable by clinician-led discussions-moderated the effect of STRIDE on adherence rates.

METHODS

From October 2019 to June 2021, 100 patients with early-stage breast cancer reporting AET-related distress were enrolled and randomly assigned to STRIDE or a medication monitoring (MM) control group. All patients stored their AET in electronic pill bottles to track objective adherence. Patients also self-reported their adherence on the Medication Adherence Report Scale-5 and their perceptions of AET on the Cancer Therapy Satisfaction Questionnaire at baseline. We conducted hierarchical linear modeling to test moderators of intervention effects on objective adherence rates. We report the time × group × moderator effects.

RESULTS

Among patients reporting greater perceived difficulties with AET adherence at baseline, STRIDE participants had higher adherence rates over time compared with MM (b = -13.80; SE = 4.56; P < .01). Patients with greater expectations of therapeutic benefit from AET also had improved adherence rates if they were assigned to STRIDE, versus MM (b = 0.25; SE = 0.10; P = .01). Patients who perceived taking AET as convenient and had been taking their AET for less time had higher adherence rates in STRIDE, versus MM.

CONCLUSION

The current study identified patient- and medication-specific factors that may augment AET adherence interventions and may be modifiable through clinician-led discussions, such as perceptions of adherence problems, therapeutic efficacy, and convenience of AET.

Identification of patient subgroups who benefit from a behavioral intervention to improve adjuvant endocrine therapy adherence: a randomized-controlled trial

PURPOSE

Adjuvant endocrine therapy (AET) reduces breast cancer morbidity and mortality; however, adherence is suboptimal. Interventions exist, yet few have improved adherence. Patient characteristics may alter uptake of an intervention to boost adherence. We examined moderators of the effect of a virtual intervention (STRIDE; #NCT03837496) on AET adherence after breast cancer.

METHODS

At a large academic medical center, patients taking AET (N = 100; Mage = 56.1, 91% White) were randomized to receive STRIDE versus medication monitoring. All stored their medication in digital pill bottles (MEMS Caps) which captured objective adherence. Participants self-reported adherence (Medication Adherence Report Scale) at 12 weeks post-baseline. Moderators included age, anxiety, and depressive symptoms (Hospital Anxiety and Depression Scale), AET-related symptom distress (Breast Cancer Prevention Trial Symptom Scale), and AET-specific concerns (Beliefs about Medications Questionnaire). We used hierarchical linear modeling (time × condition × moderator) and multiple regression (condition × moderator) to test the interaction effects on adherence.

RESULTS

Age (B = 0.05, SE = 0.02, p = 0.003) and AET-related symptom distress (B = -0.04, SE = 0.02, p = 0.02) moderated condition effect on self-reported adherence while anxiety (B = -1.20, SE = 0.53, p = 0.03) and depressive symptoms (B = -1.65, SE = 0.65, p = 0.01) moderated objective adherence effects. AET-specific concerns approached significance (B = 0.91, SE = 0.57, p = 0.12). Participants who received STRIDE and were older or presented with lower anxiety and depressive symptoms or AET-related symptom distress exhibited improved adherence. Post hoc analyses revealed high correlations among most moderators.

CONCLUSIONS

A subgroup of patients who received STRIDE exhibited improvements in AET adherence. The interrelatedness of moderators suggests an underlying profile of patients with lower symptom burden who benefitted most from the intervention.

STUDY REGISTRATION

NCT03837496.

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.

Beliefs about medicines' association with endocrine therapy adherence in early breast cancer survivors in Croatia

This observational, cross-sectional study conducted at the University Hospital Centre Zagreb (UHC Zagreb) aimed to explore patients' beliefs about adjuvant endocrine therapy (AET) as well as their association with non-adherence and sociodemographic and clinical factors. Out of 420 early breast cancer (BC) patients included in the study, 79.5 % perceived AET necessary and important for their health, as measured by the Belief About Medicines Questionnaire (BMQ), with the mean necessity score (20.4 ± 3.68) significantly higher than the mean concerns score (13 ± 4.81) (p < 0.001). Based on the Medication Adherence Report Scale (MARS-5), 44.4 % (n = 182) of the participants were non-adherers, out of which 63.2 % (n = 115) were unintentional and 36.8 % (n = 67) intentional non-adherers. Significantly higher concern beliefs were found among patients that were younger (p < 0.001), employed (p < 0.001), intentionally non-adherent to AET (p = 0.006), had a lower body-mass index (p = 0.005) and a higher level of education (p < 0.001), were premenopausal at the time of diagnosis (p < 0.001), taking tamoxifen treatment (p = 0.05) and receiving ovarian suppression (p < 0.001). Younger patients should be recognized as being at risk of non-adherence as they hold greater concern beliefs about medicines.

Randomized phase III trial evaluating motivational interviewing and text interventions to optimize adherence to breast cancer endocrine therapy (Alliance A191901): the GETSET protocol

BACKGROUND

Hormone receptor-positive (HR +) breast cancer is the most common type of breast cancer in the USA but has excellent long-term outcomes in recent decades, in part due to effective oral endocrine therapy (ET). ET medications are typically prescribed for 5 to 10 years, depending on the risk of recurrence, and must be taken daily. One limiting factor to ET efficacy is nonadherence, with high-risk groups for nonadherence including younger women and Black women.

METHODS

The Alliance for Clinical Trials in Oncology (Alliance) trial A191901 is an ongoing, four-arm (text message reminder (TMR), motivational interviewing (MI), TMR plus MI, or enhanced usual care) randomized clinical trial that tests the efficacy and effect of two interventions (TMR and/or MI) on improved ET adherence, patient-reported outcomes (PROs), and resource use requirements among HR + breast cancer survivors. Participants are randomized in a 1:1:1:1 ratio to the four arms. With an assumed loss to follow-up of approximately 11%, we plan to recruit 1180 participants. Randomization is stratified based on age and race to ensure balance between the arms, and we oversample younger and Black women, with each group representing 30% of the study population. Participants randomized to an intervention will actively participate in the intervention for 9 months, and all participants will be followed for adherence data and PRO endpoints, through the use of the Pillsy cap medication event monitoring system and Alliance ePRO survey app (i.e., Patient Cloud). The primary analysis will compare Pillsy-measured ET adherence among study arms at 12 months.

DISCUSSION

This multisite study will not only define strategies to improve adherence to breast cancer oral therapies, but it will also potentially support strategies in large cooperative research groups that can increase delivery and tolerability of ET, involve diverse patient populations in clinical research, and engage patients effectively in interventional studies, using remote and cost-effective delivery methods.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04379570 . Registered on 7 May 2020.

Investigation of Factors Affecting Adherence to Adjuvant Hormone Therapy in Early-Stage Breast Cancer Patients: A Comprehensive Systematic Review

PURPOSE

Adherence and persistence to adjuvant hormone therapy (AHT) are seldom maintained among early-stage hormone receptor-positive breast cancer (BC) survivors, despite the significant clinical benefits of long-term AHT. As the factors influencing adherence to AHT remain unclear, this study aimed to comprehensively identify such factors and classify them into specific dimensions.

METHODS

PubMed, Cochrane Library, Embase, PsycINFO, and CINAHL were searched for qualified articles. The search mainly focused on three components: early-stage (0-III) BC, oral AHT administration, and adherence to AHT, with keywords derived from MeSH and entry terms. The factors identified were then classified into six categories based on a modified WHO multidimensional model.

RESULTS

Overall, 146 studies were included; the median sample size was 651 (range, 31-40,009), and the mean age of the population was 61.5 years (standard deviation, 8.3 years). Patient- and therapy-related factors were the most frequently investigated factors. Necessity/concern beliefs and self-efficacy among patient-related factors were consistently related to better adherence than depression. Although drug side effects and medication use cannot be modified easily, a refined prescription strategy for the initiation and switching of AHT is likely to increase adherence levels.

CONCLUSION

An effective psychological program that encourages positive views and beliefs about medication and management strategies for each therapy may be necessary to improve adherence to AHT. Social support and a sense of belonging can be enhanced through community participation and social media for better adherence to AHT. Patient-centered communication and appropriate recommendations by physicians may be attributable to better adherence outcomes. Findings from systematically organized factors that influence adherence to AHT may contribute to the establishment of intervention strategies to benefit patients with early-stage BC to achieve optimal health.

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.

Adherence to Adjuvant Endocrine Therapy in Breast Cancer Patients

BACKGROUND

Adjuvant endocrine therapy (AET) reduces breast cancer recurrence and mortality of women with hormone-receptor-positive tumors, but poor adherence remains a significant problem. The aim of this study was to analyze AET side effects and their impact on adherence to treatment.

METHODS

A total of 373 breast cancer patients treated with AET filled out a specific questionnaire during their follow up visits at the Breast Unit of our Centre.

RESULTS

Side effects were reported by 81% of patients, 84% of those taking tamoxifen and 80% of those taking aromatase inhibitors (AIs). The most common side effect in the tamoxifen group was hot flashes (55.6%), while in the AI group it was arthralgia (60.6%). The addition of GnRH agonists to both tamoxifen and AI significantly worsened all menopausal symptoms. Overall, 12% of patients definitively discontinued AET due to side effects, 6.4% during the first 5 years and 24% during extended therapy. Patients who had previously received chemotherapy or radiotherapy reported a significantly lower discontinuation rate.

CONCLUSIONS

AET side effects represent a significant problem in breast cancer survivors leading to irregular assumption and discontinuation of therapy. Adherence to AET may be improved by trustful patient-physician communication and a good-quality care network.

Randomized Controlled Pilot Trial of a Low-Touch Remotely-Delivered Values Intervention to Promote Adherence to Adjuvant Endocrine Therapy Among Breast Cancer Survivors

BACKGROUND

Oral anti-cancer treatments such as adjuvant endocrine therapies (AET) for breast cancer survivors are commonly used but adherence is a challenge. Few low-touch, scalable interventions exist to increase ET adherence.

PURPOSE

To evaluate the acceptability, feasibility, and initial efficacy of a low-touch, remotely-delivered values plus AET education intervention (REACH) to promote AET adherence.

METHODS

A mixed-methods trial randomized 88 breast cancer survivors 1:1 to REACH or Education alone. Wisepill real-time electronic adherence monitoring tracked monthly AET adherence during a 1-month baseline through 6-month follow-up (FU) (primary outcome). Patient-reported outcomes were evaluated through 3- and 6-month FU (secondary). Multiple indices of intervention feasibility and acceptability were evaluated. Qualitative exit interviews (n = 38) further assessed participants' perceptions of feasibility/acceptability and recommendations for intervention adaptation.

RESULTS

The trial showed strong feasibility and acceptability, with an eligible-to-enrolled rate of 85%, 100% completion of the main intervention sessions, and "good" intervention satisfaction ratings on average. For Wisepill-assessed AET adherence, REACH outperformed Education for Month 1 of FU (p = .027) and not thereafter. Participants in REACH maintained high adherence until Month 4 of FU, whereas in Education, adherence declined significantly in Month 1. Conditions did not differ in self-reported adherence, positive affective attitudes, future intentions, or necessity beliefs. REACH trended toward less negative AET attitudes than Education at 3-month FU (p = .057) reflecting improvement in REACH (p = .004) but not Education (p = .809). Exploratory moderator analyses showed that average to highly positive baseline AET affective attitudes and oncologist-patient communication each predicted higher adherence following REACH than Education; low levels did not. Participants identified recommendations to strengthen the interventions.

CONCLUSIONS

REACH, a low-touch values intervention, showed good feasibility and acceptability, and initial promise in improving objectively-assessed AET adherence among breast cancer survivors (relative to education alone). Future research should target improving REACH's tailoring and endurance.

The impact of medication side effects on adherence and persistence to hormone therapy in breast cancer survivors: A quantitative systematic review

BACKGROUND

Hormone Therapy (HT) is recommended for most women with HR-positive primary breast cancer. When taken as intended, HT reduces breast cancer recurrence by 40% and mortality by one-third. The recommended duration of treatment ranges from 5 to 10 years depending on risk of recurrence and the specific HT regimen. However, recent data indicates that rates of HT non-adherence are high and research suggests this may be due to the impact of HT side effects. The contribution of side effects to non-adherence and non-persistence behaviours has rarely been systematically explored, thereby hindering the implementation of targeted intervention strategies. Our aim is to identify, evaluate and summarise the relationship between HT side effects and patterns of adherence and persistence.

METHODS

Electronic searches were conducted from inception and were completed by September 2021, utilising Cochrane CENTRAL, Medline, Embase, Web of Science and PsycINFO databases. Searches included a combination of terms related to breast cancer, adherence, hormone therapy and side effects.

RESULTS

Sixty-two eligible papers were identified and study quality varied by study type. Most observational and cross-sectional studies were rated good quality, whereas most controlled intervention studies were rated fair quality. Three studies were rated poor quality. The most frequently measured side effects were pain, low mood, hot flashes, insomnia, anxiety, fatigue, weight gain, concentration/memory problems.

CONCLUSIONS

This review identified a lack of consistency in the measurement of adherence and the definition of persistence across studies. The instruments used to measure side effects also varied significantly. This variation and lack of consistency makes it difficult to evaluate and summarise the role of HT side effects in HT adherence and persistence behaviour.

Escala de Adherencia Terapéutica para tratamiento de Cáncer de Mama (EAT-CaMa): Una evaluación multidimensional

Introducción: La adherencia terapéutica es un aspecto clave en el éxito del tratamiento en oncología, sin embargo, su medición es un reto dentro del sistema de salud. Asimismo, no se tienen escalas especificas validas o construidas para evaluar la adherencia en pacientes con cáncer de mama. Objetivo: Determinar las propiedades psicométricas de la Escala de Adherencia Terapéutica al Cáncer de Mama (EAT-CaMa). Método: Se empleó un diseño no experimental, instrumental con un muestreo no probabilístico. Se incluyeron 189 participantes con diagnóstico de CaMa entre 21 y 84 años. Análisis estadísticos: Se realizó un análisis factorial exploratorio y consistencia interna. Resultados: La EATCaMa de 27 reactivos, obtuvo una consistencia interna global α= 0,81 y una varianza explicada del 64%. Se identificaron factores de autoeficacia y comunicación médico paciente, así como varios indicadores. Conclusión: El EAT-CaMa es un instrumento breve, válido y confiable para la evaluación multidimensional de la adherencia al tratamiento en población con CaMa. La estructura factorial identificada corrobora componentes reportados en la literatura y clínicamente relevantes. Se recomienda su uso en la atención clínica (inicio y seguimiento del tratamiento) y en investigación.

The Impact of the COVID-19 Pandemic on Cancer Care and Health-Related Quality of Life of Non-Hispanic Black/African American, Hispanic/Latina and Non-Hispanic White Women Diagnosed with Breast Cancer in the U.S.: A Mixed-Methods Study Protocol

The COVID-19 pandemic has had critical consequences for cancer care delivery, including altered treatment protocols and delayed services that may affect patients’ quality of life and long-term survival. Breast cancer patients from minoritized racial and ethnic groups already experience worse outcomes, which may have been exacerbated by treatment delays and social determinants of health (SDoH). This protocol details a mixed-methods study aimed at comparing cancer care disruption among a diverse sample of women (non-Hispanic White, non-Hispanic Black/African American, and Hispanic/Latina) and assessing how proximal, intermediate, and distal SDoH differentially contribute to care continuity and health-related quality of life. An embedded mixed-methods design will be implemented. Eligible participants will complete an online survey, followed by a semi-structured interview (with a subset of participants) to further understand factors that influence continuity of care, treatment decision-making, and self-reported engagement. The study will identify potentially modifiable factors to inform future models of care delivery and improve care transitions. These data will provide the necessary evidence to inform whether a subsequent, multilevel intervention is warranted to improve quality of care delivery in the COVID-19 aftermath. Additionally, results can be used to identify ways to leverage existing social resources to help manage and support patients’ outcomes.

Development and Refinement of a Telehealth Intervention for Symptom Management, Distress, and Adherence to Adjuvant Endocrine Therapy after Breast Cancer

Adjuvant endocrine therapy (AET) prevents recurrence after early stage, hormone sensitive breast cancer; however, adherence to AET is suboptimal, and efficacious interventions are severely lacking. Barriers to adherence are well established; however, interventions, thus, far have failed to produce meaningful changes in adherence and have generally not followed guiding principles of psychosocial intervention development. The purpose of this paper is to describe the iterative development, using the National Institutes of Health Stage Model for Behavioral Intervention Development, of an evidence-based, patient-centered, telehealth intervention to enhance adherence, improve symptom management, and reduce distress for patients taking AET after breast cancer, with a focus on (1) a small open pilot study which informed modifications and refinement of the intervention based on quantitative and qualitative patient feedback about feasibility and acceptability and (2) the underlying theoretical and empirical rationale for each component of the finalized intervention. Clinical implications and directions for future research are discussed.

It's not an easy fix: Adherence to adjuvant endocrine therapy after breast cancer

Adjuvant endocrine therapy (AET) is a highly efficacious treatment that significantly reduces breast cancer recurrence and mortality for women with hormone-receptor positive breast cancer. Yet, many women do not adhere to prescribed AET. The overarching aim of this research was to gain a better understanding of why a significant number of women diagnosed with breast cancer have suboptimal adherence to AET. A mixed-methods approach was used to explore the personal, social, and structural factors influencing breast cancer survivors' AET adherence, including: (1) an integrative review of patient-reported factors associated with AET adherence; and (2) interviews with breast cancer survivors prescribed AET. In this paper, we summarize and discuss the key contributions of both phases of this research, implication for clinical practice, and how we might leverage the expertise of nurses in practicing to full scope to address the complex needs of breast cancer survivors prescribed AET.

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Chez les femmes atteintes d’un cancer du sein à récepteurs hormonaux positifs, l’endocrinothérapie adjuvante est très efficace pour réduire le risque de récidive et de mortalité. Pourtant, ce ne sont pas toutes les femmes qui se conforment au traitement. L’objectif principal de cette recherche était de mieux comprendre pourquoi de nombreuses femmes ayant reçu un diagnostic de cancer du sein n’adhèrent pas au traitement adjuvant. Une approche méthodologique mixte a été utilisée afin d’explorer les facteurs personnels, sociaux et structurels qui influencent l’adhésion à l’endocrinothérapie adjuvante chez les survivantes du cancer du sein. L’approche comprend: 1) une revue intégrative des facteurs mentionnés par les patientes pour expliquer l’adhésion au traitement endocrinien; et 2) des entretiens avec des survivantes du cancer du sein à qui on a prescrit le traitement adjuvant. Le présent article résume et présente les principales contributions des deux phases de cette recherche, les implications pour la pratique clinique et la manière dont nous pourrons tirer parti de l’expertise des infirmières en les amenant à exercer pleinement leur pratique pour répondre aux besoins complexes des survivantes du cancer du sein à qui l’on prescrit l’endocrinothérapie adjuvante.

Race and Patient-reported Symptoms in Adherence to Adjuvant Endocrine Therapy: A Report from the Women's Hormonal Initiation and Persistence Study

BACKGROUND

Adjuvant endocrine therapy (AET) improves outcomes in women with hormone receptor-positive (HR+) breast cancer. Suboptimal AET adherence is common, but data are lacking about symptoms and adherence in racial/ethnic minorities. We evaluated adherence by race and the relationship between symptoms and adherence.

METHODS

The Women's Hormonal Initiation and Persistence study included women diagnosed with nonrecurrent HR+ breast cancer who initiated AET. AET adherence was captured using validated items. Data regarding patient (e.g., race), medication-related (e.g., symptoms), cancer care delivery (e.g., communication), and clinicopathologic factors (e.g., chemotherapy) were collected via surveys and medical charts. Multivariable logistic regression models were employed to calculate odds ratios and 95% confidence intervals (CIs) associated with adherence.

RESULTS

Of the 570 participants, 92% were privately insured and nearly one of three were Black. Thirty-six percent reported nonadherent behaviors. In multivariable analysis, women less likely to report adherent behaviors were Black (vs. White; OR, 0.43; 95% CI, 0.27-0.67; P < 0.001) and with greater symptom burden (OR, 0.98; 95% CI, 0.96-1.00; P < 0.05). Participants more likely to be adherent were overweight (vs. normal weight) (OR, 1.58; 95% CI, 1.04-2.43; P < 0.05), sat ≤ 6 hours a day (vs. ≥6 hours; OR, 1.83; 95% CI, 1.25-2.70; P < 0.01), and were taking aromatase inhibitors (vs. tamoxifen; OR, 1.91; 95% CI, 1.28-2.87; P < 0.01).

CONCLUSIONS

Racial differences in AET adherence were observed. Longitudinal assessments of symptom burden are needed to better understand this dynamic process and factors that may explain differences in survivor subgroups.

IMPACT

Future interventions should prioritize Black survivors and women with greater symptom burden.

A Survey of Potentially Modifiable Patient-Level Factors Associated with Self-Report and Objectively Measured Adherence to Adjuvant Endocrine Therapies After Breast Cancer

PURPOSE

Despite the efficacy of adjuvant endocrine therapy (AET) in reducing breast cancer recurrence and mortality, suboptimal AET adherence is common and hence an important clinical issue among breast cancer survivors. Delineating potentially modifiable patient-level factors associated with AET adherence may support the development of successful adherence-enhancing interventions.

PATIENTS AND METHODS

The present study included 133 breast cancer survivors prescribed AET recruited from a cancer pharmacy. Women completed a baseline questionnaire examining psychosocial factors and self-reported adherence and consented to their prescription records being monitored for the proceeding 12 months to ascertain proportion of days covered (PDC), an objective measure of adherence. Regression analyses were used to identify the factors most strongly associated with both self-reported and objective adherence. Exploratory moderation analyses examined whether factors were differentially associated with adherence based on AET type (aromatase inhibitors or tamoxifen).

RESULTS

Adherence was high in this sample (PDC over 12 months was 95%). Side effect severity was most strongly associated with self-reported adherence, followed by self-efficacy, and medication/healthcare system-related barriers. Medication/healthcare system-related barriers was the only factor that uniquely predicted objective adherence. Within medication/healthcare system-related barriers, fear of side effects was most strongly associated with both measures of adherence. There were no significant interactions between AET type and potentially modifiable factors in predicting self-reported or objective adherence.

CONCLUSION

Side effects, reactions to side effects, and self-efficacy may represent modifiable targets through which AET adherence can be improved. Associations between potentially modifiable factors and adherence did not vary by AET type, despite distinct side-effect profiles.

Adherence to Adjuvant Tamoxifen in Mexican Young Women with Breast Cancer

BACKGROUND

Breast cancer (BC) in young women is characterized by an unfavorable prognosis in hormone receptor-positive/HER2-negative tumors, which may be explained by low rates of tamoxifen adherence. In Mexico, up to 14% of all BC diagnoses occur in young women and no data on tamoxifen adherence has been reported.

OBJECTIVE

To estimate the rate of adherence to adjuvant tamoxifen in Mexican young women with BC (YWBC).

METHODS

A cross-sectional survey was conducted at the National Cancer Institute in Mexico City, among YWBC (≤40 years at diagnosis) receiving adjuvant tamoxifen. Adherence was measured subjectively, through self-reported surveys, and objectively, through medication possession ratio (MPR). Descriptive statistics were used to analyze sociodemographic characteristics. To compare associations between patients' characteristics and adherence, Chi-square test was used for categorical variables and Student's t-test or Mann-Whitney U-test for quantitative variables.

RESULTS

A total of 141 YWBC receiving adjuvant tamoxifen were included. Regarding subjective adherence, 95% expressed taking tamoxifen regularly, 70% reported missing 0 doses in the past 30 days, and 71.6% reported having adverse effects. Regarding objective adherence, 74.8% of patients had an MPR ≥80%. The association between subjective and objective adherence was statistically significant (p = 0.004). Subjective adherence was associated with not skipping tamoxifen doses when feeling worse. Objective adherence was associated with having a stable job, not skipping tamoxifen doses when feeling worse, taking additional medications, and time on tamoxifen treatment. Fifty-six percent considered the information on tamoxifen to be insufficient and 37% not understandable.

CONCLUSION

In our study, high subjective and objective adherence rates to adjuvant tamoxifen were reported, although an important proportion of women reported high rates of adverse effects and not fully understanding the benefits of tamoxifen. Strategies to increase tamoxifen adherence may be even more important now that longer durations of treatment or further ovarian function suppression have become the standard of care in YWBC.

Psychosocial determinants of adherence with oral anticancer treatment: 'we don't need no education'

INTRODUCTION

Given the potentially fatal consequences of inadequate adherence with oral anticancer treatment in persons with cancer, understanding the determinants of adherence is vital. This paper aims at identifying psychosocial determinants of adherence to oral anticancer treatment.

METHODS

We reviewed the literature on psychosocial determinants of adherence with oral anticancer treatment, based on published literature in English, from 2015 to present. Literature searches were performed in PubMed, Embase, Web of Science, Cochrane library, Emcare, and PsychINFO, with 'cancer', 'medication adherence', 'psychology', and 'oral anticancer treatment' as search terms. The obtained 608 papers were screened by two independent reviewers.

RESULTS

In the 25 studies identified, illness perceptions, medication beliefs, health beliefs, and depression were found to be the major psychosocial determinants of adherence to oral anticancer treatment; sociodemographic and clinical characteristics were found to be of no major importance. The quality of the identified studies as assessed by two independent reviewers was found to be acceptable overall. The majority of papers were from North America and focused on patients with breast cancer; sample size varied from 13 to 1371; adherence was assessed with questionnaires derived from various theoretical models, pill counts and electronic pharmacy records; illness perceptions reflecting adaptive coping, and medication beliefs reflecting high necessity and low concerns were found to be associated with adherence.

CONCLUSION

Psychosocial concepts are major determinants of adherence with oral anticancer treatment. 'Beliefs about medicines' and 'illness perceptions' in particular determine adherence with this treatment. Studies aiming at impacting adherence would benefit from interventions with a solid basis in behavioral theory in order to help health care providers explore and address illness perceptions and medication beliefs. Pre-consultation screening of adherence behavior may be a helpful supportive approach to improve adherence. Blaming the victim ('patients should be educated about the importance of adherence') is better replaced by encouraging health professionals to identify and address maladaptive psychosocial determinants of adherence.

Potentially Modifiable Factors Associated with Adherence to Adjuvant Endocrine Therapy among Breast Cancer Survivors: A Systematic Review

Adjuvant endocrine therapy (AET) reduces risk of breast cancer recurrence. However, suboptimal adherence and persistence to AET remain important clinical issues. Understanding factors associated with adherence may help inform efforts to improve use of AET as prescribed. The present systematic review examined potentially modifiable factors associated with adherence to AET in accordance with PRISMA guidelines (PROSPERO registration ID: CRD42019124200). All studies were included, whether factors were significantly associated with adherence or results were null. This review also accounted for the frequency with which a potentially modifiable factor was examined and whether univariate or multivariate models were used. This review also examined whether methodological or sample characteristics were associated with the likelihood of a factor being associated with AET adherence. A total of 68 articles were included. Potentially modifiable factors were grouped into six categories: side effects, attitudes toward AET, psychological factors, healthcare provider-related factors, sociocultural factors, and general/quality of life factors. Side effects were less likely to be associated with adherence in studies with retrospective or cross-sectional than prospective designs. Self-efficacy (psychological factor) and positive decisional balance (attitude toward AET) were the only potentially modifiable factors examined ≥10 times and associated with adherence or persistence ≥75% of the time in both univariate and multivariate models. Self-efficacy and decisional balance (i.e., weight of pros vs. cons) were the potentially modifiable factors most consistently associated with adherence, and hence may be worth focusing on as targets for interventions to improve AET adherence among breast cancer survivors.

Sociodemographic, clinical, psychosocial, and healthcare-related factors associated with beliefs about adjuvant endocrine therapy among breast cancer survivors

OBJECTIVE

Adjuvant endocrine therapy (AET) reduces the risk of recurrence and mortality in women with hormone receptor-positive breast cancer. However, adherence to AET remains suboptimal. Women's beliefs about medication have been associated with medication adherence. The purpose of this study was to identify multilevel factors associated with women's beliefs about AET.

METHODS

Beliefs about AET, measured using the Belief about Medicines Questionnaire (BMQ), sociodemographic (e.g., age), psychosocial (e.g., religiosity), and healthcare factors (e.g., patient-provider communication), were collected via survey. Clinical data were abstracted from medical records. Two stepwise regression analyses models were performed to assess relationships between variables and necessity and concern beliefs.

RESULTS

In our sample of 572 women, mean BMQ concern score was 11.19 and mean necessity score was 13.85 (range 5-20). In the regression models, higher ratings of patient-provider communication were associated with lower concern and higher necessity beliefs. Higher concern beliefs were related to more AET-related symptoms (Β = 0.08; 95% CI 0.06 to 0.10; p < 0.001), lower patient satisfaction (Β = - 0.07; 95% CI - 0.09 to - 0.04; p < 0.001), and higher religiosity (Β = 0.05; 95% CI 0.01 to 0.08; p = 0.007). Higher necessity beliefs were associated with prior chemotherapy use (Β = 0.11; 95% CI 0.06 to 0.16; p < 0.005) and less education (Β = 1.00; 95% CI 0.27 to 1.73; p = 0.008).

CONCLUSIONS

Modifiable factors are related to women's AET beliefs. Healthcare interactions may play a key role with regard to shaping women's beliefs about their AET medication.

Breast Cancer Surgery Decision Role Perceptions and Choice of Surgery

BACKGROUND

Retrospective studies have reported that breast cancer patients who perceived more personal responsibility for the surgery decision were more likely to undergo aggressive surgery. We examined this in a prospective study.

METHODS

100 newly diagnosed breast cancer patients identified their decision- making role using the Patient Preference Scale. Chart review captured the initial surgery received. Patient decision role preference, role perception, role concordance, and provider role perception were compared with type of surgery to assess differences between mastectomy and lumpectomy groups and unilateral versus bilateral mastectomy. We compared type of surgery and patient role concordance. Satisfaction with Decision immediately after the visit, Decision Regret and FACT-B quality of life at 2 weeks and 6 months were assessed and compared with type of surgery.

RESULTS

Patient decision role preference (p = 0.49) and perception (p = 0.16) were not associated with type of surgery. Provider perception of patient role was associated with type of surgery, with providers perceiving more passive patient roles in the mastectomy group (p = 0.026). Patient role preference varied significantly by stage of disease (= 0.024), with stage 0 (64%, N = 6) and stage III (60%, N = 6) patients preferring active roles and stage I (60%, N = 25) and stage II (52%, N = 16) patients preferring a collaborative role.

CONCLUSIONS

Patient role preference and perception were not associated with type of surgery, while provider perception of patient role was. Patient role preference varied by stage of disease. Further study is warranted to better understand how disease factors and provider interactions affect decision role preferences and perceptions and surgical choice.

TRIAL REGISTRATION

The study was registered with clinicaltrials.gov (NCT03350854). https://clinicaltrials.gov/ct2/show/NCT03350854 .

Factors Associated with Endocrine Therapy Non-Adherence in Breast Cancer Survivors

BACKGROUND

For women with hormone receptor positive breast cancer, long-term endocrine therapy (ET) can greatly reduce the risk of recurrence, yet adherence is low- particularly among traditionally underserved populations.

METHODS

The Carolina Breast Cancer Study oversampled Black and young women (<50 years of age). Participants answered an ET-specific medication adherence questionnaire assessing reasons for non-adherence. We used principal factor analysis to identify latent factors describing ET non-adherence. We then performed multivariable regression to determine clinical and demographic characteristics associated with each ET non-adherence factor.

RESULTS

1,231 women were included in analysis, 59% reported at least one barrier to ET adherence. We identified three latent factors which we defined as: habit - challenges developing medication-taking behavior; tradeoffs - high perceived side effect burden and medication safety concerns; and resource barriers - challenges related to cost or accessibility. Older age (50+) was associated with less reporting of habit (Adjusted Risk Ratio (aRR) 0.54[95% CI: 0.43-0.69] and resource barriers (aRR 0.66[0.43-0.997]), but was not associated with tradeoff barriers. Medicaid-insured women were more likely than privately-insured to report tradeoff (aRR:1.53 [1.10-2.13]) or resource barriers (aRR:4.43[2.49-6.57]). Black race was associated with increased reporting of all factors (habit: aRR 1.29[1.09-1.53]; tradeoffs: 1.32[1.09-1.60], resources: 1.65[1.18-2.30]).

CONCLUSION

Barriers to ET adherence were described by three distinct factors, and strongly associated with sociodemographic characteristics. Barriers to ET adherence appear inadequately addressed for younger, Black, and publicly-insured breast cancer survivors. These findings underscore the importance of developing multi-faceted, patient-centered interventions that address a diverse range of barriers to ET adherence.

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.

Correspondence Between Objective and Self-reported Endocrine Therapy Adherence Among Women With Breast Cancer

Background

Among the approximately 70% of women with hormone receptor-positive breast cancer, endocrine therapies lower the likelihood of recurrence. Nonadherence to endocrine therapy predicts lower survival.

Purpose

We examined concordance between self-reported and objective indicators of adherence and predictors of over-reporting endocrine therapy adherence among survivors of breast cancer.

Methods

Women with breast cancer (N = 112) receiving their initial endocrine therapy prescription completed three assessments at prescription initiation (Time 1), 1 month (Time 2), and 4 months later (Time 3). At Time 1, participants were provided a medication event monitoring system (MEMS) cap to assess adherence; it was collected at Time 3. Women completed items regarding self-reported adherence, depressive symptoms, cancer-related coping processes, and the patient–physician relationship.

Results

MEMS was significantly negatively correlated with the self-reported nonadherence measurements of occasionally forgetting (Time 2, ρ = −.29, p < .01; Time 3, ρ = −.24, p < .01), nonadherence in the past week (Time 2, ρ = −.53, p < .01; Time 3, ρ = −.45, p < .01), and nonadherence in an average week in the past month (Time 2, ρ = −.38, p < .01; Time 3, ρ = −.39, p < .01). Concordance in objective and self-reported adherence measures was evident in 83% of women at Time 2 and 73% at Time 3. Older age was significantly associated (p < .01) with discordance.

Conclusions

Findings reveal moderate correspondence between objective and self-report measures, with self-report overestimating objective adherence. Clinicians should be aware when treating older breast cancer survivors that they are more likely to over self-report their endocrine therapy adherence.

Improving medication adherence with adjuvant aromatase inhibitor in women with breast cancer: study protocol of a randomised controlled trial to evaluate the effect of short message service (SMS) reminder

BACKGROUND

Medication adherence refers to whether a patient takes medication according to the frequency prescribed, or continues to take a prescribed medication. Inadequate adherence to medication may cause alterations in risk-benefit ratios, resulting in reduced benefits, increased risks or both, and is significantly associated with adverse clinical outcomes and higher healthcare costs. We aim to examine the effect of a computer generated short message service (SMS) reminder in improving medication adherence, and inhibiting the aromatisation process amongst breast cancer women receiving oral aromatase inhibitor therapy.

METHODS/DESIGN

In this randomised controlled trial, eligible patients will be equally allocated to receive either SMS reminder or standard care. The former receives weekly SMS reminder to take medication while the latter does not receive any. The primary endpoint of medication adherence at 1-year is assessed using the Simplified Medication Adherence Questionnaire, and compared using the χ² test. Adjustment for baseline covariate and potential confounders will be made using the logistic regression. Secondary outcomes involving estrone and androstenedione levels will be compared using the analysis of covariance, whereas the estradiol levels (< 18.4 pmol/L versus ≥18.4 pmol/L) will be compared using the χ² test, and the logistic regression. Further, the assessment of knowledge, attitude, behaviour, and barriers and facilitating factors of medication adherence will be made via logistic regression.

DISCUSSION

This will be the first study to evaluate short-term clinical outcomes from SMS reminder for breast cancer patients on aromatase inhibitor therapy. Random allocation to SMS reminder or control arm ensures that patients in both arms will be comparable with respect to demographic and clinical characteristics, and any difference in outcomes can be attributed to the intervention. Participants are not blinded to the assignment of intervention, thus there may be potential for bias in outcome assessments.

TRIAL REGISTRATION

NCT02524548 . Retrospectively registered on 17 August 2015.

Facilitating adherence to endocrine therapy in breast cancer: stability and predictive power of treatment expectations in a 2-year prospective study

PURPOSE

To identify modifiable factors predictive of long-term adherence to adjuvant endocrine therapy (AET).

METHODS

As part of a 2-year cohort study in primary care (n = 116), we investigated whether initial treatment expectations predict adherence at 24 months after controlling for demographic, medical, and psychosocial variables. Treatment expectations were measured as necessity-concern beliefs, expected side-effect severity, and expected coping with side effects. Their stability over time and differences of trajectories between the adherent and nonadherent group were examined.

RESULTS

Nonadherence at 24 months was 14.7% (n = 17). Side-effect severity at 3 months [OR 0.25, 95% CI (0.08, 0.81), p = 0.02] and necessity-concern beliefs [OR 2.03, 95% CI (1.11, 3.72), p = 0.02] were the sole predictors of adherence. Necessity-concern beliefs remained stable over 2 years, whereas expected side-effect severity (p = 0.01, η p2  = 0.07) and expected coping with side effects became less optimistic over time (p < 0.001, η p2  = 0.19), the latter particularly among nonadherers (p < 0.01, η p2  = 0.10).

CONCLUSIONS

Patients' initial necessity-concern beliefs about the AET and early severity of side effects affect long-term adherence. Expecting poor management of side effects may also facilitate nonadherence. We suggest that discussing benefits, addressing concerns of AET, and providing side-effect coping strategies could constitute a feasible and promising option to improve adherence in clinical practice.

Relationships between determinants of adjuvant endocrine therapy adherence in breast cancer

BACKGROUND

Interventions that promote adjuvant endocrine therapy (AET) adherence are critical to improve breast cancer survival. The development of interventions would benefit from a better understanding of the reasons for adherence and the causal relationships of determinants using theoretical or model approaches. The aim of the present study was to identify reasons for AET adherence in breast cancer patients with sequential relationships and inter-relationships.

METHODS

A total of 210 participants with estrogen receptor positive breast cancer who received AET completed a questionnaire assessing demographic/medical, psychological, and endocrine therapy (ET)-specific factors. A descriptive analysis was performed to identify meaningful variables. Selected variables were subjected to hierarchical regression and path analyses. The path model was tested and modified based on the research framework and the results of regression weights and model fit.

RESULTS

Analysis of sequential effects showed that ET-specific factors contributed the largest proportion of variance (13.4%) to predict AET adherence, followed by psychological factors (4.6%) and demographic/medical factors (3.1%). Analysis of inter-relationships showed that demographic/medical factors such as AET regimen type and cancer stage have direct effects on AET adherence, whereas psychological factors contribute indirectly through the mediating effects of ET-specific factors.

CONCLUSION

Assessments and interventions that encompass the patient's medication beliefs, self-efficacy, and depression are needed to promote AET adherence.

Adherence to Adjuvant Endocrine Therapy in Women With Breast Cancer: A Prospective Observational Study in Japanese Women

INTRODUCTION

Nonadherence to adjuvant endocrine therapy has been poorly studied in Asian patients with breast cancer. We therefore assessed adherence to endocrine therapy among women with breast cancer in Japan.

PATIENTS AND METHODS

We conducted a prospective observational study among Japanese women with hormone receptor-positive breast cancer. Patients brought their pill packets to visits for 1 year and answered a questionnaire. We also examined prescription records during the study period. Adherence to endocrine therapy was defined as patients who had taken > 80% of the pills according to the packets during the study. Clinicopathologic features and questionnaires were compared between adherent and nonadherent patients.

RESULTS

A total of 234 patients completed the trial, of whom 85% demonstrated adherence based on pill packets, and 98% demonstrated adherence based on prescription records. Mastectomy, higher stage, nodal metastasis and adjuvant chemotherapy were correlated with adherence based on pill packets. Adjuvant chemotherapy was an independent factor associated with adherence. According to the questionnaire, adherent patients were more likely to consult a nurse when they had trouble with their medication. These patients also emphasized the efficacy rather than the side effects of the medication. Nonadherent patients were aware that they were being nonadherent.

CONCLUSION

The results of this study revealed that 85% of patients were adherent to endocrine therapy, but physicians were unaware of the nonadherent patients. Raised awareness of nonadherence and information sharing between patients and medical teams might increase adherence to endocrine therapy.

Addressing the Survivorship Care Needs of Patients Receiving Extended Cancer Treatment

Cancer survivorship care and research has typically focused on the health care needs of people with cancer following the acute phase of treatment. Work in this area, however, has faced challenges in identifying when treatment is complete for many forms of cancer. Acknowledging this challenge, the scope of survivorship research is often expanded to include patients also receiving maintenance or prophylactic therapy. Inherent in this expanded definition is the recognition that for many individuals, cancer is a chronic disease requiring extended treatment over many years. Three distinct patient populations can be identified for which extended treatment poses important survivorship care needs that, to date, have not been adequately addressed. The first group includes patients receiving extended endocrine therapy, such as women with breast cancer receiving tamoxifen and/or aromatase inhibitors as well as men with prostate cancer receiving androgen deprivation therapy. The second group includes patients receiving extended targeted therapy to control disease, as exemplified by patients with chronic myelogenous leukemia receiving treatment with tyrosine kinase inhibitors. A key issue in both of these patient groups is the need to identify and address factors that contribute to difficulties in maintaining high levels of adherence to the prescribed therapy over extended periods of time. The third group includes patients receiving novel therapies for advanced or metastatic cancer that can extend life for prolonged periods. A key issue for this group is the need to understand and address their unique supportive care needs.

Understanding the Health Burden of Macromastia: Normative Data for the BREAST-Q Reduction Module

BACKGROUND

The BREAST-Q Reduction module evaluates outcomes in reduction mammaplasty. However, there are currently no published normative scores, limiting the interpretation of BREAST-Q data.

METHODS

The BREAST-Q Reduction module was administered via the Army of Women, an online community of women (with and without breast cancer) engaged in breast-cancer related research. Normative data were generated from women aged 18 years and older, without a history of breast cancer or breast surgery. Data analysis was performed using descriptive statistics and a linear multivariate regression. Generated normative data were compared to published BREAST-Q Reduction findings.

RESULTS

The preoperative version of the BREAST-Q Reduction module was completed by 1206 women. Participant mean age was 55 ± 13 years, mean body mass index was 27 ± 6 kg/m, and 40 percent (n = 481) had a bra cup size ≥ D. Mean normative scores were as follows: Satisfaction with Breasts, 57 ± 16; Psychosocial Well-being, 68 ± 19; Sexual Well-being, 55 ± 19; and Physical Well-being, 76 ± 11. Normative scores were lower in women with body mass index ≥ 30 and bra cup size ≥ D. In comparison to normative Army of Women scores, published BREAST-Q scores for women undergoing reduction mammaplasty were lower (worse) for preoperative patients and higher (better) for postoperative patients.

CONCLUSION

These new Army of Women normative data provide insights into breast-related satisfaction and well-being in women not pursuing breast reduction, giving new clinical context to better understand the health burden of macromastia, and to demonstrate the value of reduction mammaplasty in certain patients.

Normative Data for Interpreting the BREAST-Q: Augmentation

BACKGROUND

The BREAST-Q is a rigorously developed, well-validated, patient-reported outcome instrument with a module designed for evaluating breast augmentation outcomes. However, there are no published normative BREAST-Q scores, limiting interpretation.

METHODS

Normative data were generated for the BREAST-Q Augmentation module by means of the Army of Women, an online community of women (with and without breast cancer) engaged in breast-cancer related research. Members were recruited by means of e-mail; women aged 18 years or older without a history of breast cancer or breast surgery were invited to participate. Descriptive statistics and a linear multivariate regression were performed. A separate analysis compared normative scores to findings from previously published BREAST-Q augmentation studies.

RESULTS

The preoperative BREAST-Q Augmentation module was completed by 1211 women. Mean age was 54 ± 24 years, the mean body mass index was 27 ± 6 kg/m, and 39 percent (n = 467) had a bra cup size of D or greater. Mean scores were as follows: Satisfaction with Breasts, 54 ± 19; Psychosocial Well-being, 66 ± 20; Sexual Well-being, 49 ± 20; and Physical Well-being, 86 ± 15. Women with a body mass index of 30 kg/m or greater and bra cup size of D or greater had lower scores. In comparison with Army of Women scores, published BREAST-Q augmentation scores were lower before and higher after surgery for all scales except Physical Well-being.

CONCLUSIONS

The Army of Women normative data represent breast-related satisfaction and well-being in women not actively seeking breast augmentation. These data may be used as normative comparison values for those seeking and undergoing surgery as we did, demonstrating the value of breast augmentation in this patient population.