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Graetz I, Hu X, Kocak M, Krukowski RA, Anderson JN, Waters TM, Curry AN, Robles A, Paladino A, Stepanski E, Vidal GA, Schwartzberg LS. Remote Monitoring App for Endocrine Therapy Adherence Among Patients With Early-Stage Breast Cancer: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2417873. [PMID: 38935379 PMCID: PMC11211959 DOI: 10.1001/jamanetworkopen.2024.17873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/19/2024] [Indexed: 06/28/2024] Open
Abstract
Importance Adjuvant endocrine therapy (AET) use among women with early-stage, hormone receptor-positive breast cancer reduces the risk of cancer recurrence, but its adverse symptoms contribute to lower adherence. Objective To test whether remote monitoring of symptoms and treatment adherence with or without tailored text messages improves outcomes among women with breast cancer who are prescribed AET. Design, Setting, and Participants This nonblinded, randomized clinical trial (RCT) following intention-to-treat principles included English-speaking women with early-stage breast cancer prescribed AET at a large cancer center with 14 clinics across 3 states from November 15, 2018, to June 11, 2021. All participants had a mobile device with a data plan and an email address and were asked to use an electronic pillbox to monitor AET adherence and to complete surveys at enrollment and 1 year. Interventions Participants were randomized into 3 groups: (1) an app group, in which participants received instructions for and access to the study adherence and symptom monitoring app for 6 months; (2) an app plus feedback group, in which participants received additional weekly text messages about managing symptoms, adherence, and communication; or (3) an enhanced usual care (EUC) group. App-reported missed doses, increases in symptoms, and occurrence of severe symptoms triggered follow-ups from the oncology team. Main Outcomes and Measures The primary outcome was 1-year, electronic pillbox-captured AET adherence. Secondary outcomes included symptom management abstracted from the medical record, as well as patient-reported health care utilization, symptom burden, quality of life, physician communication, and self-efficacy for managing symptoms. Results Among 304 female participants randomized (app group, 98; app plus feedback group, 102; EUC group, 104), the mean (SD) age was 58.6 (10.8) years (median, 60 years; range, 31-83 years), and 60 (19.7%) had an educational level of high school diploma or less. The study completion rate was 87.5% (266 participants). There were no statistically significant differences by treatment group in AET adherence (primary outcome): 76.6% for EUC, 73.4% for the app group (difference vs EUC, -3.3%; 95% CI, -11.4% to 4.9%; P = .43), and 70.9% for the app plus feedback group (difference vs EUC, -5.7%; 95% CI, -13.8% to 2.4%; P = .17). At the 1-year follow-up, app plus feedback participants had fewer total health care encounters (adjusted difference, -1.23; 95% CI, -2.03 to -0.43; P = .003), including high-cost encounters (adjusted difference, -0.40; 95% CI, -0.67 to -0.14; P = .003), and office visits (adjusted difference, -0.82; 95% CI, -1.54 to -0.09; P = .03) over the previous 6 months compared with EUC participants. Conclusions and Relevance This RCT found that a remote monitoring app with alerts to the patient's care team and tailored text messages to patients did not improve AET adherence among women with early-stage breast cancer; however, it reduced overall and high-cost health care encounters and office visits without affecting quality of life. Trial Registration ClinicalTrials.gov Identifier: NCT03592771.
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Affiliation(s)
- Ilana Graetz
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Xin Hu
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville
| | - Mehmet Kocak
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Rebecca A. Krukowski
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville
| | - Janeane N. Anderson
- Department of Community and Population Health, College of Nursing, University of Tennessee Health Science Center, Memphis
| | | | - Andrea N. Curry
- West Cancer Center and Research Institute, Germantown, Tennessee
| | - Andrew Robles
- Sidney Kimmel Cancer Center, Jefferson University, Philadelphia, Pennsylvania
| | - Andrew Paladino
- College of Medicine, University of Tennessee Health Science Center, Memphis
| | | | - Gregory A. Vidal
- West Cancer Center and Research Institute, Germantown, Tennessee
- College of Medicine, University of Tennessee Health Science Center, Memphis
| | - Lee S. Schwartzberg
- Pennington Cancer Institute, Renown Health, Reno, Nevada
- Department of Medicine, University of Nevada, Reno
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Montagna E, Zagami P, Masiero M, Mazzocco K, Pravettoni G, Munzone E. Assessing Predictors of Tamoxifen Nonadherence in Patients with Early Breast Cancer. Patient Prefer Adherence 2021; 15:2051-2061. [PMID: 34552323 PMCID: PMC8450184 DOI: 10.2147/ppa.s285768] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/31/2021] [Indexed: 12/11/2022] Open
Abstract
Adjuvant endocrine therapy (AET) is generally proposed to all patients with hormone receptor-positive breast cancer to reduce the risk of recurrence and death. Adherence to therapy is crucial. However, non-adherence to AET is common, with estimates of up to 50% of patients not successfully completing a five-year course of treatment, and it is significantly associated with lower survival rates and a higher risk of recurrence. Currently, no gold standard is available to assess adherence. Several studies, most of them retrospective in nature, have used both direct and indirect methods to monitor the adherence to therapy in breast cancer. The indirect method is more widely used, and it is based on pharmacy prescription refills and patient administered questionnaires. On the other hand, direct methods such as a measurement of the level of the drug or its metabolites in blood or urine are much more precise, but more expensive and not routinely implemented. In this review, we analyzed the results of the major studies focused on the adherence to tamoxifen in breast cancer patients. We identified several factors associated with poor adherence, such as the side effects of therapy, the lack of shared decision-making between the physician and patient, the context in which the discussion takes place, and whether the patients are enrolled in a clinical trial. Moreover, we discussed possible methods to improve adherence to adjuvant therapy in breast cancer.
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Affiliation(s)
- Emilia Montagna
- Division of Medical Senology, IEO European Institute of Oncology IRCCS, Milan, Italy
- Correspondence: Emilia Montagna Division of Medical Senology, European Institute of Oncology, IRCCS, Via Ripamonti 435, Milan, 20141, ItalyTel +39 02 57489439Fax +39 02 574829212 Email
| | - Paola Zagami
- Division of Medical Senology, IEO European Institute of Oncology IRCCS, Milan, Italy
- Division of Early Drug Development for Innovative Therapies, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Marianna Masiero
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO European Institute of Oncology IRCCS, Milan, 20141, Italy
| | - Ketti Mazzocco
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO European Institute of Oncology IRCCS, Milan, 20141, Italy
| | - Gabriella Pravettoni
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO European Institute of Oncology IRCCS, Milan, 20141, Italy
| | - Elisabetta Munzone
- Division of Medical Senology, IEO European Institute of Oncology IRCCS, Milan, Italy
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Paladino AJ, Anderson JN, Krukowski RA, Waters T, Kocak M, Graff C, Blue R, Jones TN, Buzaglo J, Vidal G, Schwartzberg L, Graetz I. THRIVE study protocol: a randomized controlled trial evaluating a web-based app and tailored messages to improve adherence to adjuvant endocrine therapy among women with breast cancer. BMC Health Serv Res 2019; 19:977. [PMID: 31856812 PMCID: PMC6924011 DOI: 10.1186/s12913-019-4588-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background Long-term use of adjuvant endocrine therapy (AET) among women with early-stage, hormone receptor-positive breast cancer significantly reduces the risk of hospitalizations, cancer recurrence, and mortality. AET is associated with adverse symptoms that often result in poor adherence. A web-enabled app offers a novel way to communicate and manage symptoms for women on AET. In a region with significant racial disparities in breast cancer outcomes, our study tests the impact of a web-enabled app that collects and transmits patient-reported symptoms to healthcare teams to facilitate timely and responsive symptom management on medication adherence. Methods In this randomized controlled trial, we randomize 300 patients initiating AET to one of three arms: 1) an “App” group (n = 100) that receives weekly reminders to use the THRIVE study app; 2) an “App+Feedback” group (n = 100) that receives weekly reminders and tailored feedback based on their use of the app; or 3) a “Usual Care” group (n = 100) that receives usual care only. Participants are stratified by race: 50% White and 50% Black. The duration of the intervention is six months following enrollment, and outcomes are assessed at 12-months. The primary outcome is adherence, which is captured using an electronic monitoring pillbox. Secondary outcomes include symptom burden, quality of life, self-efficacy for managing symptoms, and healthcare costs. We also evaluate the impact of the intervention on racial disparities in adherence. Data are derived from three sources: electronic health record data to capture treatment changes, healthcare utilization, and health outcomes; self-report survey data related to adherence, symptom burden, and quality of life; and an electronic medication monitoring device that captures adherence. Discussion A successful web-enabled intervention could be disseminated across systems, conditions, and populations. By evaluating the impact of this intervention on a comprehensive set of measures, including AET adherence, patient outcomes, and costs, our study will provide valuable and actionable results for providers, policy makers, and insurers who strive to achieve the “Triple Aim” – reduce costs while improving health outcomes and the patient care experience. Trial registration NCT03592771. Prospectively registered on July 19, 2018.
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Affiliation(s)
- Andrew J Paladino
- Department of Health Policy and Management, Emory University, Rollins School of Public Health, 1518 Clifton Road, Atlanta, GA, USA.,The West Cancer Center & Research Institute, Memphis, TN, USA
| | - Janeane N Anderson
- College of Nursing, The University of Tennessee Health Science Center, 920 Madison Avenue, Memphis, TN, USA
| | - Rebecca A Krukowski
- Department of Preventive Medicine, The University of Tennessee Health Science Center, College of Medicine, 66 N Pauline St, Memphis, TN, USA
| | - Teresa Waters
- Department of Health Management and Policy, The University of Kentucky, College of Public Health, Lexington, KY, USA
| | - Mehmet Kocak
- Department of Preventive Medicine, The University of Tennessee Health Science Center, College of Medicine, 66 N Pauline St, Memphis, TN, USA
| | - Carolyn Graff
- College of Nursing, The University of Tennessee Health Science Center, 920 Madison Avenue, Memphis, TN, USA
| | - Ryan Blue
- College of Nursing, The University of Tennessee Health Science Center, 920 Madison Avenue, Memphis, TN, USA
| | - Tameka N Jones
- The West Cancer Center & Research Institute, Memphis, TN, USA
| | - Joanne Buzaglo
- Department of Patient Reported Outcomes, Vector Oncology, Memphis, TN, USA
| | - Gregory Vidal
- The West Cancer Center & Research Institute, Memphis, TN, USA
| | | | - Ilana Graetz
- Department of Health Policy and Management, Emory University, Rollins School of Public Health, 1518 Clifton Road, Atlanta, GA, USA. .,Department of Preventive Medicine, The University of Tennessee Health Science Center, College of Medicine, 66 N Pauline St, Memphis, TN, USA.
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The Association Between Out-of-Pocket Costs and Adherence to Adjuvant Endocrine Therapy Among Newly Diagnosed Breast Cancer Patients. Am J Clin Oncol 2019; 41:708-715. [PMID: 27893470 DOI: 10.1097/coc.0000000000000351] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To determine how out-of-pocket costs for adjuvant endocrine therapy (AET) medication affects adherence among newly diagnosed breast cancer survivors with private health insurance who initiate therapy. MATERIALS AND METHODS We examined medical and pharmacy claims for the 1-year period after initiating AET using the Truven Health Analytics MarketScan database. Adherence was defined as ≥80% proportion of days covered. Mean out-of-pocket costs for AET fill were measured as the sum of copayments, coinsurance, and deductibles and adjusted to 30-day amounts. Using a multivariable logistic regression model we calculated adjusted risk ratios controlling for age, comorbidities, type of surgery, use of chemotherapy and/or radiation therapy, average out-of-pocket costs for other services, and pharmacy use characteristics. RESULTS Of the 6863 women 64 years and younger who were diagnosed with breast cancer and initiated AET, 73.9% were adherent (proportion of days covered≥80%). A total of 19% of patients had <$5 monthly out-of-pocket costs for AET, 30% had $5 to $9.99, 17% had $10 to $14.99, 10% had $15 to $19.99, and 25% had $20 or greater. Patients with out-of-pocket costs for AET between $10 and $14.99, $15 and $19.99, and >$20 were 6% to 8% less likely to be adherent compared with patients paying <$5.00, after controlling for covariates (P<0.05). Out-of-pocket costs for inpatient, outpatient, and other pharmacy services were not associated with adherence. CONCLUSIONS A substantial proportion of privately insured patients are nonadherent to AET and out-of-pocket costs for AET medication are significantly associated with a greater likelihood of nonadherence.
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Graetz I, McKillop CN, Stepanski E, Vidal GA, Anderson JN, Schwartzberg LS. Use of a web-based app to improve breast cancer symptom management and adherence for aromatase inhibitors: a randomized controlled feasibility trial. J Cancer Surviv 2018; 12:431-440. [PMID: 29492753 DOI: 10.1007/s11764-018-0682-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 02/12/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE For postmenopausal women with hormone receptor-positive breast cancer, long-term use of aromatase inhibitors (AIs) significantly reduces the risk of cancer recurrence and improves survival. Still, many patients are nonadherent due to adverse side effects. We conducted a pilot randomized controlled trial to test the use of a web-based application (app) designed with and without weekly reminders for patients to report real-time symptoms and AI use outside of clinic visits with built-in alerts to patients' oncology providers. Our goal was to improve symptom burden and medication adherence. METHODS Forty-four women with early-stage breast cancer and a new AI prescription were randomized to either an App+Reminder (weekly reminders to use app) or an App (no reminders) group. Pre- and post-assessment data were collected from all participants. RESULTS Participants in the App+Reminder group had higher weekly app usage rate (74 vs. 38%, p < 0.05) during the intervention and reported higher AI adherence at 8 weeks (100 vs. 72%, p < 0.05). Symptom burden increase was higher for the App group compared to the App+Reminder group but did not reach statistical significance. CONCLUSIONS Weekly reminders to use a web-based app to report AI adherence and treatment-related symptoms demonstrated feasibility and improved short-term AI adherence, which may reduce symptom burden for women with breast cancer and a new AI prescription. IMPLICATIONS FOR CANCER SURVIVORS If short-term gains in adherence persist, this low-cost intervention could improve survival outcomes for women with breast cancer. A larger, long-term study should examine if AI adherence and symptom burden improvements persist for a 5-year treatment period.
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Affiliation(s)
- Ilana Graetz
- Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, 66 N. Pauline St., Ste. 633, Memphis, TN, 38163, USA.
| | - Caitlin N McKillop
- Department of Economics, State University of New York at Cortland, 28 Graham Ave., Cortland, NY, 13045, USA
| | - Edward Stepanski
- Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, 66 N. Pauline St., Ste. 633, Memphis, TN, 38163, USA.,Vector Oncology, 6555 Quince Rd #400, Memphis, TN, 38119, USA
| | - Gregory A Vidal
- Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, 66 N. Pauline St., Ste. 633, Memphis, TN, 38163, USA.,West Cancer Center, 7945 Wolf River Blvd, Germantown, TN, 38138, USA
| | - Janeane N Anderson
- Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, 66 N. Pauline St., Ste. 633, Memphis, TN, 38163, USA
| | - Lee S Schwartzberg
- Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, 66 N. Pauline St., Ste. 633, Memphis, TN, 38163, USA.,Vector Oncology, 6555 Quince Rd #400, Memphis, TN, 38119, USA.,West Cancer Center, 7945 Wolf River Blvd, Germantown, TN, 38138, USA
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Exploring the role of physician communication about adjuvant endocrine therapy among breast cancer patients on active treatment: a qualitative analysis. Support Care Cancer 2016; 25:75-83. [PMID: 27557832 DOI: 10.1007/s00520-016-3389-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/17/2016] [Indexed: 01/13/2023]
Abstract
PURPOSE To better understand how physicians communicate with breast cancer patients about adjuvant endocrine therapy (AET), we explored, from the breast cancer patient's perspective, dimensions of the patient-provider communication among women who were on active AET treatment. METHODS Qualitative methods using semi-structured in-depth interviews were conducted with breast cancer patients (n = 22) who filled a prescription for AET in the previous 12 months. Interview questions aimed to elicit experiences with AET. We reviewed and coded interview transcripts using qualitative principles of inductive reasoning to identify concepts and themes from interview data. RESULTS We grouped emergent themes into four major functions of physician-patient communication: (1) information exchange, (2) decision-making to take and continue AET, (3) enabling patient self-management and monitoring potential side effects, and (4) emotional support. Physicians exchanged information with patients in a way that they understood and enhanced patient's health literacy regarding the benefits and knowledge of AET. Physicians empowered patients to make decisions about their care. Patients expressed trust and confidence in their physician which helped them seek care when needed. Patients reported a high degree of self-efficacy to self-manage AET and were continuing treatment despite potential side effects. CONCLUSIONS The results from our study suggest that women's interactions and communication with their physician may be an important factor that contributes to the continued use of AET. Physicians who can communicate information about AET treatment benefits, purpose, and expectations in a way that patients can understand is a critical aspect of care that needs to be further studied.
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Roberts MC, Wheeler SB, Reeder-Hayes K. Racial/Ethnic and socioeconomic disparities in endocrine therapy adherence in breast cancer: a systematic review. Am J Public Health 2015; 105 Suppl 3:e4-e15. [PMID: 25905855 DOI: 10.2105/ajph.2014.302490] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
We examined the current literature to understand factors that influence endocrine therapy (ET) adherence among racial/ethnic and socioeconomic subpopulations of breast cancer patients. We searched PubMed and PsycINFO databases for studies from January 1, 1978, to June 20, 2014, and January 1, 1991, to June 20, 2014, respectively, and hand-searched articles from relevant literature reviews. We abstracted and synthesized results within a social ecological framework. Fourteen articles met all inclusion criteria. The majority of included articles reported significant underuse of ET among minority and low-income women. Modifiable intrapersonal, interpersonal, and community-level factors are associated with ET use, and these factors vary across subgroups. Both race/ethnicity and socioeconomic status are associated with ET use in most settings. Variation in factors associated with ET use across subgroups indicates the need for more nuanced research and targeted interventions among breast cancer patients.
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Affiliation(s)
- Megan C Roberts
- Megan C. Roberts, Stephanie B. Wheeler, and Katherine Reeder-Hayes are with the Lineberger Comprehensive Cancer Center, University of North Carolina (UNC), Chapel Hill. Megan C. Roberts and Stephanie B. Wheeler are also with the Department of Health Policy and Management, Gillings School of Global Public Health, UNC, Chapel Hill. Katherine Reeder-Hayes is also with the Division of Hematology/Oncology, School of Medicine, UNC, Chapel Hill
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Lee HS, Lee JY, Ah YM, Kim HS, Im SA, Noh DY, Lee BK. Low adherence to upfront and extended adjuvant letrozole therapy among early breast cancer patients in a clinical practice setting. Oncology 2014; 86:340-9. [PMID: 24925302 DOI: 10.1159/000360702] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 02/15/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the prevalence and causes of early discontinuation and non-adherence to upfront and extended adjuvant letrozole therapy in breast cancer patients. METHODS Adherence was assessed using medical charts and longitudinal pharmacy records of 609 patients who initiated adjuvant letrozole between January 2002 and April 2011. A Cox proportional hazards regression model was adopted to identify potential predictors of non-adherence. RESULTS The overall adherence rate after 1 year of therapy was 79.5%, with cumulative rates declining to 63.7% after 3 years and 57.1% after 5 years. A significantly lower rate of adherence in the extended adjuvant group was observed compared with the upfront adjuvant group (49.0 vs. 72.5%, p < 0.001). Adverse events (50.4%) were the major cause of early discontinuation, with musculoskeletal pain (73.2%) being the single most cited reason. Additional factors correlating with non-adherence in the upfront adjuvant group included a delay in initiation of adjuvant hormone therapy, breast-conserving surgery, calcium supplements, bisphosphonate therapy and concomitant medication for co-morbidity. CONCLUSIONS We observed that approximately 57% of patients fully adhered to letrozole therapy over a 5-year treatment period, and that the adherence to extended letrozole was meaningfully lower than the upfront adjuvant letrozole in a clinical practice setting.
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Affiliation(s)
- Hye-Suk Lee
- Division of Life and Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul, South Korea
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Huiart L, Ferdynus C, Giorgi R. A meta-regression analysis of the available data on adherence to adjuvant hormonal therapy in breast cancer: summarizing the data for clinicians. Breast Cancer Res Treat 2013; 138:325-8. [PMID: 23400580 DOI: 10.1007/s10549-013-2422-4] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 01/15/2013] [Indexed: 01/22/2023]
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Murphy CC, Bartholomew LK, Carpentier MY, Bluethmann SM, Vernon SW. Adherence to adjuvant hormonal therapy among breast cancer survivors in clinical practice: a systematic review. Breast Cancer Res Treat 2012; 134:459-78. [PMID: 22689091 DOI: 10.1007/s10549-012-2114-5] [Citation(s) in RCA: 494] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 05/23/2012] [Indexed: 01/07/2023]
Abstract
Adjuvant hormonal therapy significantly improves long-term survival of breast cancer patients with hormone receptor-positive disease. Despite the proven clinical efficacy of tamoxifen and aromatase inhibitors, many breast cancer survivors either fail to take the correct dosage at the prescribed frequency (adherence) or discontinue therapy (persistence). This systematic review aims to: (1) determine the prevalence of adherence and persistence to adjuvant hormonal therapy among breast cancer survivors in clinical practice, and (2) identify correlates of adherence and persistence. We searched Medline, PubMed, PsycINFO, and CINAHL for studies that measured rates and/or correlates of adherence and/or persistence to adjuvant hormonal therapy. Studies were reviewed in a multi-step process: (1) the lead author screened titles and abstracts of all potentially eligible studies; (2) each coauthor reviewed a random 5 % sample of abstracts; and (3) two sets of coauthors each reviewed half of all "maybe" abstracts. Any disagreements were discussed until consensus was reached. Twenty-nine studies met inclusion criteria. Prevalence of adherence ranged from 41 to 72 % and discontinuation (i.e., nonpersistence) ranged from 31 to 73 %, measured at the end of 5 years of treatment. Extremes of age (older or younger), increasing out-of-pocket costs, follow-up care with a general practitioner (vs. oncologist), higher CYP2D6 activity, switching from one form of therapy to another, and treatment side effects were negatively associated with adherence and/or persistence. Taking more medications at baseline, referral to an oncologist, and earlier year at diagnosis were positively associated with adherence and/or persistence. Adherence and persistence to adjuvant hormonal therapy among breast cancer survivors is suboptimal. Many of the correlates of adherence and persistence studied to date are not modifiable. Our review reveals a critical need for further research on modifiable factors associated with adherence to adjuvant hormonal therapy, and the development of behavioral interventions to improve adherence in this population.
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Affiliation(s)
- Caitlin C Murphy
- Center for Health Promotion and Prevention Research, The University of Texas School of Public Health, 7000 Fannin, Suite 2556B, Houston, TX 77030, USA.
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Predictors of non-adherence to aromatase inhibitors among commercially insured women with breast cancer. Breast Cancer Res Treat 2010; 125:191-200. [DOI: 10.1007/s10549-010-0952-6] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 05/12/2010] [Indexed: 10/19/2022]
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Half of breast cancer patients discontinue tamoxifen and any endocrine treatment before the end of the recommended treatment period of 5 years: a population-based analysis. Breast Cancer Res Treat 2010; 122:843-51. [PMID: 20058066 DOI: 10.1007/s10549-009-0724-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Accepted: 12/24/2009] [Indexed: 10/20/2022]
Abstract
Observational studies on long-term endocrine treatment among breast cancer patients have presented discontinuation rates on tamoxifen, but lack information on the continuance of any endocrine treatment [both tamoxifen and aromatase inhibitors (AIs)] within the same cohort. In this study we determined switching rates from tamoxifen to AIs, discontinuation rates of tamoxifen only, discontinuation rates of any endocrine treatment and determinants of first treatment switch and treatment discontinuation. Patients with early stage breast cancer (stage I-IIIa) starting on tamoxifen were selected from the linked Eindhoven Cancer Registry-PHARMO RLS cohort in the period 1998-2006. Continuous use (allowing a 60 days gap between refills) of tamoxifen only and any endocrine treatment were determined after various follow-up periods: 1, 2, 3, 4, and 5 years. Time to first switch from tamoxifen to an AI was assessed. Cox regression was used to identify determinants of first treatment switch, discontinuation of tamoxifen, and discontinuation of any endocrine treatment. A total of 1,451 new early stage breast cancer patients started on tamoxifen. Of those, 380 had a treatment switch to an AI during follow-up. Of the patients followed for 5 years, 40% continuously used tamoxifen, which was 49% for any endocrine treatment. Older age (older than 70 versus 50-69 years) was independently associated with increased discontinuation of tamoxifen and any endocrine therapy. Patients with two or more concomitant diseases (versus no comorbidity) showed an increased likelihood to stop any endocrine treatment or switch treatment from tamoxifen to an AI. In conclusion, up to half of the breast cancer patients starting tamoxifen continued 5 years of endocrine treatment. Identification of patients at risk of discontinuation will assist in the development of interventions to improve treatment continuation comparable to that of patients included in clinical trials.
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