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Fabian CJ, Mudaranthakam DP, Gajewski B, Young K, Winblad O, Khan SA, Garber JE, Esserman LJ, Yee LD, Nye L, Powers KR, Ranallo L, Kreutzjans AL, Pittman K, Altman C, Metheny T, Zelenchuk A, Komm BS, Kimler BF. Overcoming challenges in conducting early phase breast cancer prevention trials: Bazedoxifene and conjugated estrogens vs waitlist control. Contemp Clin Trials 2024; 146:107697. [PMID: 39293780 DOI: 10.1016/j.cct.2024.107697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 09/08/2024] [Accepted: 09/14/2024] [Indexed: 09/20/2024]
Abstract
BACKGROUND The combination of bazedoxifene 20 mg (BZA) and conjugated estrogens 0.45 mg (CE) marketed as Duavee® is approved for vasomotor symptom relief and osteoporosis prevention. Our pilot study suggested it had potential breast cancer risk reduction, and we proposed a multisite Phase IIB primary prevention trial assessing change in breast imaging and tissue risk biomarkers. By the time funding was acquired in February 2021, Duavee® was unavailable with an uncertain return date. A redesign was needed to salvage the study. METHODS The basic trial design was minimally altered. Women age 45-64 at elevated risk for breast cancer with vasomotor symptoms and no menses for at least 2 months have mammography, phlebotomy, and benign breast tissue sampling before and after 6 months of intervention. However, instead of Duavee® (single pill) vs placebo, women are randomized to 6 months of BZA + CE vs Waitlist. Those initially randomized to Waitlist can receive BZA + CE after 6 months. The primary endpoint is between arm difference in change in a fully automated measure of mammographic density with blood and tissue-based secondary endpoints. OUTCOMES Accrual initiation was delayed due to contractual difficulties surrounding BZA importation during COVID-19 and deploying a fully automated method (Volpara®) to assess the primary endpoint. To accommodate this delay, a mid-grant no cost extension along with amended eligibility requirements were employed. 61/120 participants needed were entered in the initial 27 months of accrual and 37 months of funding. Despite a late start, accrual is likely to be completed within the funding period.
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Affiliation(s)
- Carol J Fabian
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
| | | | - Byron Gajewski
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Kate Young
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Onalisa Winblad
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | | | | | | | | | - Lauren Nye
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Kandy R Powers
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Lori Ranallo
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Amy L Kreutzjans
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Krystal Pittman
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Christy Altman
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Trina Metheny
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Adrian Zelenchuk
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | | | - Bruce F Kimler
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
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Lloyd KE, Hall LH, Ziegler L, Foy R, Green SMC, MacKenzie M, Taylor DG, Smith SG. Acceptability of aspirin for cancer preventive therapy: a survey and qualitative study exploring the views of the UK general population. BMJ Open 2023; 13:e078703. [PMID: 38110374 DOI: 10.1136/bmjopen-2023-078703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVES Aspirin could be offered for colorectal cancer prevention for the UK general population. To ensure the views of the general population are considered in future guidance, we explored public perceptions of aspirin for preventive therapy. DESIGN We conducted an online survey to investigate aspirin use, and awareness of aspirin for cancer prevention among the UK general population. We conducted semistructured interviews with a subsample of survey respondents to explore participants' acceptability towards aspirin for cancer preventive therapy. We analysed the interview data using reflexive thematic analysis and mapped the themes onto the Theoretical Domains Framework, and the Necessity and Concerns Framework. SETTING Online survey and remote interviews. PARTICIPANTS We recruited 400 UK respondents aged 50-70 years through a market research company to the survey. We purposefully sampled, recruited and interviewed 20 survey respondents. RESULTS In the survey, 19.0% (76/400) of respondents were aware that aspirin can be used to prevent cancer. Among those who had previously taken aspirin, 1.9% (4/216) had taken it for cancer prevention. The interviews generated three themes: (1) perceived necessity of aspirin; (2) concerns about side effects; and (3) preferred information sources. Participants with a personal or family history of cancer were more likely to perceive aspirin as necessary for cancer prevention. Concerns about taking aspirin at higher doses and its side effects, such as gastrointestinal bleeding, were common. Many described wanting guidance and advice on aspirin to be communicated from sources perceived as trustworthy, such as healthcare professionals. CONCLUSIONS Among the general population, those with a personal or family history of cancer may be more receptive towards taking aspirin for preventive therapy. Future policies and campaigns recommending aspirin may be of particular interest to these groups. Multiple considerations about the benefits and risks of aspirin highlight the need to support informed decisions on the medication.
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Affiliation(s)
- Kelly E Lloyd
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Louise H Hall
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Lucy Ziegler
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Sophie M C Green
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | | | - David G Taylor
- School of Pharmacy, University College London, London, UK
| | - Samuel G Smith
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
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Khan SA, Mi X, Xu Y, Blanco LZ, Akasha AM, Pilewskie M, Degnim AC, AlHilli Z, Amin AL, Hwang ES, Guenther JM, Kocherginsky M, Benante K, Zhang S, Helland T, Hustad SS, Gursel DB, Mellgren G, Dimond E, Perloff M, Heckman-Stoddard BM, Lee O. Presurgical Oral Tamoxifen vs Transdermal 4-Hydroxytamoxifen in Women With Ductal Carcinoma In Situ: A Randomized Clinical Trial. JAMA Surg 2023; 158:1265-1273. [PMID: 37870954 PMCID: PMC10594180 DOI: 10.1001/jamasurg.2023.5113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/16/2023] [Indexed: 10/25/2023]
Abstract
Importance Oral tamoxifen citrate benefits women with ductal carcinoma in situ (DCIS), but concern about toxic effects has limited acceptance. Previous pilot studies have suggested transdermal 4-hydroxytamoxifen gel has equivalent antiproliferative efficacy to oral tamoxifen, with low systemic exposure. Objective To demonstrate that 4-hydroxytamoxifen gel applied to the breast skin is noninferior to oral tamoxifen in its antiproliferative effect in DCIS lesions. Design, Setting, and Participants This randomized, double-blind, phase 2 preoperative window trial was performed at multicenter breast surgery referral practices from May 31, 2017, to January 27, 2021. Among 408 women with estrogen receptor-positive DCIS who were approached, 120 consented and 100 initiated study treatment. The most common reasons for nonparticipation were surgical delay, disinterest in research, and concerns about toxic effects. Data were analyzed from January 26, 2021, to October 5, 2022. Intervention Random assignment to oral tamoxifen citrate, 20 mg/d, and gel placebo or 4-hydroxytamoxifen gel, 2 mg/d per breast, and oral placebo, for 4 to 10 weeks, followed by DCIS resection. Main Outcomes and Measures The primary end point was absolute change in DCIS Ki-67 labeling index (Ki67-LI). Secondary end points included 12-gene DCIS Score, breast tissue tamoxifen metabolite concentrations, tamoxifen-responsive plasma protein levels, and patient-reported symptoms. Noninferiority of Ki67-LI reduction by 4-hydroxytamoxifen gel was tested using analysis of covariance; within- and between-arm comparisons were performed with paired t tests for mean values or the Wilcoxon rank sum test for medians. Results Of 90 participants completing treatment (mean [SD] age, 55 [11] years; 8 [8.9%] Asian, 16 [17.8%] Black, 8 [8.9%] Latina, and 53 [58.9%] White), 15 lacked residual DCIS in the surgical sample, leaving 75 evaluable for the primary end point analysis (40 in the oral tamoxifen group and 35 in the 4-hydroxytamoxifen gel group). Posttreatment Ki67-LI was 3.3% higher (80% CI, 2.1%-4.6%) in the 4-hydroxytamoxifen gel group compared with the oral tamoxifen group, exceeding the noninferiority margin (2.6%). The DCIS Score decreased more with oral tamoxifen treatment (-16 [95% CI, -22 to -9.4]) than with 4-hydroxytamoxifen gel (-1.8 [95% CI, -5.8 to 2.3]). The median 4-hydroxytamoxifen concentrations deep in the breast were nonsignificantly higher in the oral tamoxifen group (5.7 [IQR, 4.0-7.9] vs 3.8 [IQR, 1.3-7.9] ng/g), whereas endoxifen was abundant in the oral tamoxifen group and minimal in the 4-hydroxytamoxifen gel group (median, 13.0 [IQR, 8.9-20.6] vs 0.3 [IQR, 0-0.3] ng/g; P < .001). Oral tamoxifen caused expected adverse changes in plasma protein levels and vasomotor symptoms, with minimal changes in the transdermal group. Conclusions and Relevance In this randomized clinical trial, antiproliferative noninferiority of 4-hydroxytamoxifen gel to oral tamoxifen was not confirmed, potentially owing to endoxifen exposure differences. New transdermal approaches must deliver higher drug quantities and/or include the most potent metabolites. Trial Registration ClinicalTrials.gov Identifier: NCT02993159.
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Affiliation(s)
- Seema A. Khan
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Xinlei Mi
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yanfei Xu
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Luis Z. Blanco
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Azza M. Akasha
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Amy C. Degnim
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Zahraa AlHilli
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Amanda L. Amin
- Department of Surgery, University Hospitals, Cleveland, Ohio
| | - E. Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Masha Kocherginsky
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kelly Benante
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Shanshan Zhang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Thomas Helland
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | | | - Demirkan B. Gursel
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Gunnar Mellgren
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Eileen Dimond
- Division of Cancer Prevention, National Cancer Institute Bethesda, Maryland
| | - Marjorie Perloff
- Division of Cancer Prevention, National Cancer Institute Bethesda, Maryland
| | | | - Oukseub Lee
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Green SM, Lloyd KE, Smith SG. Awareness of symptoms, anticipated barriers and delays to help-seeking among women at higher risk of breast cancer: A UK multicentre study. Prev Med Rep 2023; 34:102220. [PMID: 37200677 PMCID: PMC10186484 DOI: 10.1016/j.pmedr.2023.102220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 05/20/2023] Open
Abstract
Women with a family history of breast cancer have an increased lifetime risk of the disease. Delay in symptom presentation can lead to poorer outcomes. Low awareness of breast cancer symptoms and help-seeking barriers have been associated with delay in presentation in the general population. Symptom awareness and help-seeking barriers among women at increased risk of breast cancer are unknown. We conducted analysis of survey data which included women with moderate and high risk of breast cancer from 20 secondary and tertiary care clinics in England (n = 408). Women completed a validated survey assessing breast cancer symptom awareness, barriers to help-seeking and anticipated delay in help-seeking. Women recognised an average of 9.1/11 breast cancer symptoms (SD = 2.1). Nipple rash was the least recognised symptom (51.0%). Women educated to at least degree level had higher awareness than those with lower education (β = 0.14, 95% CI 0.13, 0.99, p = 0.011). Women at lower socioeconomic status (SES) had lower awareness than those at higher SES (β = -0.13, 95% CI -1.09, -0.07, p = 0.027). Women reported several anticipated help-seeking barriers (mean = 4.0/11, SD = 2.8). Waiting to see if a symptom will pass was the most commonly reported barrier to help-seeking (71.5%). Most women (376/408; 92.2%) reported that they would seek medical help within 2 weeks of discovering a breast cancer symptom. Interventions to increase awareness of non-lump breast cancer symptoms and reduce help-seeking barriers are needed, with considerations of appropriate reading levels and modalities for women with lower education and SES.
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Affiliation(s)
| | | | - Samuel G. Smith
- Corresponding author at: Leeds Institute of Health Sciences, University of Leeds, LS2 9LU, UK.
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Law R, Krupa K, Rusby J. Preventative therapy for breast cancer: a clinical experience. Breast Cancer Res Treat 2023:10.1007/s10549-023-06985-1. [PMID: 37336835 PMCID: PMC10361902 DOI: 10.1007/s10549-023-06985-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/24/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Breast Cancer incidence in the UK is estimated to rise to 71,000 per year by 2035. Preventative strategies could significantly reduce this. Preventative therapy reduces women's risk of oestrogen receptor positive breast cancer, but uptake remains low. Having established a preventative therapy clinic as part of a wider breast cancer prevention project, we explored qualitative data to inform future preventative efforts. METHOD Women aged 30 to 60 who had benign diagnoses at a symptomatic breast clinic or were under mammographic surveillance in the moderate risk family history clinic were invited to participate in the study. Those who expressed an interest and completed an initial questionnaire had their breast cancer risk calculated using the IBIS risk calculator. Those at increased risk were invited to a consultation about preventative therapy. RESULTS 182 women were identified as increased risk (≥ 17% lifetime or ≥ 3% 10-year risk NICE guidelines: Familial breast cancer: classification, care and managing breast cancer and related risks in people with a family history of breast cancer, 20131) of whom 91 women (50%) would not have been identified by family history criteria alone. 96% attended a risk/prevention consultation and all eligible women accepted screening mammography but only 14 (8%) women requested a preventative therapy prescription during the duration of the study. Reluctance to take medication and inconvenient time of life were common reasons for declining preventative therapy. Despite this, the majority were grateful for breast cancer risk and prevention information. CONCLUSIONS Women at increased risk of breast cancer accept additional screening but are reluctant to take preventative therapy. This suggests that stratified screening methods using risk calculations would have high uptake. Raising awareness of preventative therapy is important and the breast cancer community has yet to find the optimum timing and formula for discussing it and must accept women's informed preferences above artificial targets. REGISTRATION NUMBERS The PIONEER study was granted Health Research Authority (HRA) ethical approval by the Westminster Ethics Committee. IRAS project ID 265619, ClinicalTrials.gov Identifier: NCT04574063. Recruitment began in September 2020 and was completed in October 2021.
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Affiliation(s)
- Rebekah Law
- The Royal Marsden Hospital, London, UK.
- Institute of Cancer Research, London, UK.
| | | | - Jennifer Rusby
- The Royal Marsden Hospital, London, UK
- Institute of Cancer Research, London, UK
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Usher-Smith JA, Hindmarch S, French DP, Tischkowitz M, Moorthie S, Walter FM, Dennison RA, Stutzin Donoso F, Archer S, Taylor L, Emery J, Morris S, Easton DF, Antoniou AC. Proactive breast cancer risk assessment in primary care: a review based on the principles of screening. Br J Cancer 2023; 128:1636-1646. [PMID: 36737659 PMCID: PMC9897164 DOI: 10.1038/s41416-023-02145-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
In the UK, the National Institute for Health and Care Excellence (NICE) recommends that women at moderate or high risk of breast cancer be offered risk-reducing medication and enhanced breast screening/surveillance. In June 2022, NICE withdrew a statement recommending assessment of risk in primary care only when women present with concerns. This shift to the proactive assessment of risk substantially changes the role of primary care, in effect paving the way for a primary care-based screening programme to identify those at moderate or high risk of breast cancer. In this article, we review the literature surrounding proactive breast cancer risk assessment within primary care against the consolidated framework for screening. We find that risk assessment for women under 50 years currently satisfies many of the standard principles for screening. Most notably, there are large numbers of women at moderate or high risk currently unidentified, risk models exist that can identify those women with reasonable accuracy, and management options offer the opportunity to reduce breast cancer incidence and mortality in that group. However, there remain a number of uncertainties and research gaps, particularly around the programme/system requirements, that need to be addressed before these benefits can be realised.
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Affiliation(s)
- Juliet A. Usher-Smith
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Hindmarch
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - David P. French
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Marc Tischkowitz
- grid.5335.00000000121885934Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Sowmiya Moorthie
- grid.5335.00000000121885934PHG Foundation, University of Cambridge, Cambridge, UK
| | - Fiona M. Walter
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Rebecca A. Dennison
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Francisca Stutzin Donoso
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Psychology, University of Cambridge, Cambridge, UK
| | - Lily Taylor
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jon Emery
- grid.1008.90000 0001 2179 088XCentre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, VIC Australia
| | - Stephen Morris
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Douglas F. Easton
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Antonis C. Antoniou
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Janssen AM, Dam J, Prins J, Buffart LM, de Bruin M. Systematic adaptation of the adherence improving self-management strategy to support breast cancer survivors' adherence to adjuvant endocrine therapy: An intervention mapping approach. Eur J Cancer Care (Engl) 2022; 31:e13721. [PMID: 36263723 PMCID: PMC9787620 DOI: 10.1111/ecc.13721] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 08/17/2022] [Accepted: 09/14/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Non-adherence to adjuvant endocrine therapy (AET) for breast cancer leads to increased recurrence and mortality risk and healthcare costs. Evidence on feasible, effective AET adherence interventions is scarce. This paper describes the systematic adaptation of the cost-effective adherence improving self-management strategy (AIMS) for patients with HIV to AET for women after breast cancer treatment. METHODS We followed the intervention mapping protocol for adapting interventions by conducting a needs assessment, reviewing target behaviours and determinants, reassessing behaviour change methods and adapting programme content. Therefore, we performed a literature review, consulted behavioural theory and organised nine advisory board meetings with patients and healthcare professionals. RESULTS Non-adherence occurs frequently among AET users. Compared to HIV treatment, AET is less effective, and AET side effects are more burdensome. This drives AET treatment discontinuation. However, the key determinants of non-adherence are largely similar to HIV treatment (e.g. motivation, self-regulation and patient-provider relationship); therefore, most strategies in AIMS-HIV also seem suitable for AIMS-AET. Modifications were required, however, regarding supporting patients with coping with side effects and sustaining treatment motivation. CONCLUSION AIMS seems to be a suitable framework for adherence self-management across conditions and treatments. Intervention mapping offered a transparent, systematic approach to adapting AIMS-HIV to AET.
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Affiliation(s)
- Anna M. Janssen
- Department of IQ Health, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Joëlle Dam
- Department of IQ Health, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Judith Prins
- Department of Medical Psychology, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Laurien M. Buffart
- Department of Physiology, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Marijn de Bruin
- Department of IQ Health, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
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Lloyd KE, Foy R, Hall LH, Ziegler L, Green SMC, Haider ZF, Taylor DG, MacKenzie M, Smith SG. Barriers and facilitators to using aspirin for preventive therapy: a qualitative study exploring the views and experiences of people with Lynch syndrome and healthcare providers. Hered Cancer Clin Pract 2022; 20:30. [PMID: 35999639 PMCID: PMC9396868 DOI: 10.1186/s13053-022-00235-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NG151) recommends considering daily aspirin for people with Lynch syndrome to reduce colorectal cancer risk. However, deciding whether to initiate aspirin could be a complex decision for patients and their healthcare providers, as both the potential benefits and harms need to be considered. METHODS We conducted semi-structured interviews to explore the barriers and facilitators to using aspirin for preventive therapy. We recruited 15 people with Lynch syndrome, and 23 healthcare providers across multiple professions in primary, and specialist care (e.g. clinical genetics) in the United Kingdom. Interview schedules were informed by the Theoretical Domains Framework. RESULTS There were three themes: 1) Considering potential harms and benefits; 2) Healthcare pathway; 3) Patients' level of interest in aspirin. All healthcare providers, across primary and specialist care, viewed general practitioners (GPs) as being responsible for prescribing and overseeing the use of aspirin. However, GPs were unfamiliar with aspirin for preventive therapy, and concerned about prescribing at higher doses (300-600 mg). To support decision-making, GPs wanted clarification from specialist clinicians on the evidence and dose to prescribe. Not all participants with Lynch syndrome received information on aspirin from their healthcare provider, and several were unsure who to discuss aspirin with. GPs were more inclined to prescribe aspirin for patients with expressed preferences for the medication, however several patients were uncertain and wanted further guidance. CONCLUSIONS Coordinated and multilevel strategies are needed, addressing the needs of both GPs and people with Lynch syndrome, to ensure consistent implementation of national guidance on aspirin for preventive therapy.
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Affiliation(s)
- Kelly E Lloyd
- Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL, UK.
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL, UK
| | - Louise H Hall
- Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL, UK
| | - Lucy Ziegler
- Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL, UK
| | - Sophie M C Green
- Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL, UK
| | - Zainab F Haider
- Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL, UK
| | - David G Taylor
- School of Pharmacy, University College London, London, UK
| | | | - Samuel G Smith
- Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL, UK
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9
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Law RSL, Krupa K, Dowsett M, Rusby JE. Breast Cancer Prevention Is Better Than Cure. JCO Oncol Pract 2022; 18:521-523. [PMID: 35312351 DOI: 10.1200/op.22.00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Rebekah S L Law
- Rebekah S.L. Law, MBBS, and Katherine Krupa, MBBS, The Royal Marsden Hospital, London, United Kingdom; Mitch Dowsett, PhD, The Institute of Cancer Research, London, United Kingdom; and Jennifer E. Rusby, BM BCh, DM, The Royal Marsden Hospital, London, United Kingdom
| | - Katherine Krupa
- Rebekah S.L. Law, MBBS, and Katherine Krupa, MBBS, The Royal Marsden Hospital, London, United Kingdom; Mitch Dowsett, PhD, The Institute of Cancer Research, London, United Kingdom; and Jennifer E. Rusby, BM BCh, DM, The Royal Marsden Hospital, London, United Kingdom
| | - Mitch Dowsett
- Rebekah S.L. Law, MBBS, and Katherine Krupa, MBBS, The Royal Marsden Hospital, London, United Kingdom; Mitch Dowsett, PhD, The Institute of Cancer Research, London, United Kingdom; and Jennifer E. Rusby, BM BCh, DM, The Royal Marsden Hospital, London, United Kingdom
| | - Jennifer E Rusby
- Rebekah S.L. Law, MBBS, and Katherine Krupa, MBBS, The Royal Marsden Hospital, London, United Kingdom; Mitch Dowsett, PhD, The Institute of Cancer Research, London, United Kingdom; and Jennifer E. Rusby, BM BCh, DM, The Royal Marsden Hospital, London, United Kingdom
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10
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Lloyd KE, Hall LH, King N, Thorneloe RJ, Rodriguez-Lopez R, Ziegler L, Taylor DG, MacKenzie M, Smith SG. Aspirin use for cancer prevention: A systematic review of public, patient and healthcare provider attitudes and adherence behaviours. Prev Med 2022; 154:106872. [PMID: 34762964 PMCID: PMC8803547 DOI: 10.1016/j.ypmed.2021.106872] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/08/2021] [Accepted: 11/04/2021] [Indexed: 12/21/2022]
Abstract
We undertook a systematic review to synthesise the data on attitudes and behaviour towards the use of aspirin for cancer prevention, and healthcare providers' attitudes towards implementing aspirin in practice. Searches were carried out across 12 databases (e.g. MEDLINE, EMBASE). We used the Mixed Methods Appraisal Tool to evaluate study quality, and conducted a narrative synthesis of the data. The review was pre-registered (PROSPERO: CRD42018093453). Thirty-eight studies were identified. Uptake and adherence data were all from trials. Trials recruited healthy participants, those at higher risk of cancer, and those with cancer. Four studies reported moderate to high (40.9-77.7%) uptake to an aspirin trial among people who were eligible. Most trials (18/22) reported high day-to-day adherence (≥80%). Three trials observed no association between gender and adherence. One trial found no association between adherence and colorectal cancer risk. Three studies reported moderate to high (43.6-76.0%) hypothetical willingness to use aspirin. Two studies found that a high proportion of healthcare providers (72.0-76.0%) perceived aspirin to be a suitable cancer prevention option. No qualitative studies were identified. The likelihood that eligible users of aspirin would participate in a trial evaluating the use of aspirin for preventive therapy was moderate to high. Among participants in a trial, day-to-day adherence was high. Further research is needed to identify uptake and adherence rates in routine care, the factors affecting aspirin use, and the barriers to implementing aspirin into clinical care.
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Affiliation(s)
- Kelly E Lloyd
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Louise H Hall
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Natalie King
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Rachael J Thorneloe
- Centre for Behavioural Science & Applied Psychology, Sheffield Hallam University, Sheffield, UK
| | | | - Lucy Ziegler
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - David G Taylor
- School of Pharmacy, University College London, London, UK
| | | | - Samuel G Smith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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11
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Macdonald C, Chamberlain JA, Mazza D, Milne RL, Phillips KA. Underutilisation of breast cancer prevention medication in Australia. Breast 2021; 60:35-37. [PMID: 34455228 PMCID: PMC8399345 DOI: 10.1016/j.breast.2021.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/09/2021] [Accepted: 08/19/2021] [Indexed: 11/17/2022] Open
Abstract
Increased implementation of proven prevention strategies is required to combat rising breast cancer incidence. We assessed use of risk reducing medication (RRMed) by Australian women at elevated breast cancer risk. Only 2.4% had ever used RRMed. Higher breast cancer risk was statistically significantly associated with use of RRMed (OR 1.82, 95%CI: 1.08–3.07, p = 0.02 for ≥30% lifetime risk compared with 16%–29% lifetime risk), but parity, education level and family history of breast cancer were not. Breast cancer prevention medications are underutilised. Efforts are needed to incorporate breast cancer risk assessment and risk management discussions into routine health assessments for women. Risk-reducing medication is infrequently used by Australian women at increased risk of breast cancer. Higher breast cancer risk is associated with greater uptake of risk reducing medication, but not with adherence. Routine breast cancer risk assessment may increase risk reducing medication use.
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Affiliation(s)
- Courtney Macdonald
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | | | - Danielle Mazza
- Department of General Practice, Monash University, Melbourne, Australia
| | - Roger L Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia; Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Melbourne, Australia
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- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia; The Research Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Kelly-Anne Phillips
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.
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12
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Breast cancer worry in higher-risk women offered preventive therapy: a UK multicentre prospective study. Breast Cancer Res Treat 2021; 188:703-712. [PMID: 33733302 PMCID: PMC8720078 DOI: 10.1007/s10549-021-06183-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/05/2021] [Indexed: 01/14/2023]
Abstract
Purpose Women’s worry about developing breast cancer may influence their decision to use preventive therapy. However, the direction of this relationship has been questioned. We prospectively investigated the relationship between breast cancer worry and uptake of preventive therapy. The socio-demographic and clinical factors associated with high breast cancer worry were also investigated. Methods Women at increased risk of developing breast cancer were recruited from clinics across England (n = 408). Participants completed a survey on their breast cancer worry, socio-demographic and clinical factors. Uptake of tamoxifen was recorded at 3 months (n = 258 women, 63.2%). Both primary and sensitivity analyses were conducted using different classifications of low, medium and high worry. Results 39.5% of respondents reported medium breast cancer worry at baseline and 21.2% reported high worry. Ethnic minority women were more likely to report high worry than white women (OR = 3.02, 95%CI 1.02, 8.91, p = 0.046). Women educated below degree level were more likely to report high worry than those with higher education (OR = 2.29, 95%CI 1.28, 4.09, p = 0.005). No statistically significant association was observed between worry and uptake. In the primary analysis, fewer respondents with medium worry at baseline initiated tamoxifen (low worry = 15.5%, medium = 13.5%, high = 15.7%). In the sensitivity analysis, participants with medium worry reported the highest uptake of tamoxifen (19.7%). Conclusions No association was observed between worry and uptake, although the relationship was affected by the categorisation of worry. Standardised reporting of the classification of worry is warranted to allow transparent comparisons across cohorts. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06183-x.
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13
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Lee O, Pilewskie M, Karlan S, Tull MB, Benante K, Xu Y, Blanco L, Helenowski I, Kocherginsky M, Yadav S, Hosseini O, Hansen N, Bethke K, Muzzio M, Troester MA, Dimond E, Perloff M, Heckman-Stoddard B, Khan SA. Local Transdermal Delivery of Telapristone Acetate Through Breast Skin, Compared With Oral Treatment: A Randomized Double-Blind, Placebo-Controlled Phase II Trial. Clin Pharmacol Ther 2021; 109:728-738. [PMID: 32996592 PMCID: PMC8388824 DOI: 10.1002/cpt.2041] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 08/25/2020] [Indexed: 12/20/2022]
Abstract
Oral breast cancer prevention medications entail systemic exposure, limiting acceptance by high-risk women. Delivery through the breast skin, although an attractive alternative, requires demonstration of drug distribution throughout the breast. We conducted a randomized double-blind, placebo-controlled phase II clinical trial comparing telapristone acetate, a progesterone receptor antagonist, administered orally (12 mg/day) or transdermally (12 mg/breast) for 4 ± 1 weeks to women planning mastectomy. Plasma and tissue concentrations, measured at five locations in the mastectomy specimen using liquid chromatography tandem mass spectrometry were compared. In 60 evaluable subjects, median drug concentration (ng/g tissue) was 103 (interquartile range (IQR): 46.3-336) in the oral vs. 2.82 (IQR: 1.4-5.5) in the transdermal group. Despite poor dermal permeation, within-breast drug distribution pattern was identical in both groups (R2 = 0.88, P = 0.006), demonstrating that transdermally and orally delivered drug is distributed similarly through the breast, and is strongly influenced by tissue adiposity (P < 0.0001). Other skin-penetrant drugs should be tested for breast cancer prevention.
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Affiliation(s)
- Oukseub Lee
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Melissa Pilewskie
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Scott Karlan
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mary B Tull
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kelly Benante
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Yanfei Xu
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Luis Blanco
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Irene Helenowski
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Masha Kocherginsky
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shivangi Yadav
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Omid Hosseini
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nora Hansen
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kevin Bethke
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Miguel Muzzio
- Analytical Chemistry Division, Illinois Institute of Technology Research Institute, Chicago, Illinois, USA
| | - Melissa A Troester
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Eileen Dimond
- National Cancer Institute Division of Cancer Prevention, Bethesda, Maryland, USA
| | - Marjorie Perloff
- National Cancer Institute Division of Cancer Prevention, Bethesda, Maryland, USA
| | | | - Seema A Khan
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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14
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Bojanic K, Vukadin S, Grgic K, Malenica L, Sarcevic F, Smolic R, Kralik K, Včev A, Wu GY, Smolic M. The accuracy of breast cancer risk self-assessment does not correlate with knowledge about breast cancer and knowledge and attitudes towards primary chemoprevention. Prev Med Rep 2020; 20:101229. [PMID: 33145151 PMCID: PMC7593623 DOI: 10.1016/j.pmedr.2020.101229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 01/02/2023] Open
Abstract
The increase of breast cancer (BC) incidence has drawn attention to BC risk as means of reducing mortality and morbidity of the disease. The aim of this study was to determine the accuracy of BC risk perception, evaluate factors that affect risk perception and assess the correlation between BC risk perception and attitudes towards BC chemoprevention. A cross-sectional study included total of 258 women with average and high-risk for BC according to the Breast Cancer Risk Assessment Tool (BCRAT). All data were collected by face-to-face interview by three trained 6th year medical school students using a 54-item questionnaire. Each participant's actual BC risk was compared to a perceived risk and the accuracy of the BC risk self-assessment was determined. 72% of high-risk women underestimated their BC risk (p < 0.001). One third of subjects with a family history of BC have also underestimated their own risk (p = 0.002). Women who responded to screening mammography were more informed about BC risk factors (p = 0.001). General knowledge about BC chemoprevention was surprisingly low, regardless of the accuracy of BC risk self-assessment. High-risk women appear to be unrealistically optimistic, since there was a significant difference between the accuracy of self-perceived risk and the objective BC risk.
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Affiliation(s)
- Kristina Bojanic
- Department of Biophysics and Radiology, Faculty of Dental Medicine and Health Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia.,Department of Biophysics and Radiology, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia.,Department of Radiology, Health Center Osijek, Osijek 31000, Croatia
| | - Sonja Vukadin
- Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia.,Department of Pharmacology, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia
| | - Kaja Grgic
- Department of Pharmacology, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia
| | - Luka Malenica
- Department of Patophysiology, Physiology and Immunology, Faculty of Dental Medicine and Health Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia
| | - Filip Sarcevic
- Department of Pharmacology, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia
| | - Robert Smolic
- Department of Patophysiology, Physiology and Immunology, Faculty of Dental Medicine and Health Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia.,Department of Patophysiology, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia.,Department of Internal Medicine, University Hospital Osijek, Osijek 31000, Croatia
| | - Kristina Kralik
- Department of Medical Statistics and Medical Informatics, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia
| | - Aleksandar Včev
- Department of Patophysiology, Physiology and Immunology, Faculty of Dental Medicine and Health Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia.,Department of Patophysiology, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia.,Department of Internal Medicine, University Hospital Osijek, Osijek 31000, Croatia
| | - George Y Wu
- Department of Internal Medicine, Division of Gastrenterology/Hepatology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06032, USA
| | - Martina Smolic
- Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia.,Department of Pharmacology, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek 31000, Croatia
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15
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Thorneloe RJ, Hall LH, Walter FM, Side L, Lloyd KE, Smith SG. Knowledge of Potential Harms and Benefits of Tamoxifen among Women Considering Breast Cancer Preventive Therapy. Cancer Prev Res (Phila) 2020; 13:411-422. [PMID: 31988145 PMCID: PMC7611305 DOI: 10.1158/1940-6207.capr-19-0424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/19/2019] [Accepted: 01/21/2020] [Indexed: 12/28/2022]
Abstract
Tamoxifen reduces breast cancer incidence in women at increased risk, but may cause side effects. We examined women's knowledge of tamoxifen's potential harms and benefits, and the extent to which knowledge reflects subjective judgments of awareness and decision quality. After a hospital appointment, 408 (55.7%) women at increased risk of breast cancer completed a survey assessing objective knowledge about the potential benefit (risk reduction) and harms (endometrial cancer, thromboembolic events, and menopausal side effects) of tamoxifen, and subjective tamoxifen knowledge and decisional quality. Two hundred fifty-eight (63.2%) completed a 3-month follow-up survey. Sixteen percent (15.7%) of participants recognized the potential benefit and three major harms of using tamoxifen. These women were more likely to have degree-level education [vs. below degree level; OR, 2.24; 95% confidence interval (CI), 1.11-4.55] and good numeracy (vs. poor numeracy; OR, 5.91; 95% CI, 1.33-26.19). Tamoxifen uptake was higher in women who recognized all harms and benefits (vs. not recognizing; OR, 2.47; 95% CI, 0.94-6.54). Sixty-six percent (65.8%) of tamoxifen users were unaware of its potential benefit and harms. Most (87.1%) women reported feeling informed about tamoxifen, and subjective decisional quality was high [Mean (SD), 17.03 (1.87), out of 18]. Knowledge regarding the potential harms and benefit of tamoxifen is low in women considering prevention therapy, and they may need additional support to make informed decisions about tamoxifen preventive therapy.
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Affiliation(s)
| | - Louise Hazel Hall
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Fiona Mary Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Lucy Side
- Wessex Clinical Genetics Service, University Hospitals Southampton, Southampton, United Kingdom
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16
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Nelson HD, Fu R, Zakher B, Pappas M, McDonagh M. Medication Use for the Risk Reduction of Primary Breast Cancer in Women: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 322:868-886. [PMID: 31479143 DOI: 10.1001/jama.2019.5780] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Medications to reduce risk of breast cancer are effective for women at increased risk but also cause adverse effects. OBJECTIVE To update the 2013 US Preventive Services Task Force systematic review on medications to reduce risk of primary (first diagnosis) invasive breast cancer in women. DATA SOURCES Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, EMBASE, and MEDLINE (January 1, 2013, to February 1, 2019); manual review of reference lists. STUDY SELECTION Discriminatory accuracy studies of breast cancer risk assessment methods; randomized clinical trials of tamoxifen, raloxifene, and aromatase inhibitors for primary breast cancer prevention; studies of medication adverse effects. DATA EXTRACTION AND SYNTHESIS Investigators abstracted data on methods, participant characteristics, eligibility criteria, outcome ascertainment, and follow-up. Results of individual trials were combined by using a profile likelihood random-effects model. MAIN OUTCOMES AND MEASURES Probability of breast cancer in individuals (area under the receiver operating characteristic curve [AUC]); incidence of breast cancer, fractures, thromboembolic events, coronary heart disease events, stroke, endometrial cancer, and cataracts; and mortality. RESULTS A total of 46 studies (82 articles [>5 million participants]) were included. Eighteen risk assessment methods in 25 studies reported low accuracy in predicting the probability of breast cancer in individuals (AUC, 0.55-0.65). In placebo-controlled trials, tamoxifen (risk ratio [RR], 0.69 [95% CI, 0.59-0.84]; 4 trials [n = 28 421]), raloxifene (RR, 0.44 [95% CI, 0.24-0.80]; 2 trials [n = 17 806]), and the aromatase inhibitors exemestane and anastrozole (RR, 0.45 [95% CI, 0.26-0.70]; 2 trials [n = 8424]) were associated with a lower incidence of invasive breast cancer. Risk for invasive breast cancer was higher for raloxifene than tamoxifen in 1 trial after long-term follow-up (RR, 1.24 [95% CI, 1.05-1.47]; n = 19 747). Raloxifene was associated with lower risk for vertebral fractures (RR, 0.61 [95% CI, 0.53-0.73]; 2 trials [n = 16 929]) and tamoxifen was associated with lower risk for nonvertebral fractures (RR, 0.66 [95% CI, 0.45-0.98]; 1 trial [n = 13 388]) compared with placebo. Tamoxifen and raloxifene were associated with increased thromboembolic events compared with placebo; tamoxifen was associated with more events than raloxifene. Tamoxifen was associated with higher risk of endometrial cancer and cataracts compared with placebo. Symptomatic effects (eg, vasomotor, musculoskeletal) varied by medication. CONCLUSIONS AND RELEVANCE Tamoxifen, raloxifene, and aromatase inhibitors were associated with lower risk of primary invasive breast cancer in women but also were associated with adverse effects that differed between medications. Risk stratification methods to identify patients with increased breast cancer risk demonstrated low accuracy.
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Rongwei Fu
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University, Portland
| | - Bernadette Zakher
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University, Portland
| | - Miranda Pappas
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Marian McDonagh
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
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17
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Thorneloe RJ, Horne R, Side L, Wolf MS, Smith SG. Beliefs About Medication and Uptake of Preventive Therapy in Women at Increased Risk of Breast Cancer: Results From a Multicenter Prospective Study. Clin Breast Cancer 2019; 19:e116-e126. [PMID: 30518498 PMCID: PMC6395889 DOI: 10.1016/j.clbc.2018.10.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/12/2018] [Accepted: 10/24/2018] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Uptake of preventive therapies for breast cancer is low. We examined whether women at increased risk of breast cancer can be categorized into groups with similar medication beliefs, and whether belief group membership was prospectively associated with uptake of preventive therapy. PATIENTS AND METHODS Women (n = 732) attending an appointment to discuss breast cancer risk were approached; 408 (55.7%) completed the Beliefs About Medicines and the Perceived Sensitivity to Medicines questionnaires. Uptake of tamoxifen at 3 months was reported in 258 (63.2%). The optimal number of belief groups were identified using latent profile analysis. RESULTS Uptake of tamoxifen was 14.7% (38/258). One in 5 women (19.4%; 78/402) reported a strong need for tamoxifen. The model fit statistics supported a 2-group model. Both groups held weak beliefs about their need for tamoxifen for current and future health. Group 2 (38%; 154/406 of the sample) reported stronger concerns about tamoxifen and medicines in general, and stronger perceived sensitivity to the negative effects of medicines compared with group 1 (62%; 252/406). Women with low necessity and lower concerns (group 1) were more likely to initiate tamoxifen (18.3%; 33/180) than those with low necessity and higher concerns (group 2) (6.4%; 5/78). After adjusting for demographic and clinical factors, the odds ratio was 3.37 (95% confidence interval, 1.08-10.51; P = .036). CONCLUSION Uptake of breast cancer preventive therapy was low. A subgroup of women reported low need for preventive therapy and strong medication concerns. These women were less likely to initiate tamoxifen. Medication beliefs are targets for supporting informed decision-making.
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Affiliation(s)
| | - Rob Horne
- Centre for Behavioural Medicine, School of Pharmacy, University College London, London, United Kingdom
| | - Lucy Side
- Wessex Clinical Genetics Service, University Hospitals Southampton, Southampton, United Kingdom
| | - Michael Scott Wolf
- Division of General Internal Medicine and Geriatrics, Northwestern University, Evanston, IL
| | - Samuel George Smith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.
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