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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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Walsh EA, Post K, Massad K, Horick N, Antoni MH, Penedo FJ, Safren SA, Partridge AH, Peppercorn J, Park ER, Temel JS, Greer JA, Jacobs JM. Identification of patient subgroups who benefit from a behavioral intervention to improve adjuvant endocrine therapy adherence: a randomized-controlled trial. Breast Cancer Res Treat 2024; 204:547-559. [PMID: 38231313 DOI: 10.1007/s10549-023-07228-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE Adjuvant endocrine therapy (AET) reduces breast cancer morbidity and mortality; however, adherence is suboptimal. Interventions exist, yet few have improved adherence. Patient characteristics may alter uptake of an intervention to boost adherence. We examined moderators of the effect of a virtual intervention (STRIDE; #NCT03837496) on AET adherence after breast cancer. METHODS At a large academic medical center, patients taking AET (N = 100; Mage = 56.1, 91% White) were randomized to receive STRIDE versus medication monitoring. All stored their medication in digital pill bottles (MEMS Caps) which captured objective adherence. Participants self-reported adherence (Medication Adherence Report Scale) at 12 weeks post-baseline. Moderators included age, anxiety, and depressive symptoms (Hospital Anxiety and Depression Scale), AET-related symptom distress (Breast Cancer Prevention Trial Symptom Scale), and AET-specific concerns (Beliefs about Medications Questionnaire). We used hierarchical linear modeling (time × condition × moderator) and multiple regression (condition × moderator) to test the interaction effects on adherence. RESULTS Age (B = 0.05, SE = 0.02, p = 0.003) and AET-related symptom distress (B = -0.04, SE = 0.02, p = 0.02) moderated condition effect on self-reported adherence while anxiety (B = -1.20, SE = 0.53, p = 0.03) and depressive symptoms (B = -1.65, SE = 0.65, p = 0.01) moderated objective adherence effects. AET-specific concerns approached significance (B = 0.91, SE = 0.57, p = 0.12). Participants who received STRIDE and were older or presented with lower anxiety and depressive symptoms or AET-related symptom distress exhibited improved adherence. Post hoc analyses revealed high correlations among most moderators. CONCLUSIONS A subgroup of patients who received STRIDE exhibited improvements in AET adherence. The interrelatedness of moderators suggests an underlying profile of patients with lower symptom burden who benefitted most from the intervention. STUDY REGISTRATION NCT03837496.
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Affiliation(s)
- Emily A Walsh
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Fifth Floor, Coral Gables, FL, 33146, USA.
| | - Kathryn Post
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Katina Massad
- University of Missouri School of Medicine, Columbia, MO, USA
| | - Nora Horick
- Massachusetts General Hospital, Boston, MA, USA
| | - Michael H Antoni
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Fifth Floor, Coral Gables, FL, 33146, USA
| | - Frank J Penedo
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Fifth Floor, Coral Gables, FL, 33146, USA
| | - Steven A Safren
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Fifth Floor, Coral Gables, FL, 33146, USA
| | - Ann H Partridge
- Harvard Medical School, Boston, MA, USA
- Dana Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey Peppercorn
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Elyse R Park
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jennifer S Temel
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Joseph A Greer
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jamie M Jacobs
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Bright EE, Finkelstein LB, Nealis MS, Genung SR, Wrigley J, Gu HCJ, Schmiege SJ, Arch JJ. A Systematic Review and Meta-Analysis of Interventions to Promote Adjuvant Endocrine Therapy Adherence Among Breast Cancer Survivors. J Clin Oncol 2023; 41:4548-4561. [PMID: 37531593 PMCID: PMC10553065 DOI: 10.1200/jco.23.00697] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/26/2023] [Accepted: 06/12/2023] [Indexed: 08/04/2023] Open
Abstract
PURPOSE Adjuvant endocrine therapy (AET) adherence among breast cancer survivors is often suboptimal, leading to higher cancer recurrence and mortality. Intervention studies to promote AET adherence have burgeoned, more than doubling in number since this literature was last reviewed. The current aim is to provide an up-to-date systematic review and meta-analysis of interventions to enhance AET adherence and to identify strengths and limitations of existing interventions to inform future research and clinical care. METHODS Systematic searches were conducted in three electronic databases. Studies were included in the systematic review if they examined an intervention for promoting AET adherence among breast cancer survivors. Studies were further included in the meta-analyses if they examined a measure of AET adherence (defined as compliance or persistence beyond initiation) and reported (or provided upon request) sufficient information to calculate an effect size. RESULTS Of 5,045 unique records, 33 unique studies representing 375,951 women met inclusion criteria for the systematic review. Interventions that educated patients about how to manage side effects generally failed to improve AET adherence, whereas policy changes that lowered AET costs consistently improved adherence. Medication reminders, communication, and psychological/coping strategies showed varied efficacy. Of the 33 studies that met the inclusion criteria for the systematic review, 25 studies representing 367,873 women met inclusion criteria for the meta-analysis. The meta-analysis showed statistically significant effects of the adherence interventions overall relative to study-specified control conditions (number of studies [k] = 25; odds ratio, 1.412; 95% CI, 1.183 to 1.682; P = .0001). Subgroup analyses showed that there were no statistically significant differences in effect sizes by study design (randomized controlled trial v other), publication year, directionality of the intervention (unidirectional v bidirectional contact), or intervention type. CONCLUSION To our knowledge, this is the first known meta-analysis to demonstrate a significant effect for interventions to promote AET adherence. The systematic review revealed that lowering medication costs and a subgroup of psychosocial and reminder interventions showed the most promise, informing future research, policy, and clinical directions.
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Affiliation(s)
- Emma E. Bright
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO
| | - Lauren B. Finkelstein
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO
| | - Madeline S. Nealis
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO
| | - Sarah R. Genung
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO
| | - Jordan Wrigley
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO
| | - Heng Chao J. Gu
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO
| | - Sarah J. Schmiege
- Department of Biostatistics and Informatics, Colorado School of Public Health at the Anschutz Medical Campus, University of Colorado Denver, Aurora, CO
| | - Joanna J. Arch
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO
- Cancer Prevention and Control, University of Colorado Cancer Center, School of Medicine, the Anschutz Medical Campus, Aurora, CO
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Yang S, Park SW, Bae SJ, Ahn SG, Jeong J, Park K. Investigation of Factors Affecting Adherence to Adjuvant Hormone Therapy in Early-Stage Breast Cancer Patients: A Comprehensive Systematic Review. J Breast Cancer 2023; 26:309-333. [PMID: 37272247 PMCID: PMC10475712 DOI: 10.4048/jbc.2023.26.e22] [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: 11/16/2022] [Revised: 02/05/2023] [Accepted: 04/16/2023] [Indexed: 06/06/2023] Open
Abstract
PURPOSE Adherence and persistence to adjuvant hormone therapy (AHT) are seldom maintained among early-stage hormone receptor-positive breast cancer (BC) survivors, despite the significant clinical benefits of long-term AHT. As the factors influencing adherence to AHT remain unclear, this study aimed to comprehensively identify such factors and classify them into specific dimensions. METHODS PubMed, Cochrane Library, Embase, PsycINFO, and CINAHL were searched for qualified articles. The search mainly focused on three components: early-stage (0-III) BC, oral AHT administration, and adherence to AHT, with keywords derived from MeSH and entry terms. The factors identified were then classified into six categories based on a modified WHO multidimensional model. RESULTS Overall, 146 studies were included; the median sample size was 651 (range, 31-40,009), and the mean age of the population was 61.5 years (standard deviation, 8.3 years). Patient- and therapy-related factors were the most frequently investigated factors. Necessity/concern beliefs and self-efficacy among patient-related factors were consistently related to better adherence than depression. Although drug side effects and medication use cannot be modified easily, a refined prescription strategy for the initiation and switching of AHT is likely to increase adherence levels. CONCLUSION An effective psychological program that encourages positive views and beliefs about medication and management strategies for each therapy may be necessary to improve adherence to AHT. Social support and a sense of belonging can be enhanced through community participation and social media for better adherence to AHT. Patient-centered communication and appropriate recommendations by physicians may be attributable to better adherence outcomes. Findings from systematically organized factors that influence adherence to AHT may contribute to the establishment of intervention strategies to benefit patients with early-stage BC to achieve optimal health.
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Affiliation(s)
- Seongwoo Yang
- HERINGS, The Institute of Advanced Clinical & Biomedical Research, Seoul, Korea
| | - Seong Won Park
- HERINGS, The Institute of Advanced Clinical & Biomedical Research, Seoul, Korea
| | - Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine/Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine/Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine/Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyounghoon Park
- HERINGS, The Institute of Advanced Clinical & Biomedical Research, Seoul, Korea.
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Stewart SJF, Slodkowska-Barabasz J, McGeagh L, Moon Z, Brett J, Wells M, Brown MC, Turner M, Horne R, Fenlon D, Rehman F, Cain H, Donnelly P, Harmer V, Turner L, Rose J, Sharp L, Watson E. Development of the HT&Me intervention to support women with breast cancer to adhere to adjuvant endocrine therapy and improve quality of life. Breast 2023; 70:32-40. [PMID: 37300986 PMCID: PMC10382955 DOI: 10.1016/j.breast.2023.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/22/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Breast cancer is the most common cancer in women worldwide. Approximately 80% of breast cancers are oestrogen receptor positive (ER+). Patients treated surgically are usually recommended adjuvant endocrine therapy (AET) for 5-10 years. AET significantly reduces recurrence, but up to 50% of women do not take it as prescribed. OBJECTIVE To co-design and develop an intervention to support AET adherence and improve health-related quality-of-life (QoL) in women with breast cancer. METHODS Design and development of the HT&Me intervention took a person-based approach and was guided by the Medical Research Council framework for complex interventions, based on evidence and underpinned by theory. Literature reviews, behavioural analysis, and extensive key stakeholder involvement informed 'guiding principles' and the intervention logic model. Using co-design principles, a prototype intervention was developed and refined. RESULTS The blended tailored HT&Me intervention supports women to self-manage their AET. It comprises initial and follow-up consultations with a trained nurse, supported with an animation video, a web-app and ongoing motivational 'nudge' messages. It addresses perceptual (e.g. doubts about necessity, treatment concerns) and practical (e.g. forgetting) barriers to adherence and provides information, support and behaviour change techniques to improve QoL. Iterative patient feedback maximised feasibility, acceptability, and likelihood of maintaining adherence; health professional feedback maximised likelihood of scalability. CONCLUSIONS HT&Me has been systematically and rigorously developed to promote AET adherence and improve QoL, and is complemented with a logic model documenting hypothesized mechanisms of action. An ongoing feasibility trial will inform a future randomised control trial of effectiveness and cost-effectiveness.
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Affiliation(s)
- Sarah-Jane F Stewart
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, UK
| | | | - Lucy McGeagh
- Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, UK
| | - Zoe Moon
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, UK
| | - Jo Brett
- Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, UK
| | - Mary Wells
- Imperial College Healthcare NHS Trust, UK
| | - Morven C Brown
- Population Health Sciences Institute, Newcastle University, UK; Newcastle University Centre for Cancer, Newcastle University, UK
| | - Mark Turner
- Research Software Engineering, Newcastle University, UK
| | - Robert Horne
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, UK
| | - Deborah Fenlon
- Faculty of Medicine and Life Science, Swansea University, UK
| | | | - Henry Cain
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK
| | | | | | | | - Jan Rose
- Patient and Public Involvement Representatives, UK
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, UK; Newcastle University Centre for Cancer, Newcastle University, UK
| | - Eila Watson
- Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, UK.
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Wreyford L, Gururajan R, Zhou X. When can cancer patient treatment nonadherence be considered intentional or unintentional? A scoping review. PLoS One 2023; 18:e0282180. [PMID: 37134109 PMCID: PMC10155980 DOI: 10.1371/journal.pone.0282180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 02/10/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Treatment nonadherence in cancer patients remains high with most interventions having had limited success. Most studies omit the multi-factorial aspects of treatment adherence and refer to medication adherence. The behaviour is rarely defined as intentional or unintentional. AIM The aim of this Scoping Review is to increase understanding of modifiable factors in treatment nonadherence through the relationships that physicians have with their patients. This knowledge can help define when treatment nonadherence is intentional or unintentional and can assist in predicting cancer patients at risk of nonadherence and in intervention design. The scoping review provides the basis for method triangulation in two subsequent qualitative studies: 1. Sentiment analysis of online cancer support groups in relation to treatment nonadherence; 2. A qualitative validation survey to refute / or validate claims from this scoping review. Thereafter, framework development for a future (cancer patient) online peer support intervention. METHODS A Scoping Review was performed to identify peer reviewed studies that concern treatment / medication nonadherence in cancer patients-published between 2000 to 2021 (and partial 2022). The review was registered in the Prospero database CRD42020210340 and follows the PRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Searches. The principles of meta-ethnography are used in a synthesis of qualitative findings that preserve the context of primary data. An aim of meta-ethnography is to identify common and refuted themes across studies. This is not a mixed methods study, but due to a limited qualitativevidence base and to broaden findings, the qualitative elements (author interpretations) found within relevant quantitative studies have been included. RESULTS Of 7510 articles identified, 240 full texts were reviewed with 35 included. These comprise 15 qualitative and 20 quantitative studies. One major theme, that embraces 6 sub themes has emerged: 'Physician factors can influence patient factors in treatment nonadherence'. The six (6) subthemes are: 1. Suboptimal Communication; 2. The concept of Information differs between Patient and Physician; 3.Inadequate time. 4. The need for Treatment Concordance is vague or missing from concepts; 5. The importance of Trust in the physician / patient relationship is understated in papers; 6. Treatment concordance as a concept is rarely defined and largely missing from studies. LINE OF ARGUMENT WAS DRAWN Treatment (or medication) nonadherence that is intentional or unintentional is often attributed to patient factors-with far less attention to the potential influence of physician communication factors. The differentation between intentional or unintentional nonadherence is missing from most qualitative and quantitative studies. The holistic inter-dimensional / multi-factorial concept of 'treatment adherence' receives scant attention. The main focus is on medication adherence / nonadherence in the singular context. Nonadherence that is unintentional is not necessarily passive behaviour and may overlap with intentional nonadherence. The absence of treatment concordance is a barrier to treatment adherence and is rarely articulated or defined in studies. CONCLUSION This review demonstrates how cancer patient treatment nonadherence is often a shared outcome. An equal focus on physican and patient factors can increase understanding of the two main types of nonadherence (intentional or unintentional). This differentation should help improve the fundamentals of intervention design.
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Affiliation(s)
- Leon Wreyford
- University of Southern Queensland (USQ), Toowoomba, Qld, Australia
| | - Raj Gururajan
- University of Southern Queensland (USQ), Toowoomba, Qld, Australia
| | - Xujuan Zhou
- University of Southern Queensland (USQ), Toowoomba, Qld, Australia
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Jacobs JM, Post K, Massad K, Horick N, Walsh EA, Cohn J, Rapoport CS, Clara AJ, Antoni MH, Safren SA, Partridge A, Peppercorn J, Park E, Temel JS, Greer JA. A telehealth intervention for symptom management, distress, and adherence to adjuvant endocrine therapy: A randomized controlled trial. Cancer 2022; 128:3541-3551. [PMID: 35924869 PMCID: PMC9465981 DOI: 10.1002/cncr.34409] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Patients taking adjuvant endocrine therapy (AET) after breast cancer face adherence challenges and symptom-related distress. We conducted a randomized trial to evaluate the feasibility, acceptability, and preliminary efficacy of a telehealth intervention (Symptom-Targeted Randomized Intervention for Distress and Adherence to Adjuvant Endocrine Therapy [STRIDE]) for patients taking AET. METHODS From October 2019 to June 2021, 100 patients reporting difficulty with AET were randomly assigned to either STRIDE or a medication monitoring (MedMon) control group. STRIDE included six weekly small-group videoconferencing sessions and two individual calls. We defined feasibility as having >50% of eligible patients enroll, >70% complete the 12-week assessment, and > 70% of STRIDE patients complete ≥4/6 sessions. We monitored adherence with the Medication Event Monitoring System Caps (MEMS Caps). At baseline and 12- and 24-weeks after baseline, patients self-reported adherence (Medication Adherence Report Scale), AET satisfaction (Cancer Therapy Satisfaction Questionnaire), symptom distress (Breast Cancer Prevention Trial-Symptom Checklist), self-management of symptoms (Self-efficacy for Symptom Management-AET), coping (Measure of Current Status), quality of life (QOL; Functional Assessment of Cancer Therapy-Breast), and mood (Hospital Anxiety and Depression Scale). We used linear mixed effects models to assess the effect of STRIDE on longitudinal outcomes. RESULTS We enrolled 70.9% (100/141) of eligible patients; 92% completed the 12-week assessment, and 86% completed ≥4/6 STRIDE sessions. Compared with MedMon, STRIDE patients reported less symptom distress (B[difference] = -1.91; 95% CI, -3.29 to -0.52; p = .007) and better self-management of AET symptoms, coping, QOL, and mood. We did not observe significant differences in AET satisfaction or adherence. CONCLUSIONS STRIDE is feasible and acceptable, showing promise for improving outcomes in patients taking AET after breast cancer. LAY SUMMARY Patients taking adjuvant endocrine therapy (AET) after breast cancer may face challenges while following their treatment regimen. In this randomized controlled trial of 100 patients taking AET, a brief, small-group virtual intervention (STRIDE) was well-received by patients and led to improvements in how upset patients were due to symptoms, how confident they were in managing symptoms, and how well they could cope with stress. Thus, STRIDE is a promising intervention and should be tested in future multi-site trials.
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Affiliation(s)
- Jamie M. Jacobs
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
- Harvard Medical School, Boston, Massachusetts 02114
| | - Kathryn Post
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
- Harvard Medical School, Boston, Massachusetts 02114
| | - Katina Massad
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
| | - Nora Horick
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
- Harvard Medical School, Boston, Massachusetts 02114
| | - Emily A. Walsh
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
| | - Julia Cohn
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
| | - Chelsea S. Rapoport
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
| | - Amy J. Clara
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
| | | | | | - Ann Partridge
- Harvard Medical School, Boston, Massachusetts 02114
- Dana-Farber Cancer Institute, Boston, MA 02115
| | - Jeffrey Peppercorn
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
- Harvard Medical School, Boston, Massachusetts 02114
| | - Elyse Park
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
- Harvard Medical School, Boston, Massachusetts 02114
| | - Jennifer S. Temel
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
- Harvard Medical School, Boston, Massachusetts 02114
| | - Joseph A. Greer
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02134
- Harvard Medical School, Boston, Massachusetts 02114
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Green SMC, French DP, Graham CD, Hall LH, Rousseau N, Foy R, Clark J, Parbutt C, Raine E, Gardner B, Velikova G, Moore SJL, Buxton J, Smith SG. Supporting adjuvant endocrine therapy adherence in women with breast cancer: the development of a complex behavioural intervention using Intervention Mapping guided by the Multiphase Optimisation Strategy. BMC Health Serv Res 2022; 22:1081. [PMID: 36002831 PMCID: PMC9404670 DOI: 10.1186/s12913-022-08243-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/21/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Adjuvant endocrine therapy (AET) reduces the risk of breast cancer recurrence and mortality. However, up to three-quarters of women with breast cancer do not take AET as prescribed. Existing interventions to support adherence to AET have largely been unsuccessful, and have not focused on the most salient barriers to adherence. This paper describes the process of developing four theory-based intervention components to support adherence to AET. Our aim is to provide an exemplar of intervention development using Intervention Mapping (IM) with guidance from the Multiphase Optimisation Strategy (MOST). METHODS Iterative development followed the six-stage IM framework with stakeholder involvement. Stage 1 involved a literature review of barriers to adherence and existing interventions, which informed the intervention objectives outlined in Stage 2. Stage 3 identified relevant theoretical considerations and practical strategies for supporting adherence. Stage 4 used information from Stages 1-3 to develop the intervention components. Stages 1-4 informed a conceptual model for the intervention package. Stages 5 and 6 detailed implementation considerations and evaluation plans for the intervention package, respectively. RESULTS The final intervention package comprised four individual intervention components: Short Message Service to encourage habitual behaviours surrounding medication taking; an information leaflet to target unhelpful beliefs about AET; remotely delivered Acceptance and Commitment Therapy-based guided self-help to reduce psychological distress; and a website to support self-management of AET side-effects. Considerations for implementation within the NHS, including cost, timing and mode of delivery were outlined, with explanation as to how using MOST can aid this. We detail our plans for the final stage of IM which involve feasibility testing. This involved planning an external exploratory pilot trial using a 24-1 fractional factorial design, and a process evaluation to assess acceptability and fidelity of intervention components. CONCLUSIONS We have described a systematic and logical approach for developing a theoretically informed intervention package to support medication adherence in women with breast cancer using AET. Further research to optimise the intervention package, guided by MOST, has the potential to lead to more effective, efficient and scalable interventions.
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Affiliation(s)
- Sophie M. C. Green
- grid.9909.90000 0004 1936 8403Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL UK
| | - David P. French
- grid.5379.80000000121662407Manchester Centre for Health Psychology, University of Manchester, Manchester, UK
| | - Christopher D. Graham
- grid.4777.30000 0004 0374 7521Department of Psychology, Queen’s University Belfast, Belfast, UK
| | - Louise H. Hall
- grid.9909.90000 0004 1936 8403Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL UK
| | - Nikki Rousseau
- grid.9909.90000 0004 1936 8403Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Robbie Foy
- grid.9909.90000 0004 1936 8403Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL UK
| | - Jane Clark
- grid.443984.60000 0000 8813 7132St. James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Catherine Parbutt
- grid.443984.60000 0000 8813 7132St. James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Erin Raine
- grid.9909.90000 0004 1936 8403Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL UK
| | - Benjamin Gardner
- grid.13097.3c0000 0001 2322 6764Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Galina Velikova
- grid.443984.60000 0000 8813 7132Leeds Institute of Medical Research at St James’s, University of Leeds, St James’s University Hospital, Leeds, UK ,grid.443984.60000 0000 8813 7132Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK
| | - Sally J. L. Moore
- grid.9909.90000 0004 1936 8403Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL UK
| | - Jacqueline Buxton
- grid.9909.90000 0004 1936 8403Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL UK
| | | | - Samuel G. Smith
- grid.9909.90000 0004 1936 8403Leeds Institute of Health Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9NL UK
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9
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Dang TH, Forkan ARM, Wickramasinghe N, Jayaraman PP, Alexander M, Burbury K, Schofield P. Investigation of Intervention Solutions to Enhance Adherence to Oral Anticancer Medicines in Adults: Overview of Reviews. JMIR Cancer 2022; 8:e34833. [PMID: 35475978 PMCID: PMC9096640 DOI: 10.2196/34833] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/26/2022] [Accepted: 03/15/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Adherence to anticancer medicines is critical for the success of cancer treatments; however, nonadherence remains challenging, and there is limited evidence of interventions to improve adherence to medicines in patients with cancer. OBJECTIVE This overview of reviews aimed to identify and summarize available reviews of interventions to improve adherence to oral anticancer medicines in adult cancer survivors. METHODS A comprehensive search of 7 electronic databases was conducted by 2 reviewers who independently conducted the study selection, quality assessment using the A Measurement Tool to Assess Systematic Reviews 2, and data extraction. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 checklist was adapted to report the results. RESULTS A total of 29 reviews were included in the narrative synthesis. The overall quality of the systematic reviews was low. The 4 main strategies to promote adherence were focused on education, reminders, behavior and monitoring, and multicomponent approaches. Digital technology-based interventions were reported in most reviews (27/29, 93%). A few interventions applied theories (10/29, 34%), design frameworks (2/29, 7%), or engaged stakeholders (1/29, 3%) in the development processes. The effectiveness of interventions was inconsistent between and within reviews. However, interventions using multiple strategies to promote adherence were more likely to be effective than single-strategy interventions (12/29, 41% reviews). Unidirectional communication (7/29, 24% reviews) and technology alone (11/29, 38% reviews) were not sufficient to demonstrate improvement in adherence outcomes. Nurses and pharmacists played a critical role in promoting patient adherence to oral cancer therapies, especially with the support of digital technologies (7/29, 24% reviews). CONCLUSIONS Multicomponent interventions are potentially effective in promoting patient adherence to oral anticancer medicines. The seamless integration of digital solutions with direct clinical contacts is likely to be effective in promoting adherence. Future research for developing comprehensive digital adherence interventions should be evidence-based, theory-based, and rigorously evaluated.
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Affiliation(s)
- Thu Ha Dang
- Department of Psychology, School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
- Behavioural Sciences Unit, Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Digital Health Cooperative Research Centre, Sydney, Australia
| | - Abdur Rahim Mohammad Forkan
- Digital Innovation Lab, School of Science, Computing and Engineering Technologies, Swinburne University of Technology, Melbourne, Australia
| | - Nilmini Wickramasinghe
- Department Health and Bio Statistics, School of Health Sciences and Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, Australia
- Epworth Healthcare, Melbourne, Australia
| | - Prem Prakash Jayaraman
- Digital Innovation Lab, School of Science, Computing and Engineering Technologies, Swinburne University of Technology, Melbourne, Australia
| | - Marliese Alexander
- Pharmacy Department, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Kate Burbury
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- Digital and Healthcare Innovation, Peter McCallum Cancer Centre, Melbourne, Australia
| | - Penelope Schofield
- Behavioural Sciences Unit, Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- Department of Psychology, and Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, Australia
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10
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Effect of a Smart Pill Bottle Reminder Intervention on Medication Adherence, Self-efficacy, and Depression in Breast Cancer Survivors. Cancer Nurs 2022; 45:E874-E882. [PMID: 34661562 PMCID: PMC9584037 DOI: 10.1097/ncc.0000000000001030] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Globally, breast cancer has been identified as the most common cancer among women. The clinical efficacy of adjuvant oral antiestrogen therapy-including tamoxifen and aromatase inhibitors-has been proven to be clinically efficacious for breast cancer survivors. However, medication adherence for these therapies remains suboptimal among breast cancer survivors. OBJECTIVE The aim of this study was to evaluate the effect of a reminder intervention-a smart pill bottle paired with the Pillsy mobile application-on medication adherence, medication self-efficacy, and depression, among breast cancer survivors who were undergoing oral antiestrogen therapy. METHODS This study is a randomized controlled trial. Sixty-one women were allocated to an experimental group (n = 31) and the control group (n = 30). The experimental group received the reminder intervention of a smart pill bottle for 4 weeks. Study outcomes were identified as medication adherence, medication self-efficacy, and depression. RESULTS Fifty-seven women completed the follow-up measurement. Significant differences in favor of the experimental group were noted for medication adherence ( P = .004) and medication self-efficacy ( P = .004). There was no statistically significant difference between the 2 groups with regard to depression ( P = .057). CONCLUSIONS Reminder intervention using smart pill bottles was effective in improving medication adherence and medication self-efficacy among breast cancer survivors undergoing oral antiestrogen therapy. IMPLICATIONS FOR PRACTICE A smart pill bottle method of intervention can be a useful reminder strategy to improve medication adherence among breast cancer survivors.
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11
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Brief relaxation training is associated with long-term endocrine therapy adherence among women with breast cancer: post hoc analysis of a randomized controlled trial. Breast Cancer Res Treat 2021; 190:79-88. [PMID: 34410568 DOI: 10.1007/s10549-021-06361-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/08/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Despite life-saving potential, many women struggle to adhere to adjuvant endocrine therapy (AET) for their breast cancer (BCa). Prior research has demonstrated that emotional distress is a barrier to AET adherence. We followed women from a trial to test the long-term effects of two 5-week post-surgical group-based stress management interventions, cognitive behavioral therapy (CBT), and relaxation training versus an attention-matched health education control, on AET adherence. METHODS We conducted a long-term follow-up (median = 8 years) of women randomized to CBT, relaxation training, or health education after surgery for stage 0-3 BCa. We measured adherence with the Endocrine Therapy Medication Usage Questionnaire (ETMUQ). First, we established factors on the ETMUQ via confirmatory factor analysis. We then used Bayesian structural equation modeling to regress these factors on study arm, controlling for age and treatments received. RESULTS Of those who completed long-term follow-up (n = 59, 44.7%), over half (n = 33; 55.9%) reported problems with adherence generally. Women receiving relaxation training (n = 15) had better adherence than those receiving health education (n = 24) on the Forgetfulness/Inconsistency [B(SE) = 0.25(0.14), p = 0.049] and Intentional Nonadherence [B(SE) = 0.31(0.14), p = 0.018] factors of the ETMUQ. Similar results were observed for those receiving relaxation training compared to CBT (n = 20): Forgetfulness/Inconsistency [B(SE) = - 0.47(0.25), p = 0.031]; Intentional Nonadherence [B(SE) = - 0.31(0.15), p = 0.027]. CONCLUSION Women receiving relaxation training were less likely to (1) forget to take their AET and (2) intentionally miss doses of AET in the long term compared to women receiving health education or CBT. This is evidence for the need of randomized trials that aim to improve adherence by incorporating theoretically based behavioral change techniques. TRIAL REGISTRATION AND DATES Trial 2R01-CA-064710 was registered March 26, 2006.
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12
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Pirolli AV, Brusamarello T, Everton SS, Andrzejevski VMS. The role of the clinical pharmacist in guiding adjuvant hormonal therapy in patients with breast cancer. J Oncol Pharm Pract 2021; 28:1368-1374. [PMID: 34225523 DOI: 10.1177/10781552211029361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Breast cancer is the most prevalent type of cancer among women, affecting about 2.1 million worldwide and is responsible for the highest number of cancer-related deaths among women. Approximately 80% of breast cancers express on the surface of hormone receptor cells, such as progesterone and estrogen. In these cases, Adjuvant Hormonal Therapy (AHT) is indicated for a period of five to ten years and consists of taking a daily oral pill. The two most used drugs in AHT are tamoxifen and Aromatase Inhibitors. One of the issues most faced by individuals who are subjected to long periods of treatment is the lack of medication adherence and, consequently, therapeutic inefficiency. It is believed that the monitoring by the pharmacist can contribute to the reduction of errors inherent to the medication, making the treatment more effective and improving the patient's quality of life. The present study aimed to know the perception of patients who live with breast cancer and who do AHT in relation to the educational performance of the clinical pharmacist. This is a qualitative, descriptive and exploratory study, carried out from March to October 2020, with 15 women undergoing treatment at the oncology unit of a tertiary-care hospital in south of Brazil. The data were obtained through a semi-structured interview using an instrument composed of two parts, one referring to the characterization of the participants and the other with the guiding question of the research: "How do you perceive the role of the pharmacist in relation to the guidelines for the use of adjuvant hormonal therapy?". The method of theoretical saturation was used to perform the sample closure and the thematic analysis was used to analyze the data. The participants were between 32 and 74 years old, seven were on tamoxifen therapy and eight on anastrozole, ten were on the first year of treatment, two on the second and three on the third year. The themes that emerged were: pharmacist-patient interaction as a safety factor in hormone therapy; role of the pharmacist in the development of strategies for self-management of the patients during hormone therapy; and, challenges for the pharmacist in relation to hormone therapy through continued guidance. It was evident that the pharmacist's educational action encouraged the participants to carry out the treatment in a more confident and assertive manner according to their particularities and beliefs.
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Affiliation(s)
- Amanda V Pirolli
- Complexo Hospital de Clínicas from the Federal University of Paraná, Curitiba-Paraná, Brazil
| | - Tatiana Brusamarello
- Complexo Hospital de Clínicas from the Federal University of Paraná, Curitiba-Paraná, Brazil
| | - Stella S Everton
- Complexo Hospital de Clínicas from the Federal University of Paraná, Curitiba-Paraná, Brazil
| | - Vânia M S Andrzejevski
- Complexo Hospital de Clínicas from the Federal University of Paraná, Curitiba-Paraná, Brazil
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13
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Vaz-Luis I, Francis PA, Di Meglio A, Stearns V. Challenges in Adjuvant Therapy for Premenopausal Women Diagnosed With Luminal Breast Cancers. Am Soc Clin Oncol Educ Book 2021; 41:1-15. [PMID: 33989019 DOI: 10.1200/edbk_320595] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
More than 90% of women with newly diagnosed breast cancer present with stage I to III disease and, with optimal multidisciplinary therapy, are likely to survive their disease. Of these patients, 70% are hormone receptor-positive and candidates for adjuvant endocrine therapy. The adoption of cumulatively better adjuvant treatments contributed to improved outcomes in patients with hormone receptor-positive, early-stage breast cancer. Premenopausal women with hormone receptor-positive breast cancer often present with complex disease and have inferior survival outcomes compared with their postmenopausal counterparts. Risk stratification strategies, including classic clinicopathologic features and newer gene expression assays, can assist in treatment decisions, including adjuvant chemotherapy use and type or duration of endocrine therapy. Gene expression assays may help identify patients who can safely forgo chemotherapy, although to a lesser extent among premenopausal patients, in whom they may play a role only in node-negative disease. Patients at lower risk of recurrence can be adequately treated with tamoxifen alone, whereas higher-risk patients benefit from ovarian function suppression with tamoxifen or an aromatase inhibitor. The role of adding newer therapies such as CDK4/6 inhibitors to adjuvant endocrine therapy is not yet clear. Breast cancer treatments are associated with several side effects, with major impact on patients' quality of life and treatment adherence, particularly in premenopausal women for whom these side effects may be more prominent as the result of the abrupt decrease in estrogen concentrations. Personalized management of treatment side effects, addressing patients' concerns, and health promotion should be an integral part of the care of premenopausal women diagnosed with luminal breast cancers.
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Affiliation(s)
- Ines Vaz-Luis
- INSERM Unit 981-Molecular Predictors and New Targets in Oncology, Gustave Roussy, Villejuif, France
| | - Prudence A Francis
- Peter MacCallum Cancer Centre, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Antonio Di Meglio
- INSERM Unit 981-Molecular Predictors and New Targets in Oncology, Gustave Roussy, Villejuif, France
| | - Vered Stearns
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD
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14
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Jacobs JM, Rapoport CS, Horenstein A, Clay M, Walsh EA, Peppercorn J, Temel JS, Greer JA. Study protocol for a randomised controlled feasibility trial of a virtual intervention (STRIDE) for symptom management, distress and adherence to adjuvant endocrine therapy after breast cancer. BMJ Open 2021; 11:e041626. [PMID: 33397667 PMCID: PMC7783524 DOI: 10.1136/bmjopen-2020-041626] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Patient adherence to adjuvant endocrine therapy (AET) after a diagnosis of hormone-sensitive breast cancer is poor. Previous interventions have failed to produce changes in adherence, address patient preferences or include theoretically informed and evidence-based components. Therefore, we iteratively developed a patient-centred, evidence-based, small-group, videoconference intervention to improve adherence and symptom management as well as reduce distress for patients taking AET after breast cancer (Symptom-Targeted Randomised Intervention for Distress and Adherence to Adjuvant Endocrine Therapy, STRIDE). METHODS AND ANALYSIS The current study is a non-blinded, randomised, controlled, feasibility trial of STRIDE compared with a medication monitoring control group. The primary objective is to examine the feasibility and acceptability of STRIDE, while secondary objectives are to assess changes in objective and subjective adherence, symptom distress and satisfaction with AET. Patients will be recruited from the Massachusetts General Hospital Cancer Center in Boston, Massachusetts. The total number of patients accrued will be 75, with ≥60 patients completing the study. All patients will store their AET in an electronic pill bottle for objective adherence monitoring. Patients randomly assigned to the STRIDE intervention will receive 6 weekly 1-hour sessions, in small groups of two, delivered via videoconferencing by a trained mental health professional. Patients assigned to the control group will store their medication in the electronic pill bottle and receive follow-up oncology care as usual. All participants will complete self-report psychosocial measures at baseline, 12 weeks and 24 weeks postbaseline. ETHICS AND DISSEMINATION The study is funded by the National Cancer Institute of the National Institutes of Health and is approved by the Dana-Farber/Harvard Cancer Center Institutional Review Board (Protocol #18-603, V.1.2, first approval date 1 February 2019). The study will be reported in accordance with the Consolidated Standards of Reporting Trials statement for non-pharmacological trials. Results will be published in peer-reviewed academic journals, presented at scientific meetings and disseminated to patient organisations and media outlets.Trial registration numberNCT03837496; Pre-results.
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Affiliation(s)
- Jamie M Jacobs
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Chelsea S Rapoport
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Arielle Horenstein
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychology, Temple University, Philadelphia, Pennsylvania, USA
| | - Madison Clay
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily A Walsh
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychology, University of Miami, Coral Gables, Florida, USA
| | - Jeffrey Peppercorn
- Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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15
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Lin M, Hackenyos D, Savidge N, Weidner RA, Murphy-Banks R, Fleckner T, Parsons SK, Rodday AM. Enhancing patients' understanding of and adherence to oral anticancer medication: Results of a longitudinal pilot intervention. J Oncol Pharm Pract 2020; 27:1409-1421. [PMID: 32996363 DOI: 10.1177/1078155220960800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Oral anticancer medications (OAM) make administration more convenient for patients, but shifts the responsibility of care from clinical providers to the patients themselves. Following an institutional pilot study showing inadequate understanding and adherence among vulnerable patients taking OAM, a longitudinal intervention was developed using an oncology specialty pharmacist and medication navigators to enhance OAM understanding and adherence. METHODS Patients initiating OAM were approached for four formalized teaching and check-in sessions, supplemented with medication information sheets and individualized calendars. At each session, participants were assessed on their OAM understanding and adherence using teach-back and validated measures. A study evaluation elicited feedback from participants on the usefulness of the intervention. RESULTS Of 80 eligible patients, 58 (72.5%) received formal OAM teaching from the specialty pharmacist. Of those, 54 (93.1%) enrolled in the study with 39 (72%) completing the intervention for final analysis. At study completion, all participants adequately understood OAM taking, but 41.0% had inadequate understanding of OAM handling. Throughout the study, participants reported issues that were addressed by the intervention team (28.2% to 31.6%) as well as those requiring additional assistance from the treatment team (26.3% to 38.5%), Most participants found the intervention to be very beneficial (initial evaluation, 86.5%; final evaluation, 76.9%). CONCLUSIONS This pilot intervention addressed gaps identified by our institutional assessment through formalized OAM teaching and follow-up. Improved understanding of taking and handling OAM through this subsequent study illustrated the enhanced effect of a multidisciplinary and multicomponent intervention to better educate and support patients on OAM.
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Affiliation(s)
| | | | | | | | | | - Tara Fleckner
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, USA
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16
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Dean LT, George M, Lee KT, Ashing K. Why individual-level interventions are not enough: Systems-level determinants of oral anticancer medication adherence. Cancer 2020; 126:3606-3612. [PMID: 32438466 PMCID: PMC7467097 DOI: 10.1002/cncr.32946] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/15/2020] [Accepted: 01/30/2020] [Indexed: 02/06/2023]
Abstract
Nonadherence to oral anticancer medications (OAMs) in the United States is as low as 33% for some cancers. The reasons for nonadherence to these lifesaving medications are multifactorial, yet the majority of studies focus on patient-level factors influencing uptake and adherence. Individually based interventions to increase patient adherence have not been effective, and this warrants attention to factors at the payor, pharmaceutical, and clinical systems levels. Based on the authors' research and clinical experiences, this commentary brings fresh attention to the long-standing issue of OAM nonadherence, a growing quality-of-care issue, from a systems perspective. In this commentary, the key driving factors in pharmaceutical and payor systems (state and federal laws, payor/insurance companies, and pharmaceutical companies), clinical systems (hospitals and providers), and patient contexts that have trickle-down effects on patient adherence to OAMs are outlined. In the end, the authors' recommendations include examining the influence of laws governing OAM drug pricing, OAM supply, and provider reimbursement; reducing the need for prior authorization of long-approved OAMs; identifying cost-effective ways for providers to monitor nonadherence; examining issues of provider bias in OAM prescriptions; and further elucidating in which contexts patients are likely to be able to adhere. These recommendations offer a starting point for an examination of the chain of systems influencing patient adherence and may help to finally resolve persistently high levels of OAM nonadherence.
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Affiliation(s)
- Lorraine T Dean
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Marshalee George
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kimberley T Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kimlin Ashing
- City of Hope Comprehensive Cancer Center, Division of Health Equities, City of Hope, Duarte, California, USA
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17
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Rosenberg SM, Petrie KJ, Stanton AL, Ngo L, Finnerty E, Partridge AH. Interventions to Enhance Adherence to Oral Antineoplastic Agents: A Scoping Review. J Natl Cancer Inst 2020; 112:443-465. [PMID: 31899790 PMCID: PMC7225676 DOI: 10.1093/jnci/djz244] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 11/11/2019] [Accepted: 12/23/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND As new targeted oral antineoplastic therapies have emerged in recent years, the development of effective strategies that promote optimal adherence to cancer medication regimens has become an important priority. METHODS We conducted a scoping literature review to search for English language articles published through July 15, 2019, to identify studies that reported the testing and/or evaluation of interventions to improve adherence to oral antineoplastic agents. RESULTS A total of 56 articles were selected for review. Of the studies evaluated, 14 were randomized trials. All interventions except two targeted adult patients. Thirty-three studies enrolled fewer than 100 patients. Most interventions were education- and counseling-based and centered on provision of information about the drug and strategies to manage side effects. Only eight studies used an mHealth tool and/or text messages to target nonadherence. Among studies with a comparison sample, fewer than one-half (44.7%) reported statistically significant improvements in adherence or persistence associated with the intervention; however, some pharmacist-directed programs, particularly those that integrated monitoring or routine follow-up with a provider, did demonstrate efficacy. CONCLUSION Although the development of adherence-promoting interventions for oral antineoplastic therapies has increased recently, few have been rigorously tested. The nascent literature suggests those that are pharmacist directed and use regular monitoring show promise, though additional prospective studies are needed. Study methodology, population selection, and potential challenges that may be encountered in the implementation and dissemination phases should be considered when developing new interventions to address nonadherence to oral antineoplastic treatment.
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Affiliation(s)
| | - Keith J Petrie
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Annette L Stanton
- Jonsson Comprehensive Cancer Center, Department of Psychology, University of California Los Angeles, Los Angeles, CA, USA
- Department of Psychiatry/Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - Lan Ngo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Emma Finnerty
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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18
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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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19
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Ahlstedt Karlsson S, Wallengren C, Olofsson Bagge R, Henoch I. "It is not just any pill"-Women's experiences of endocrine therapy after breast cancer surgery. Eur J Cancer Care (Engl) 2019; 28:e13009. [PMID: 30748038 DOI: 10.1111/ecc.13009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 11/05/2018] [Accepted: 01/17/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVE For patients diagnosed with hormone-receptor-positive breast cancer, endocrine therapy (ET) is usually prescribed to reduce recurrence and mortality rates. Despite the benefits, compliance with treatment varies. The aim of this study was to provide qualitative data about women's experiences with ET after breast cancer surgery. METHODS Twenty-five women, treated with Tamoxifen after breast cancer surgery, were interviewed in seven focus groups. Six open-ended questions were used to explore their experiences. The interviews were recorded, transcribed verbatim and analysed using inductive content analysis. RESULTS The analysis resulted in three categories that described the women's experiences: the treatment "creates discomfort"; "promotes levels of management"; and "causes feelings of abandonment". Women's experiences of treatment could at first glance be seen as positive, as perceived protection, but after further analysis, a deeper meaning was identified: protection with reservation. When experiencing discomfort, the women tried to manage the situation, although the mode of management sometimes varied. The women reported that they needed support, but when the support did not appear, they felt as though they had been abandoned. Moreover, knowledge about side effects became an obstacle, as it could create fear of more severe symptoms. They also described that their disease was perceived by healthcare professionals as "cancer light". CONCLUSION The information needs to be customised specifically to each person.
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Affiliation(s)
- Susanne Ahlstedt Karlsson
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Catarina Wallengren
- Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Ingela Henoch
- Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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20
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Ali EE, Chan SSL, Poh HY, Susanto YA, Suganya T, Leow JL, Pang CK, Chew L, Yap KYL. Design Considerations in the Development of App-Based Oral Anticancer Medication Management Systems: a Qualitative Evaluation of Pharmacists' and Patients' Perspectives. J Med Syst 2019; 43:63. [PMID: 30726518 DOI: 10.1007/s10916-019-1168-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 01/15/2019] [Indexed: 12/23/2022]
Abstract
Smartphone apps can potentially help in enhancing oral anticancer medication (OAM) adherence. Patient adoption and efficacy of such apps depends on inclusion of user-centred and evidence-based features. The objective of this study was to identify important design considerations from the perspectives of patients taking OAMs, caregivers and oncology pharmacists. The study employed a qualitative study design. Data were collected using in-depth interviews with patients (n = 15), caregivers (n = 3) and pharmacists (n = 16). Interviews were audio-recorded, transcribed verbatim and inductive thematic analysis approach was used in data analysis. Monitoring medication-related problems, medication information, replacement of or integration with current systems and accessibility of app content on devices other than smartphones were the key themes identified in the analysis. Flexible input methods for monitored data, glanceability of monitored reports/information, near real-time adherence enhancing and symptom management interventions and customisable reminder options were design considerations identified under the monitoring medication-related problems theme. Participants suggested the provision of focused and easily understandable medication information with a potential for personalisation. Integration of app-based adherence systems with patients' electronic medical records with added mechanisms for alerts in the dispensing system was also suggested as a key design requirement to improve quality of patient care and facilitate adoption by clinicians. Finally, smartphones were the most favoured platform with optional accessibility of app content on other devices. In conclusion, important design considerations were identified through a user-centred design approach. The findings will help developers and clinicians in the design of new app-based systems and evaluation of existing ones.
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Affiliation(s)
- Eskinder Eshetu Ali
- Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Sharlene Si Ling Chan
- Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Huan Yu Poh
- Department of Electrical and Computer Engineering, Faculty of Engineering, National University of Singapore, Block E4, Level 5, 4 Engineering Drive 3, Singapore, 117583, Singapore
| | - Yosua Amadeus Susanto
- Department of Electrical and Computer Engineering, Faculty of Engineering, National University of Singapore, Block E4, Level 5, 4 Engineering Drive 3, Singapore, 117583, Singapore
| | - Thendral Suganya
- Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Jo Lene Leow
- Department of Pharmacy, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, 169610, Singapore
| | - Chee Khiang Pang
- Department of Electrical and Computer Engineering, Faculty of Engineering, National University of Singapore, Block E4, Level 5, 4 Engineering Drive 3, Singapore, 117583, Singapore
- Engineering Cluster, Singapore Institute of Technology, 10 Dover Drive, Singapore, 138683, Singapore
| | - Lita Chew
- Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, Singapore, 117543, Singapore
- Department of Pharmacy, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, 169610, Singapore
| | - Kevin Yi-Lwern Yap
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, 3086, Victoria, Australia.
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21
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Pieters HC, Green E, Khakshooy S, Sleven M, Stanton AL. A qualitative comparison of how older breast cancer survivors process treatment information regarding endocrine therapy. PLoS One 2019; 14:e0210972. [PMID: 30703119 PMCID: PMC6354984 DOI: 10.1371/journal.pone.0210972] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 01/04/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND It remains unclear how information about aromatase inhibitors (AI) impacts women's decision-making about persistence with endocrine therapy. PURPOSE To describe and compare how women treated for primary early stage breast cancer either persisting or not persisting with an AI received, interpreted, and acted upon AI-related information. DESIGN Thematic analysis was used to sort and compare the data into the most salient themes. PARTICIPANTS Women (N = 54; 27 persisting, 27 not persisting with an AI) aged 65-93 years took part in qualitative interviews. RESULTS Women in both subgroups described information similarly in terms of its value, volume, type, and source. Aspects of AI-related information that either differed between the subgroups or were misunderstood by one or both subgroups included: (1) knowledge of AI or tamoxifen prior to cancer diagnosis, (2) use of online resources, (3) misconceptions about estrogen, hormone replacement therapies and AI-related symptoms, and (4) risk perception and the meaning and use of recurrence statistics such as Oncotype DX. CONCLUSIONS Persisters and nonpersisters were similar in their desire for more information about potential side effects and symptom management at AI prescription and subsequent appointments. Differences included how information was obtained and interpreted. Interactive discussion questions are shared that can incorporate these findings into clinical settings.
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Affiliation(s)
- Huibrie C Pieters
- School of Nursing, University of California at Los Angeles, Los Angeles, United States of America
| | - Emily Green
- School of Nursing, University of California at Los Angeles, Los Angeles, United States of America
| | - Sally Khakshooy
- Cedars Sinai Medical Center, Los Angeles, United States of America
| | - Miriam Sleven
- Torrance Memorial Medical Center, Torrance, California, United States of America
| | - Annette L Stanton
- Departments of Psychology and Psychiatry & Biobehavioral Sciences, University of California, Los Angeles, United States of America
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22
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Finitsis DJ, Vose BA, Mahalak JG, Salner AL. Interventions to promote adherence to endocrine therapy among breast cancer survivors: A meta‐analysis. Psychooncology 2018; 28:255-263. [PMID: 30511789 DOI: 10.1002/pon.4959] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/26/2018] [Accepted: 11/26/2018] [Indexed: 12/21/2022]
Affiliation(s)
- David J. Finitsis
- Hartford HealthCare Cancer InstituteHartford Hospital Hartford Connecticut
- Department of PsychiatryYale University School of Medicine New Haven Connecticut
| | - Brittany A. Vose
- Hartford HealthCare Cancer InstituteHartford Hospital Hartford Connecticut
| | - Justin G. Mahalak
- Hartford HealthCare Cancer InstituteHartford Hospital Hartford Connecticut
| | - Andrew L. Salner
- Hartford HealthCare Cancer InstituteHartford Hospital Hartford Connecticut
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23
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Heiney SP, Parker PD, Felder TM, Adams SA, Omofuma OO, Hulett JM. A systematic review of interventions to improve adherence to endocrine therapy. Breast Cancer Res Treat 2018. [PMID: 30387003 DOI: 10.1007/s10549-018-5012-7.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Adherence to endocrine therapy for hormone positive breast cancer is a significant problem, especially in minority populations. Further, endocrine therapy reduces recurrence and thus mortality. However, little data are available on interventions to improve adherence. The authors conducted a systematic review to examine the impact of interventions, strategies, or approaches aimed to improve endocrine therapy adherence among women with breast cancer. A secondary aim was to determine if interventions had any cultural modifications. METHODS Two of the authors examined articles published between 2006 and 2017 from a wide variety of databases using Covidence systematic review platform. RESULTS In total, 16 eligible studies met criteria for review including 4 randomized controlled trials, 4 retrospective studies, and 8 with various observational designs. Eligible studies used a broad range of definitions for adherence and measured adherence by self-report, medical records, claims data, and combinations of these. All used 80% medication possession ratio as a standard for adherence. Patient information/education was the most frequent intervention strategy but did not demonstrate a significant effect except in one study. Significant results were noted when education was combined with communication strategies. CONCLUSIONS Researchers need a standard definition for adherence and a reliable measure that is feasible to use in a variety of studies. While education may be a necessary component of an intervention, when used alone, it is not a sufficient approach to change behavior.
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Affiliation(s)
- Sue P Heiney
- College of Nursing, School of Medicine, University of South Carolina, 1601 Greene St, Columbia, 29208, SC, USA.
| | | | - Tisha M Felder
- College of Nursing, Arnold School of Public Health, University of South Carolina, Columbia, USA
| | - Swann Arp Adams
- College of Nursing, Arnold School of Public Health, University of South Carolina, Columbia, USA
| | - Omonefe O Omofuma
- Arnold School of Public Health, University of South Carolina, Columbia, USA
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24
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Heiney SP, Parker PD, Felder TM, Adams SA, Omofuma OO, Hulett JM. A systematic review of interventions to improve adherence to endocrine therapy. Breast Cancer Res Treat 2018; 173:499-510. [PMID: 30387003 DOI: 10.1007/s10549-018-5012-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 10/15/2018] [Indexed: 01/15/2023]
Abstract
PURPOSE Adherence to endocrine therapy for hormone positive breast cancer is a significant problem, especially in minority populations. Further, endocrine therapy reduces recurrence and thus mortality. However, little data are available on interventions to improve adherence. The authors conducted a systematic review to examine the impact of interventions, strategies, or approaches aimed to improve endocrine therapy adherence among women with breast cancer. A secondary aim was to determine if interventions had any cultural modifications. METHODS Two of the authors examined articles published between 2006 and 2017 from a wide variety of databases using Covidence systematic review platform. RESULTS In total, 16 eligible studies met criteria for review including 4 randomized controlled trials, 4 retrospective studies, and 8 with various observational designs. Eligible studies used a broad range of definitions for adherence and measured adherence by self-report, medical records, claims data, and combinations of these. All used 80% medication possession ratio as a standard for adherence. Patient information/education was the most frequent intervention strategy but did not demonstrate a significant effect except in one study. Significant results were noted when education was combined with communication strategies. CONCLUSIONS Researchers need a standard definition for adherence and a reliable measure that is feasible to use in a variety of studies. While education may be a necessary component of an intervention, when used alone, it is not a sufficient approach to change behavior.
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Affiliation(s)
- Sue P Heiney
- College of Nursing, School of Medicine, University of South Carolina, 1601 Greene St, Columbia, 29208, SC, USA.
| | | | - Tisha M Felder
- College of Nursing, Arnold School of Public Health, University of South Carolina, Columbia, USA
| | - Swann Arp Adams
- College of Nursing, Arnold School of Public Health, University of South Carolina, Columbia, USA
| | - Omonefe O Omofuma
- Arnold School of Public Health, University of South Carolina, Columbia, USA
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25
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Adherence to Oral Administration of Endocrine Treatment in Patients With Breast Cancer: A Qualitative Study. Cancer Nurs 2018; 41:E57-E63. [PMID: 27922917 DOI: 10.1097/ncc.0000000000000452] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Breast cancer is the most common cancer in women in the world, and it is also the leading cause of cancer deaths among women. Nevertheless, breast cancer survival has increased as a result of improvements in early diagnosis and therapy, for example, oral endocrine therapy. Despite the importance of adherence to endocrine therapy, its trend appears complex and multidimensional and therefore has many loopholes and missing information. OBJECTIVE The study aims to explore the experiences of adherence to endocrine therapy in women with breast cancer and their perceptions of the challenges they face in adhering to their medication prescribed. METHODS The study used a qualitative exploratory design, with face-to-face semistructured interviews. Data were analyzed using framework analysis in accordance with Ritchie and Spencer's approach. RESULTS The sample included 27 women. Seven themes were identified: the different faces of adherence, fear of the drug, adherence stimulates the balance of the experience of illness, adherence influences the future of disease, adherence requires attention to the person, knowledge seeking, and "forgetfulness" activates the search for functional strategies. CONCLUSIONS This study shows that adherence assumes different connotations that are mainly influenced by the type of relationship established with health professionals the attention paid to the person, the information received, and the influence that the drug has on the disease. IMPLICATIONS FOR PRACTICE It appears that fear has a strong influence on the behaviors involved in taking the therapy. The only way to overcome irrational fear is to improve the patient's knowledge.
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26
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Women's Beliefs on Early Adherence to Adjuvant Endocrine Therapy for Breast Cancer: A Theory-Based Qualitative Study to Guide the Development of Community Pharmacist Interventions. PHARMACY 2018; 6:pharmacy6020053. [PMID: 29890738 PMCID: PMC6024955 DOI: 10.3390/pharmacy6020053] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/02/2018] [Accepted: 06/05/2018] [Indexed: 12/31/2022] Open
Abstract
Adjuvant endocrine therapy (AET) taken for a minimum of five years reduces the recurrence and mortality risks among women with hormone-sensitive breast cancer. However, adherence to AET is suboptimal. To guide the development of theory-based interventions to enhance AET adherence, we conducted a study to explore beliefs regarding early adherence to AET. This qualitative study was guided by the Theory of Planned Behavior (TPB). We conducted focus groups and individual interviews among women prescribed AET in the last two years (n = 43). The topic guide explored attitudinal (perceived advantages and disadvantages), normative (perception of approval or disapproval), and control beliefs (barriers and facilitating factors) towards adhering to AET. Thematic analysis was conducted. Most women had a positive attitude towards AET regardless of their medication-taking behavior. The principal perceived advantage was protection against a recurrence while the principal inconvenience was side effects. Almost everyone approved of the woman taking her medication. The women mentioned facilitating factors to encourage medication-taking behaviors and cope with side effects. For adherent women, having trouble establishing a routine was their main barrier to taking medication. For non-adherent women, it was side effects affecting their quality of life. These findings could inform the development of community pharmacy-based adherence interventions.
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27
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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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28
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Interventions to improve endocrine therapy adherence in breast cancer survivors: what is the evidence? J Cancer Surviv 2018; 12:348-356. [PMID: 29396760 DOI: 10.1007/s11764-017-0674-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/29/2017] [Indexed: 01/01/2023]
Abstract
PURPOSE Endocrine therapy reduces the risk of breast cancer recurrences and mortality in hormone receptor-positive (HR+) breast cancer survivors. However, non-adherence to treatment remains a significant problem. The aim of this study was to review current literature and ongoing trials to identify interventions employed to improve adherence to adjuvant endocrine therapy (AET) in breast cancer survivors. METHODS We searched PubMed and the National Library of Medicine registry of clinical trials using the terms "breast cancer" and "adherence" or "compliance" and "intervention" and "medication" or "endocrine therapy" or "hormone therapy" to identify published studies as well as ongoing clinical trials. RESULTS Three hundred and sixty-three studies were identified; five studies met the inclusion criteria. Most studies enrolled postmenopausal women diagnosed with early stage HR+ breast cancer. Providing educational materials was the most common intervention implemented to improve adherence to one or more aromatase inhibitors. None of the studies found a significant improvement in adherence with the intervention evaluated. Twelve clinical trials investigating various interventions, mostly based on technology, to improve AET adherence were also identified. CONCLUSIONS Improving adherence to AET in HR+ breast cancer survivors is an urgent medical need. While newer clinical trials are overcoming some of the limitations seen with published studies, tailored interventions led by clinicians need further investigation. IMPLICATIONS FOR CANCER SURVIVORS Our study highlights the unmet clinical need to develop and test feasible interventions to improve AET adherence in HR+ breast cancer survivors to extend their long-term survival.
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Grabeel KL, Russomanno J, Oelschlegel S, Tester E, Heidel RE. Computerized versus hand-scored health literacy tools: a comparison of Simple Measure of Gobbledygook (SMOG) and Flesch-Kincaid in printed patient education materials. J Med Libr Assoc 2018; 106:38-45. [PMID: 29339932 PMCID: PMC5764592 DOI: 10.5195/jmla.2018.262] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 09/01/2017] [Indexed: 11/20/2022] Open
Abstract
Objective The research compared and contrasted hand-scoring and computerized methods of evaluating the grade level of patient education materials that are distributed at an academic medical center in east Tennessee and sought to determine if these materials adhered to the American Medical Association’s (AMA’s) recommended reading level of sixth grade. Methods Librarians at an academic medical center located in the heart of Appalachian Tennessee initiated the assessment of 150 of the most used printed patient education materials. Based on the Flesch-Kincaid (F-K) scoring rubric, 2 of the 150 documents were excluded from statistical comparisons due to the absence of text (images only). Researchers assessed the remaining 148 documents using the hand-scored Simple Measure of Gobbledygook (SMOG) method and the computerized F-K grade level method. For SMOG, 3 independent reviewers hand-scored each of the 150 documents. For F-K, documents were analyzed using Microsoft Word. Reading grade levels scores were entered into a database for statistical analysis. Inter-rater reliability was calculated using intra-class correlation coefficients (ICC). Paired t-tests were used to compare readability means. Results Acceptable inter-rater reliability was found for SMOG (ICC=0.95). For the 148 documents assessed, SMOG produced a significantly higher mean reading grade level (M=9.6, SD=1.3) than F-K (M=6.5, SD=1.3; p<0.001). Additionally, when using the SMOG method of assessment, 147 of the 148 documents (99.3%) scored above the AMA’s recommended reading level of sixth grade. Conclusions Computerized health literacy assessment tools, used by many national patient education material providers, might not be representative of the actual reading grade levels of patient education materials. This is problematic in regions like Appalachia because materials may not be comprehensible to the area’s low-literacy patients. Medical librarians have the potential to advance their role in patient education to better serve their patient populations.
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Patient-reported factors associated with adherence to adjuvant endocrine therapy after breast cancer: an integrative review. Breast Cancer Res Treat 2017; 167:615-633. [DOI: 10.1007/s10549-017-4561-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 10/27/2017] [Indexed: 01/10/2023]
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31
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Treatment Decisions and Adherence to Adjuvant Endocrine Therapy in Breast Cancer. CURRENT BREAST CANCER REPORTS 2017. [DOI: 10.1007/s12609-017-0248-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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32
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Stüber T, van Ewijk R, Diessner J, Kühn T, Flock F, Felberbaum R, Blettner M, Kreienberg R, Janni W, Wöckel A, Singer S, Schwentner L. Which patient- and physician-related factors are associated with guideline adherent initiation of adjuvant endocrine therapy? Results of the prospective multi-centre cohort study BRENDA II. Breast Cancer 2016; 24:281-287. [PMID: 27193566 DOI: 10.1007/s12282-016-0701-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 05/06/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND We analysed factors that might influence patients' and physicians' decisions against the initiation of guideline adherent adjuvant endocrine therapy (ET). METHODS In a prospective multi-centre study, including four certified breast cancer centres in Germany, patients with primary breast cancer were included from 2009 to 2012. Patients completed a questionnaire prior to surgery, adjuvant therapy, and 6 months after adjuvant therapy. This questionnaire assessed health-related quality of life (QoL), psychiatric co-morbidity, demographic characteristics, and the intensity of fear for ET. Guideline adherence was classified based on an algorithm derived from international guidelines. The tumour board's (TB) decisions against or for ET was documented. The TB was blinded regarding the guideline results. RESULTS In 666 patients, adjuvant ET was indicated according to the guideline recommendations. The TB decided in 92.3 % (n = 615) of those that adjuvant ET was indicated. TB's decision against ET was associated with the younger age of patients (OR = 0.5; 95 % CI 0.3-0.9) and poor QoL (OR = 1.7; 95 % CI 1.0-2.8). In 93 patients, ET was not indicated according to the guidelines, and the TB decided in 84 of those not to prescribe ET. The TB decided in 93.4 % of the cases according to the guidelines. Of the patients, where the TB prescribed ET, 5 % (n = 31) decided against ET. This decision was associated with fear of ET (OR = 2.2; 95 % CI 1.0-5.2) and higher age (OR 9; 95 % CI 1.0-48.1). Psychiatric co-morbidity (OR = 1.8; 95 % CI 0.7-4.2), poor QoL (OR = 0.4; 95 % CI 0.2-1.2), and education (OR = 1.2; 95 % CI 0.5-2.6) were not associated with the decision. DISCUSSION Guideline adherent implementation of adjuvant ET is high. Physicians' decision against ET is mainly associated with patients' younger age and poor quality of life, whereas patients' decision, once the TB decided to initiate ET and if ET is indicated by guidelines, is associated with higher age and fear of ET.
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Affiliation(s)
- Tanja Stüber
- Department of Gynecology and Obstetrics, University Würzburg, Joseph-Schneider Str. 4, 97080, Würzburg, Germany.
| | - Reyn van Ewijk
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Centre Mainz, Obere Zahlbacher Straße 69, 55131, Mainz, Germany
- Department of Economics, Johannes Gutenberg University Mainz, Jakob-Welder-Weg 4, 55128, Mainz, Germany
| | - Joachim Diessner
- Department of Gynecology and Obstetrics, University Würzburg, Joseph-Schneider Str. 4, 97080, Würzburg, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Hospital Esslingen, Hirschlandstraße 97, 73730, Esslingen, Germany
| | - Felix Flock
- Department of Gynecology and Obstetrics, Hospital Memmingen, Bismarkstraße 23, 87700, Memmingen, Germany
| | - Riccardo Felberbaum
- Department of Gynecology and Obstetrics, Hospital Kempten, Robert-Weixler-Straße 50, 87439, Kempten, Germany
| | - Maria Blettner
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Centre Mainz, Obere Zahlbacher Straße 69, 55131, Mainz, Germany
| | - Rolf Kreienberg
- Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075, Ulm, Germany
| | - Wolfgang Janni
- Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075, Ulm, Germany
| | - Achim Wöckel
- Department of Gynecology and Obstetrics, University Würzburg, Joseph-Schneider Str. 4, 97080, Würzburg, Germany
| | - Susanne Singer
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Centre Mainz, Obere Zahlbacher Straße 69, 55131, Mainz, Germany
- University Cancer Centre, Mainz, Germany
| | - Lukas Schwentner
- Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075, Ulm, Germany
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Behavioral Interventions to Enhance Adherence to Hormone Therapy in Breast Cancer Survivors: A Systematic Literature Review. Clin Breast Cancer 2016; 16:247-255.e3. [PMID: 27133733 DOI: 10.1016/j.clbc.2016.03.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/22/2016] [Indexed: 01/08/2023]
Abstract
Adjuvant hormone therapy contributes to reductions in recurrence and mortality for women with hormone receptor-positive breast cancer. However, adherence to hormone therapy is suboptimal. This is the first systematic literature review examining interventions aimed at improving hormone therapy adherence. Researchers followed the PRISMA guidelines. PubMed-Medline, CINAHL, PsychInfo, Ovid-Medline, and EMBASE were searched for behavioral interventions that aimed to enhance adherence to adjuvant hormone therapy in breast cancer survivors. A total of 376 articles were screened for eligibility. Five articles met the study criteria. All interventions presented adherence outcomes after 1-year follow-up. None significantly enhanced adherence compared to the usual care in the primary analysis (odds ratios ranged from 1.03 to 2.06 for adherence and from 1.11 to 1.18 for persistence). All studies targeted patients, and only 3 studies included postmenopausal breast cancer patients. Three tested the same intervention consisting of educational materials. Only one was conducted in the United States. Only one reported participants' ethnicity. Overall, it was unclear whether the studies contained bias. The use of different terminology and operationalization of adherence made comparisons challenging. Interventions to improve adherence to adjuvant hormone therapy in US breast cancer populations that include survivors who are ethnically diverse, premenopausal, and receiving tamoxifen therapy are necessary to inform future interventions. Adoption of consistent adherence definitions/measurements will provide a clearer framework to consolidate aggregate findings. Given the limited efficacy of tested interventions, it is important to engage oncologists and researchers to develop approaches that target different components associated with hormone therapy adherence, such as doctor-patient communication or social support.
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Kadakia KC, Snyder CF, Kidwell KM, Seewald NJ, Flockhart DA, Skaar TC, Desta Z, Rae JM, Otte JL, Carpenter JS, Storniolo AM, Hayes DF, Stearns V, Henry NL. Patient-Reported Outcomes and Early Discontinuation in Aromatase Inhibitor-Treated Postmenopausal Women With Early Stage Breast Cancer. Oncologist 2016; 21:539-46. [PMID: 27009936 PMCID: PMC4861358 DOI: 10.1634/theoncologist.2015-0349] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/27/2015] [Indexed: 12/03/2022] Open
Abstract
In the prospective Exemestane and Letrozole Pharmacogenetics trial of adjuvant aromatase inhibitor (AI) therapy for early-stage breast cancer, worsening of multiple treatment-related symptoms during AI therapy predicted AI early discontinuation. If these findings are confirmed in independent trials, early detection of changes in PRO measures could be used clinically to target interventions in patients at high risk for early discontinuation. Background. Early discontinuation of aromatase inhibitors (AIs) is common and leads to poor outcomes but is challenging to predict. In the Exemestane and Letrozole Pharmacogenetics trial, a high rate of early discontinuation due to intolerance was observed. We hypothesized that early changes in patient-reported outcomes (PROs) predict AI discontinuation and that biochemical factors are associated with changes in PROs. Patients and Methods. Postmenopausal women with early-stage breast cancer enrolled in a prospective randomized trial of exemestane versus letrozole completed questionnaires at baseline and serially over 24 months to assess overall quality of life (EuroQOL Visual Analog Scale [VAS]); mood; and multiple symptoms, including a musculoskeletal symptom cluster. A joint mixed-effects/survival model was used to estimate the effect of the change in PROs on AI discontinuation. Associations between biochemical factors and change in PROs were examined. Results. A total of 490 patients were analyzed. Worsening of EuroQOL VAS and the musculoskeletal cluster were associated with the highest risk for early discontinuation (hazard ratio [HR], 2.77 [95% confidence interval (CI), 2.72–2.81; p = .015]; HR, 4.39 [95% CI, 2.40–8.02; p < .0001], respectively). Pharmacokinetics and estrogen metabolism were not consistently associated with change in PRO measures. No clinically significant differences in any PRO between AIs were observed. Conclusion. Changes in PROs early during AI therapy were associated with treatment discontinuation. Identification of these changes could be used to target interventions in patients at high risk for early discontinuation. Implications for Practice: Early changes in patient-reported outcomes (PROs) can predict nonpersistence to aromatase inhibitor therapy. If used in clinical practice, PROs might identify women at highest risk for early discontinuation and allow for interventions to improve tolerance before significant toxicities develop. Further research is needed to improve capturing PROs in routine clinical practice.
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Affiliation(s)
- Kunal C Kadakia
- University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan, USA
| | - Claire F Snyder
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Nicholas J Seewald
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - David A Flockhart
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Todd C Skaar
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Zereunesay Desta
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James M Rae
- University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan, USA
| | - Julie L Otte
- Indiana University School of Nursing, Indianapolis, Indiana, USA
| | | | - Anna M Storniolo
- Melvin and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Daniel F Hayes
- University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan, USA
| | - Vered Stearns
- Breast Cancer Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - N Lynn Henry
- University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan, USA
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Greer JA, Amoyal N, Nisotel L, Fishbein JN, MacDonald J, Stagl J, Lennes I, Temel JS, Safren SA, Pirl WF. A Systematic Review of Adherence to Oral Antineoplastic Therapies. Oncologist 2016; 21:354-76. [PMID: 26921292 DOI: 10.1634/theoncologist.2015-0405] [Citation(s) in RCA: 218] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/08/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Oral antineoplastic therapies not only improve survival but also reduce the burden of care for patients. Yet patients and clinicians face new challenges in managing adherence to these oral therapies. We conducted a systematic literature review to assess rates and correlates of adherence to oral antineoplastic therapies and interventions aimed at improving adherence. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a comprehensive literature search of the Ovid MEDLINE database from January 1, 2003 to June 30, 2015, using relevant terminology for oral antineoplastic agents. We included observational, database, and intervention studies. At least two researchers evaluated each paper to ensure accuracy of results and determine risk of bias. RESULTS We identified 927 records from the search and screened 214 abstracts. After conducting a full-text review of 167 papers, we included in the final sample 51 papers on rates/correlates of adherence to oral antineoplastic therapy and 12 papers on intervention studies to improve adherence. Rates of adherence varied widely, from 46% to 100%, depending on patient sample, medication type, follow-up period, assessment measure, and calculation of adherence. Of the intervention studies, only 1 of the randomized trials and 2 of the cohort studies showed benefit regarding adherence, with the majority suffering high risk of bias. CONCLUSIONS Although no reliable estimate of adherence to oral antineoplastic therapies can be gleaned from the literature, a substantial proportion of patients struggle to adhere to these medications as prescribed. The few intervention studies for adherence have notable methodological concerns, thereby limiting the evidence to guide practice in promoting medication adherence among patients with cancer.
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Affiliation(s)
- Joseph A Greer
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Amoyal
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren Nisotel
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Joel N Fishbein
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - James MacDonald
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jamie Stagl
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Inga Lennes
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | - William F Pirl
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Abstract
INTRODUCTION Aromatase inhibitor (AI) therapy is the current preferred choice of endocrine therapy in postmenopausal estrogen receptor-positive breast cancer patients thanks to their improved effectiveness compared to tamoxifen. Despite the absence of increased endometrial pathology and deep venous thrombosis seen in tamoxifen-users, the safety profile of AIs consists of a variety of bothersome side effects negatively influencing daily functioning. AREAS COVERED Besides the well-known adverse effects on joints and bone and the vasomotor system, more neglected and latent toxicity like cognitive problems and vulvovaginal atrophy will be discussed. Concern has been raised in terms of increased risk of fractures and cardiovascular events with chronic AI use. EXPERT OPINION Placebo-controlled long-term studies carefully monitoring these adverse events, together with more extensive research in the etiologies, are warranted.
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Quinn EM, Fleming C, O'Sullivan MJ. Endocrine therapy adherence: a cross-sectional study of factors affecting adherence and discontinuation of therapy. Ir J Med Sci 2015; 185:383-92. [PMID: 25971465 DOI: 10.1007/s11845-015-1307-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/26/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND/AIMS Adjuvant endocrine therapy for at least 5 years improves oncological outcomes in oestrogen receptor-positive breast cancer. Adherence rates to prescribed endocrine therapy are low and the search for modifiable causes of this continues. The aim of this study was to assess adherence rates in an Irish cohort of breast cancer patients prescribed adjuvant endocrine therapy and to assess modifiable factors associated with suboptimal adherence. METHODS A cross-sectional anonymous survey was performed on 261 patients currently prescribed endocrine therapy. Data were collected regarding demographics, treatment, social and emotional factors and medication side effects. Each patient completed a medication adherence score and provided information about discontinuation of therapy and reasons for same. RESULTS Only 67.8 % of patients assessed demonstrated complete medication adherence on the medication adherence scale. Twenty-nine patients (10.9 %) permanently stopped taking their prescribed endocrine therapy. Suboptimal adherence was more likely in younger patients (p < 0.001), those in employment (p = 0.005), those who experienced side effects (p = 0.006), those who perceived themselves to have low levels of emotional support (p < 0.001) and those who use the internet to read about their illness (p = 0.003). CONCLUSIONS Endocrine therapy adherence is suboptimal in almost one-third of patients in our cohort. Appropriate assessment and management of side effects and negative emotions, combined with direction of patients to accurate internet sources of information, could help improve endocrine therapy adherence in women with early-stage breast cancer.
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Affiliation(s)
- E M Quinn
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland.
| | - C Fleming
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland
| | - M J O'Sullivan
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland
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Markopoulos C, Neven P, Tanner M, Marty M, Kreienberg R, Atkins L, Franquet A, Gnant M, Neciosup S, Tesarova P, Barni S, Deschamp V. Does patient education work in breast cancer? Final results from the global CARIATIDE study. Future Oncol 2015; 11:205-17. [DOI: 10.2217/fon.14.179] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
ABSTRACT Aim: To determine the impact of educational materials (EMs) on the treatment compliance of postmenopausal women with hormone receptor-positive (HR+) early-stage breast cancer. Patients & methods: Patients (n = 2757) were randomized to standard aromatase inhibitors (AI) alone (group A) or with EMs (group B) in a global, real-world setting. Results: The 2-year results (n = 2242) showed EMs had no impact on compliance (82 vs 82%, group A vs B), compliance with initial AI (82 vs 81%) or persistence (90 vs 88%), confirming the 1-year interim analysis (n = 2567). Of the 2082 patients considered compliant at 1 year, 77% remained compliant at 2 years. Discontinuations (9%) were mainly attributed to AI-related side effects (68% of discontinuations). Exploratory analyses suggest a relationship between patient characteristics and compliance behaviors. Conclusion: EMs do not improve compliance in this patient population. Compliance and persistence are complex end points influenced by multiple variables. Side effects were the main reasons for discontinuations.
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Affiliation(s)
| | | | - Minna Tanner
- Department of Oncology, Tampere University Hospital, Tampere, Finland
| | | | | | | | - Ann Franquet
- International Drug Development Institute (IDDI), Louvain-la-Neuve, Belgium
| | - Michael Gnant
- Department of Surgery & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Silvia Neciosup
- Instituto Nacional de Enfermedades Neoplasicas (INEN), Lima, Peru
| | - Petra Tesarova
- First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic
| | - Sandro Barni
- Oncologia Medica, Azienda Ospedaliera Treviglio – Caravaggio, Treviglio, Italy
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Kasi PM, Ruddy KJ. Factors influencing treatment adherence and discontinuation in women with breast cancer. BREAST CANCER MANAGEMENT 2015. [DOI: 10.2217/bmt.14.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Although all aspects of breast cancer care rely to some extent on patient behaviors, the endocrine therapies, which are orally administered at home, are the most impacted by nonadherence and nonpersistence. A variety of issues can interfere with a breast cancer patient's adherence and persistence including the following: sociodemographic factors; healthcare team and system-related factors (such as inadequate visit time and poor medication distribution services); condition-related factors (such as prognosis); therapy-related factors (such as side effects); and patient-related factors (such as attitudes, beliefs, perceptions, and expectations). In our review, we describe evidence regarding the most powerful factors mediating adherence and persistence in breast cancer patients, and explore potential interventions to reduce nonadherence and nonpersistence, primarily based on data in patients taking adjuvant endocrine therapy.
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Affiliation(s)
| | - Kathryn J Ruddy
- Division of Oncology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA
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Ren Y, Black DM, Mittendorf EA, Liu P, Li X, Du XL, He J, Yang J, Hunt KK, Yi M. Crossover effects of estrogen receptor status on breast cancer-specific hazard rates by age and race. PLoS One 2014; 9:e110281. [PMID: 25333877 PMCID: PMC4204865 DOI: 10.1371/journal.pone.0110281] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 09/15/2014] [Indexed: 01/13/2023] Open
Abstract
Background Previous studies found that the risk of breast cancer–related death is greater in estrogen receptor (ER)-negative disease than in ER-positive disease within 5 years of diagnosis, but greater for ER-positive disease than for ER-negative disease more than 5 years after diagnosis. This phenomenon is referred to as ER-positive and -negative crossover. Our aim was to evaluate this crossover by determining the timing of the hazard of breast cancer death by patient, clinical, and tumor factors. Methods Patients with breast cancer diagnosed between 1990 and 2005 were identified from the Surveillance, Epidemiology, and End Results database. The cohort was evaluated by age at diagnosis, race, tumor ER status, tumor and nodal stage, and tumor grade. Disease-specific (DS) hazard rates were calculated. Results Of the 439,444 patients identified, 77.5% had ER-positive disease. Overall, ER-negative to ER-positive DS hazard rates crossed between the years 7 and 8 after diagnosis. Earlier crossover was linked to black or Hispanic race, young age (<40 years), or tumors that were larger, higher grade, or affected the nodes. Young black (<40 years) patients who had a T3/T4 tumor with positive nodes, grade III or undifferentiated, had the earliest crossover, in year 4. Conclusions The timing of crossover of death hazard for ER-positive and ER-negative disease varies by clinical and tumor factors. These findings may help guide recommendations regarding the duration of endocrine therapy for patients with ER-positive cancer.
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Affiliation(s)
- Yu Ren
- Department of Surgical Oncology, The First Affiliated Hospital of Xian Jiaotong University, School of Medicine, Xian, China
| | - Dalliah M. Black
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Elizabeth A. Mittendorf
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Peijun Liu
- Department of Translational Medicine, The First Affiliated Hospital of Xian Jiaotong University, School of Medicine, Xian, China
| | - Xu Li
- Department of Translational Medicine, The First Affiliated Hospital of Xian Jiaotong University, School of Medicine, Xian, China
| | - Xianglin L. Du
- Division of Epidemiology Human Genetics, and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas, United States of America
| | - Jianjun He
- Department of Surgical Oncology, The First Affiliated Hospital of Xian Jiaotong University, School of Medicine, Xian, China
| | - Jin Yang
- Department of Medical Oncology, The First Affiliated Hospital of Xian Jiaotong University, School of Medicine, Xian, China
| | - Kelly K. Hunt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Min Yi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
- Department of Translational Medicine, The First Affiliated Hospital of Xian Jiaotong University, School of Medicine, Xian, China
- * E-mail:
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