Prescription refill, patient self-report and physician report in assessing adherence to oral endocrine therapy in early breast cancer patients: a retrospective cohort study in Catalonia, Spain

The Impact of the COVID-19 Pandemic on Adherence to Endocrine Therapy for Breast Cancer in Catalonia (Spain)

Purpose. To assess the impact of the COVID-19 pandemic on adherence to oral endocrine therapy in patients diagnosed with breast cancer in the public healthcare system in Catalonia (Spain). Methods. Retrospective cohort study in patients starting endocrine therapy from 2017 to 2021. Adherence was measured during the first year of treatment, and the impact of the pandemic was calculated according to the calendar year and whether the first year of treatment included the peak period of the pandemic in our setting (March-September 2020). Analyses were performed using a chi-square test and multivariable logistic regression, with results stratified by year, age group, and drug type. Results. Mean overall adherence during the first year of treatment was 89.6% from 2017 to 2021. In contrast, the patients who started treatment in 2019 and 2020 and whose treatment included the peak pandemic period presented an adherence of 87.0% and 86.5%, respectively. Young age and tamoxifen or combination therapy were predictors of low adherence. An increase in neoadjuvant therapy was also observed in 2020. Conclusions. The COVID-19 pandemic had only a modest impact on adherence to endocrine therapy (≈3%), despite the enormous disruptions for patients, the healthcare system in general, and cancer care in particular that were occurring in that period.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adherence to endocrine therapy in early breast cancer in relation to Cytochrome P450 2D6 genotype: a comparison between pharmacy dispensation data and medical records

PURPOSE

Suboptimal adherence to adjuvant endocrine treatment (AET) is an important clinical concern. A correlation between CYP2D6 activity and tamoxifen discontinuation has been described. The main aim of this study was to investigate the consistency between pharmacy dispensation data and medical records on adherence to AET.

METHODS

Adherence was calculated for patients with at least 4.5 years of follow up and was defined as Medical Possession Rate ≥ 80%. Subgroup analyses were performed based on menopausal status, recurrence risk and CYP2D6 activity.

RESULTS

In 86% of the 1235 included patients the consistency between the two sources of information was within 80-125%. Poor consistency, < 80%, was most frequent in the premenopausal/ high-risk group and CYP2D6 Poor Metabolizers (PMs). Among 899 patients with at least 4.5 years follow up, 72% were adherent to tamoxifen based on pharmacy dispensation data, compared with 77% as reported by medical records. When including patients who switched to aromatase inhibitors after tamoxifen, adherence increased to 82% and 88%, respectively. Adherence did not differ by menopausal status or risk for recurrence. CYP2D6 PMs had poorer adherence (54%) to tamoxifen compared to patients with the highest CYP2D6 activity (83%).

CONCLUSIONS

There was a good consistency between medical records and pharmacy dispensing data on the use of AET. Adherence to AET was adequate, especially when including switch to aromatase inhibitors. Surprisingly, CYP2D6 PMs had low adherence to tamoxifen, despite a likely reduced risk of side effects according to previous data.

Adherence to oral hormonal anticancer agents in breast cancer

There is an increasing trend towards using oral antitumoral agents in oncological patients. Compared to parenteral therapy, oral treatment offers convenience for both the patient and the healthcare system, with similar efficacy. However, the benefit deriving from oral drugs will be obtained only if patients adhere strictly to the treatment. Medical oncologists must therefore seek to optimize patient adherence. Breast cancer patients, particularly, are often treated with oral hormonal anticancer agents. In this review, we summarized evidence about adherence of breast cancer patients to oral hormonal anticancer agents and the consequences of poor compliance, the barriers to oral treatment and strategies to overcome them.

Using population-based data to evaluate the impact of adherence to endocrine therapy on survival in breast cancer through the web-application BreCanSurvPred

We show how the use and interpretation of population-based cancer survival indicators can help oncologists talk with breast cancer (BC) patients about the relationship between their prognosis and their adherence to endocrine therapy (ET). The study population comprised a population-based cohort of estrogen receptor positive BC patients (N = 1268) diagnosed in Girona and Tarragona (Northeastern Spain) and classified according to HER2 status (+ / −), stage at diagnosis (I/II/III) and five-year cumulative adherence rate (adherent > 80%; non-adherent ≤ 80%). Cox regression analysis was performed to identify significant prognostic factors for overall survival, whereas relative survival (RS) was used to estimate the crude probability of death due to BC (P_BC). Stage and adherence to ET were the significant factors for predicting all-cause mortality. Compared to stage I, risk of death increased in stage II (hazard ratio [HR] 2.24, 95% confidence interval [CI]: 1.51–3.30) and stage III (HR 5.11, 95% CI 3.46–7.51), and it decreased with adherence to ET (HR 0.57, 95% CI 0.41–0.59). P_BC differences were higher in non-adherent patients compared to adherent ones and increased across stages: stage I: 6.61% (95% CI 0.05–13.20); stage II: 9.77% (95% CI 0.59–19.01), and stage III: 22.31% (95% CI 6.34–38.45). The age-adjusted survival curves derived from this modeling were implemented in the web application BreCanSurvPred (https://pdocomputation.snpstats.net/BreCanSurvPred). Web applications like BreCanSurvPred can help oncologists discuss the consequences of non-adherence to prescribed ET with patients.

Factors influencing five-year adherence to adjuvant endocrine therapy in breast cancer patients: A systematic review

Purpose

This systematic review aimed to determine the rate and identify correlates of adherence and persistence over five years of treatment with adjuvant endocrine therapy in female breast cancer patients.

Methods

Relevant articles were identified from Medline, Embase, AMED, PsycINFO, International Pharmaceutical Abstracts, and APA PsycArticles. Studies that measured patient adherence in the implementation or persistence phase for a period of at least five years using objective or multiple measures of adherence and investigated correlates of adherence were included. The titles, abstracts and full articles were screened and reviewed by two authors and any discrepancies were discussed with a third author.

Results

Twenty-six studies were included. Mean rate of adherence at five-year for implementation phase was 66.2% (SD = 17.3%), and mean persistence was 66.8% (SD = 14.5%). On average, adherence decreased by 25.5% (SD = 9.3%) from the first to fifth year. Higher rate of adherence was observed through self-report in comparison to database or medical record. Older age, younger age, higher comorbidity index, depression and adverse effects were associated with lower adherence. Treatment with aromatase inhibitors, received chemotherapy, and prior medication use were associated with improved adherence.

Conclusion

Adherence to adjuvant endocrine therapy decreased from the first to fifth year of treatment. On average, one-third of patients were not adherent to treatment by the fifth year. Nineteen recurring factors were found to be significantly associated with long-term adherence in multiple studies. Further research using objective or multiple measures of adherence are needed to improve validity of results.

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On average, adherence fell by 25.5% from the first to the fifth year of treatment.

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Self-reported adherence may overestimate patient adherence.

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Nineteen recurring factors were associated with adherence.

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Having adverse effects was negatively associated with adherence.

Patterns of first-line targeted therapy utilization and adherence among older adults diagnosed with metastatic renal cell carcinoma

BACKGROUND

Despite the rapid approval of targeted therapies for metastatic renal cell carcinoma (mRCC) evidence on real world treatment patterns remains limited. This study evaluated patterns of first-line targeted therapy utilization and adherence in older adults, a population with a high burden of RCC.

METHODS

2093 patients aged ≥66 years with a primary diagnosis of mRCC were identified from United States (US)-based cancer registry and administrative claims data (2007-2015). We included only patients with de novo disease. We assessed the initiation of first-line targeted therapy within four months of diagnosis and persistence and adherence to targeted therapy, using the proportion of days covered (PDC). Multivariable logistic regression yielded adjusted odds ratios (ORs) and 95% confidence intervals (CIs) to describe characteristics associated with targeted therapy versus no targeted therapy initiation and for high (≥80% PDC) versus low adherence.

RESULTS

28.8% of patients received first-line targeted therapy within four months of diagnosis, with the proportion of patients receiving targeted therapy increasing over time. Older age (one-year increment OR:0.95 95%CI 0.93, 0.97), high comorbidity burden (OR:0.65 95%CI0.46, 0.93) and clear cell histology (OR:1.54 95%CI 1.19, 2.00) were associated with targeted therapy initiation. 48.2% of patients exhibited a high PDC to oral targeted therapy at 120 days, which was attenuated with inclusion of patients who died during the time period (34.2% PDC ≥80%).

CONCLUSION

Increasing age, high comorbidity burden and non-clear cell histology were associated with decreased targeted therapy initiation among patients with de novo mRCC. Our findings suggest adherence to oral therapies was low; future research exploring the mechanisms and impact of low adherence in this older patient population is warranted.

Gynecologic Symptoms among Hormone Receptor-Positive Breast Cancer Patients on Oral Endocrine Therapy: A Cross-Sectional Study

Endocrine therapy (ET) for hormone receptor-positive (HR+) breast cancer can contribute to gynecologic symptoms (GS) that impact vaginal health, sexual function, and quality of life (QoL). A cross-sectional study was conducted at St. Michael’s Hospital in Toronto, Canada between July 2017 and June 2018 to examine the occurrence and frequency of GS among HR+ breast cancer patients on ET, patient-provider communication, female sexual dysfunction (FSD), and QoL. A Treatment Experience questionnaire was developed for this study and the Female Sexual Function Index (FSFI) and Menopause-Specific Quality of Life questionnaire (MENQOL) were also administered. Of 151 patients surveyed, 77 (51.0%) were on tamoxifen and 74 (49.0%) on an aromatase inhibitor. Most patients (84.1%, 95% confidence interval [CI] 77.3% to 89.5%) experienced at least one GS “all the time” or “often”, or one or more infections, in the past year. Only 44 (31.9%) patients reported that their oncologist had ever previously asked them about experiencing GS. The prevalence of FSD was 61.2% (95% CI 46.2% to 74.8%) among 49 sexually active patients that completed the FSFI. Symptoms captured in the MENQOL’s vasomotor domain were deemed most bothersome. Side effect management and patient-provider communication should be prioritized to optimize GS, vaginal health, and sexual function of ET users.

Adherence to treatment with oral antineoplastic therapy in outpatients

BACKGROUND

Multiple factors have defined the success of treatment with oral antineoplastic, especially adherence to the therapeutic regimen. The aim of this study was to describe the profile of individuals in treatment with oral antineoplastic according to the sociodemographic and clinical epidemiology factors as well as to estimate the association with those to Non-adherence to the treatment with oral antineoplastic.

METHODS

A cross-sectional observational study was performed in the chemotherapy outpatient's department from December 2015 to March 2016 at a teaching hospital. The outcome Non-adherence was evaluated according to Morisky Green test. The variables which have reached statistical significance in the bivariate analysis were tested in the multivariate model to evaluate if they remained associated to "Non-adherence" according to the Poisson logistic regression and corrected by robust variance.

RESULTS

In total, 233 patients were analyzed and 60.9% were found in Non-adherence to the treatment with oral antineoplastic according Morisky Green test (MMAS8), in which forgetfulness were often and had driven to non-adherence outcome. Multivariate analysis found three final predictors for Non-adherence which were own income, carer, unease and had needed urgency services in the last year.

CONCLUSION

This study reveals several factors associated with nonadherence. Those outcomes show that the patient's journey during antineoplastic treatment must be discussed and addressed in a broad way together with measures in public health policies.

Impact of an Oral Antineoplastic Renewal Clinic on Medication Possession Ratio and Cost-Savings

Purpose

The primary objective of this study was to evaluate the impact of a pharmacist-driven oral antineoplastic (OAN) renewal clinic on medication adherence and cost savings.

Methods

This was a preimplementation and postimplementation retrospective cohort evaluation within a single US Department of Veterans Affairs health care system following implementation of a pharmacist-managed OAN refill clinic. The primary outcome was medication adherence defined as the median medication possession ratio (MPR) before and after implementation of the clinic. Secondary outcomes included the proportion of patients who were adherent from pre- to postimplementation and estimated cost-savings of this clinic. Patients were eligible for inclusion if they had received at least 2 prescriptions of the most commonly prescribed oral antineoplastic agents at the institution between September 1, 2013 and January 31, 2015.

Results

Of preimplementation patients, 96 of 99 (96.9%) were male and all patients (n = 35) in the postimplementation group were male. The mean age of the preimplementation group was 69.2 years while the postimplementation group was 68.4 years. Median MPR in the preimplementation group was 0.94, compared with 1.06 in the postimplementation group (P < .001). Thirty-six (36.7%) patients in the preimplementation group were considered nonadherent to their OAN regimen compared with zero patients in the postimplementation group. Estimated total cost savings was $36,335 in the postimplementation period.

Conclusions

Implementation of a pharmacist-driven OAN renewal clinic was associated with a 12% increase in median MPR while saving an estimated $36,335 during the 5-month postimplementation period.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Long-term efficacy of capecitabine plus oxaliplatin chemotherapy on stage III colon cancer: A meta-analysis

BACKGROUND

Many clinical studies for the long-term survival or efficacy of capecitabine plus oxaliplatin (XELOX) in colon cancer have already been studied, but its clinical benefit is controversial.

AIM

To evaluate the long-term efficacy of XELOX regimen in comparison with other adjuvant chemotherapy protocols in colon cancer.

METHODS

By searching the PubMed, EMBASE and Cochrane databases, a total of 12 randomized controlled trials involving 6698 stage III colon cancer cases (XELOX protocol: n = 3298 cases; other adjuvant chemotherapy protocol: n = 3268 cases) were included. The parameter outcomes included the overall survival and the disease-free survival. The quality control of selected literature was based on the Jadad scale and the GRADE system.

RESULTS

In comparison to other adjuvant chemotherapy regimen, XELOX regimen showed a better overall survival (odds ratio = 1.29, 95% confidence interval: 1.15-1.44, P < 0.0001) and a better disease-free survival (odds ratio = 1.32, 95% confidence interval: 1.18-1.46, P < 0.0001) for colon cancer patients, suggesting the XELOX regimen can be a good option for postoperative treatment of stage III colon cancer.

CONCLUSION

The XELOX regimen can be a preferred option for adjuvant treatment of stage III colon cancer after surgery.

Adherence trajectories of adjuvant endocrine therapy in the five years after its initiation among women with non-metastatic breast cancer: a cohort study using administrative databases

PURPOSE

Despite the benefits of adjuvant endocrine therapy (AET) for reducing recurrence and mortality risks after hormone-sensitive breast cancer, AET adherence is sub-optimal for a high proportion of women. However, little is known about long-term patterns of AET adherence over the minimally recommended 5 years. Our objectives were to: (1) identify 5-year AET adherence trajectory groups; (2) describe trajectory groups according to adherence measures traditionally used (i.e., Proportion of Days Covered); and (3) explore factors associated with trajectories.

METHODS

We conducted a 5-year cohort study using data from a French national study that included AET dispensing data. Women diagnosed with first non-metastatic breast cancer and having at least 1 AET dispensing in the 12 months after diagnosis were included. Group-based trajectory modeling was used to identify adherence trajectory groups by clustering similar patterns of monthly AET dispensing. Multinomial logistic regressions were used to identify factors associated with trajectories.

RESULTS

Among 674 women, five AET adherence trajectory groups were identified: (1) quick decline and stop (5.2% of women); (2) moderate decline and stop (6.4%); (3) slow decline (17.2%); (4) high adherence (30.0%); and (5) maintenance of very high adherence (41.2%). Mean 5-year Proportion of Days Covered varied from 10 to 97% according to trajectories. Women who did not receive chemotherapy or a personalized care plan were more likely to belong to trajectories where AET adherence declined and stopped.

CONCLUSION

Our results provide information on the diversity of longitudinal AET adherence patterns, the timing of decline and discontinuation and associated factors that could inform healthcare professionals.

Nonadherent behaviors among young women on adjuvant endocrine therapy for breast cancer

BACKGROUND

Young age is a known factor associated with suboptimal adherence to endocrine therapy (ET) for adjuvant breast cancer (BC) treatment. This study was aimed at assessing nonadherent behaviors and associated factors among young women with early-stage hormone receptor-positive BC.

METHODS

As part of a multicenter, prospective cohort of women with a diagnosis of BC at or under the age of 40 years, participants were surveyed 30 months after their diagnosis about adherent behaviors. Among those who reported taking ET, adherence was measured with a 3-item Likert-type scale: Do you ever forget to take your ET? If you feel worse when you take your ET, do you stop taking it? Did you take your ET exactly as directed by your doctor over the last 3 months? Women reporting at least 1 nonadherent behavior were classified as nonadherers. Variables with a P value <.20 were included in a multivariable logistic model.

RESULTS

Among 384 women, 194 (51%) were classified as nonadherers. Univariate factors that retained significance in the multivariable model included educational level (odds ratio [OR], 0.50 for high vs low; P = .04), level of social support according to the Medical Outcome Study Social Support Survey (OR, 0.98 per 1 point; P = .01), and confidence with the decision regarding ET measured on a 0 to 10 numerical scale (OR, 0.63 for high vs low; P = .04).

CONCLUSIONS

Findings from this study could help to identify young patients at higher risk for nonadherence. Interventions adapted to the level of education and aimed at reinforcing support and patients' confidence in their decision to take ET could improve adherence and associated outcomes in this population.

Effect of Adherence on Pharmacokinetic/Pharmacodynamic Relationships of Oral Targeted Anticancer Drugs

The emergence of oral targeted anticancer agents transformed several cancers into chronic conditions with a need for long-term oral treatment. Although cancer is a life-threatening condition, oncology medication adherence-the extent to which a patient follows the drug regimen that is intended by the prescriber-can be suboptimal in the long term, as in any other chronic disease. Poor adherence can impact negatively on clinical outcomes, notably because most of these drugs are given as a standard non-individualized dosage despite marked inter-individual variabilities that can lead to toxic or inefficacious drug concentrations. This has been especially studied with the prototypal drug imatinib. In the context of therapeutic drug monitoring (TDM), increasingly advocated for oral anticancer treatment optimization, unreported suboptimal adherence affecting drug intake history may lead to significant bias in the concentration interpretation and inappropriate dosage adjustments. In the same way, suboptimal adherence may also bias the results of pharmacokinetic modeling studies, which will affect in turn Bayesian TDM interpretation that relies on such population models. Detailed knowledge of the influence of adherence on plasma concentrations in pharmacokinetic studies or in routine TDM programs is however presently missing in the oncology field. Studies on this topic are therefore eagerly awaited to better pilot the treatment of cancer with the new targeted agents and to find their optimal dosage regimen. Hence, the development and assessment of effective medication adherence programs are warranted for these treatments.

Good adherence to adjuvant endocrine therapy in early breast cancer - a population-based study based on the Swedish Prescribed Drug Register

INTRODUCTION

Adjuvant endocrine therapy improves recurrence-free and overall survival in primary breast cancer. However, not all patients complete their planned treatment, mostly because of side-effects. The aim of this study was to examine the adherence to adjuvant endocrine therapy in a cohort of primary breast cancer patients in Region Jönköping County, Sweden, after 3 and 5 years.

MATERIAL AND METHODS

The Swedish Breast Cancer Register was used to identify patients diagnosed with hormone receptor positive breast cancer in Region Jönköping County between 2009 and 2012. Adherence was evaluated based on data from the Swedish Prescribed Drug Register, and Medication Possession Ratio (MPR), defined as the days' supply of medication during the period from the first dispensing till the last dispensing in the time period (3 and 5 years), divided by number of days. Adherence was defined as MPR ≥80%. Regression analyses were used to identify subgroups associated with adherence; age, type of endocrine treatment, additional adjuvant therapy, and hospital responsible for the follow-up (Eksjö, Jönköping, and Värnamo).

RESULTS

We identified 634 patients who were recommended adjuvant endocrine therapy and to be able to estimate adherence after 3 and 5 years, 488 patients were included in the analysis. After 3 years of treatment, 91.2% of the patients (95% confidence interval (CI) 88.7-93.6; n = 445), were found to be adherent. The corresponding figure for the 271 patients who had completed 5 years of treatment was 91.5% (95% CI 88.2-94.8; n = 248). No subgroups (age, endocrine therapy, radio/chemotherapy, or hospital) were significantly associated with adherence in the multiple logistic regression analysis.

DISCUSSION

This study shows substantially higher adherence to adjuvant endocrine therapy than previously reported. Reasons for this could be differences in routines for therapy information and follow-up, but this needs to be further investigated.

Adjuvant hormonal therapy for early breast cancer: an epidemiologic study of medication adherence

PURPOSE

The aim of this study was to determine the prevalence of adherence to adjuvant hormonal therapy (AHT) and to identify risk factors for medication non-adherence in clinical practice in patients with early-stage hormone receptor (HR)-positive breast cancer (BC) previously treated with chemotherapy.

METHODS

We carried out a cross-sectional, observational, prospective, and multicenter survey based on a structured self-report postal questionnaire (35 items investigating six areas). A sample of 474 patients was drawn from 676 patients potentially eligible. The structured and validated Morisky Medication Adherence Scale-4 items was used for measuring medication adherence. An analysis of risk factors for non-adherence to AHT was performed using a two-step approach: univariate, then multivariate analysis.

RESULTS

A total of 280 patients out of the 428 analyzed patients participated in the survey, yielding a response rate of 65.4% [60.9-69.9]. The prevalence of adherence to AHT was estimated at 68.6% [63.1-74.0], corresponding to a high level of adherence. Three risk factors for non-adherence to AHT were identified: > 2 medications to treat comorbidities (p-value = 0.003), age less than 65 years (p-value = 0.008), and patient management in a university hospital setting (p-value = 0.014).

CONCLUSIONS

Non-adherence is a common, complex, and multidimensional healthcare problem. This better understanding and knowledge of risk factors will allow healthcare providers (such as oncologists, general practitioners, pharmacists) to more easily identify patients at risk for non-adherence and help them provide appropriate information about AHT and its management, thus improving medication adherence in their patients.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Fatores associados à adesão e à persistência na hormonioterapia em mulheres com câncer de mama

RESUMO: Introdução: A hormonioterapia no câncer de mama é fundamental para a transição do tratamento ativo aos cuidados de sobrevivência, pois melhora significativamente os resultados de sobrevida em longo prazo, além de propiciar melhor qualidade de vida e reduzir os custos de hospitalização. Porém, para atingir resultados desejáveis, são importantes a adesão e a persistência no tratamento recomendado. Metodologia: Estudo de coorte retrospectivo com 182 mulheres em tratamento hormonal identificadas em unidade oncológica de alta complexidade da Região Sudeste do Brasil e acompanhadas até 2014. Foram realizadas análise bivariada, para investigar os fatores associados à adesão, e regressão multivariada de Cox, para identificar variáveis associadas à descontinuidade do tratamento ao longo do tempo. Resultados: A adesão geral foi de 85,2% e a persistência, de 45,4% após 5 anos. Não foi encontrada associação entre as variáveis independentes estudadas e a adesão. Mulheres com estadiamento avançado (hazard ratio - HR = 2,24; intervalo de confiança de 95% - IC95% 1,45 - 3,45), que não realizaram cirurgia (HR = 3,46; IC95% 2,00 - 5,97) e com 3 ou mais internações hospitalares (HR = 6,06; IC95% 2,53 - 14,54) exibiram maior risco de descontinuidade. Discussão: As variáveis associadas à persistência refletem a relação entre a maior gravidade da doença e a interrupção do tratamento hormonal adjuvante. Conclusão: Apesar da alta adesão, observa-se aumento progressivo do número de pacientes que não persistem no tratamento, devido a características relacionadas à gravidade da doença, contribuindo para uma resposta terapêutica inadequada.

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

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

Adherence to Adjuvant Endocrine Therapy in Christchurch Women with Early Breast Cancer

AIMS

To assess adherence to adjuvant endocrine therapy by a real-world cohort of women in Christchurch and to determine any associated factors.

MATERIALS AND METHODS

Records were retrieved of all women newly diagnosed with early breast cancer and registered on the Christchurch Breast Cancer Patient Register over 4 years from June 2009. Demographic and pathological factors, dates of starting and stopping endocrine therapies and reported side-effects were collected. The proportion remaining on endocrine therapy was analysed by Kaplan-Meier curve; Cox regression analysis was used to identify independent factors influencing adherence.

RESULTS

Of 1213 women, 1018 (83.9%) had oestrogen receptor-positive tumours, of whom 674 (66.2%) started adjuvant endocrine therapy, including 62 (9.2%) neoadjuvantly. Uptake was 52.4% of those with T1 tumours, 89% with T2 tumours, 93% with T3/T4 tumours, 92.7% with node-positive tumours and 49.7% with node-negative tumours. The initial endocrine therapy was an aromatase inhibitor in 254 (38%) and tamoxifen for 412 (61%). At 1 year, 90% remained adherent, at 2 years 84%, at 3 years 81%, at 4 years 76%, at 4.5 years 71% and at 5 years 50%, with a median duration of 60 months (56-64 months, 95% confidence interval) and a median follow-up of 33 months. Overall, 135 (20%) women stopped treatment for adverse events or poor tolerability. A longer persistence with endocrine therapy was associated with node-positive tumours (hazard ratio 1.38, P = 0.003), but not first hormone used; aromatase inhibitor compared with tamoxifen, P = 0.76.

CONCLUSION

Adjuvant endocrine therapy use fell to 50% by 5 years, limiting possible survival benefits, providing support for efforts to increase compliance.

Factors Predicting Adherence to a Tailored-Dose Adjuvant Treatment on the Basis of Geriatric Assessment in Elderly People With Colorectal Cancer: A Prospective Study

BACKGROUND

Selecting elderly people with colorectal cancer (CRC) for adjuvant chemotherapy is challenging. Comprehensive geriatric assessment (CGA) can help by classifying them according to their frailty profile. The supposed benefit of chemotherapy is on the basis of the rate of treatment adherence. In this study we evaluated tolerance and adherence to tailored-dose adjuvant therapy on the basis of CGA in a cohort of older patients with high-risk stage II and stage III CRC.

PATIENTS AND METHODS

This was a prospective study in 193 consecutive patients aged 75 years or older. On the basis of CGA results, we classified patients as fit, medium fit, or unfit, administering standard therapy, adjusted treatment, and best supportive care, respectively. We recorded planned chemotherapy, toxicity, and completion of the treatment. A logistic multivariate analysis was carried out.

RESULTS

Seventeen (15%) of the 141 candidates for chemotherapy (n = 86 fit and n = 55 medium fit) refused treatment; associated factors included polypharmacy (odds ratio [OR], 5.34; 95% confidence interval [CI], 1.55-18.40) and rectal location (OR, 5.61; 94% CI, 1.45-21.49). Of the 105 (74%) patients receiving chemotherapy, 20 (27%) fit and 4 (13%) medium fit patients experienced Grade 3 to 4 toxicity (P = .11) without association to explanatory variables. Approximately 55% of patients treated with chemotherapy received at least 80% of the planned dose (55% fit and 58% medium fit patients; P = .7). Factors associated with completion of chemotherapy were the absence of toxicity (OR, 7.67; 95% CI, 2.41-24.43) and social support (OR, 2.29; 95% CI, 0.08-1.04).

CONCLUSION

CGA is useful for selecting elderly patients for adjuvant chemotherapy, adapting the dose to their frailty profile, and identifying adherence-related factors amenable to modification through CGA-based interventions.

Self-Reported Adherence to Capecitabine on XELOX Treatment as Adjuvant Therapy for Colorectal Cancer

Adherence has become an important issue in modern oncology treatment. Most studies have included heterogeneous target tumor types, regimens, and therapy settings. Our study focused on capecitabine during capecitabine plus oxaliplatin (XELOX) treatment as an adjuvant therapy for colorectal cancer. The main aims of this study were to evaluate real-life adherence to capecitabine and to investigate candidate factors that might decrease adherence. We studied 338 consecutive patients who received XELOX treatment between December 1, 2011, and April 30, 2015, at the Cancer Institute Hospital of the Japanese Foundation for Cancer Research. Our study assessed adherence to capecitabine through patient-reported treatment diaries and interviewed nonadherents to determine the reasons for not taking capecitabine at a pharmaceutical outpatient clinic. We calculated the adherence rate in a cycle as: number of times the patient took capecitabine/28. Relative dose intensities and factors associated with deteriorating adherence to capecitabine were retrospectively surveyed from electronic patient records. Uni- and multivariate logistic regression analyses were used to investigate factors associated with optimal adherence. The study covered 282 patients who received 2,055 cycles of XELOX. Median adherence rate was 94.0% in the first cycle, and median relative dose intensity of capecitabine was 77.8%. The most common reasons for nonadherence were nausea/vomiting and diarrhea. The presence of the following factors was not significantly associated with adherence: ECOG performance status ≥1 (p = 0.715), clinical stage (p = 0.408), primary tumor site (p = 0.576), age ≥70 years at study entry (p = 0.757), female gender (p = 0.504), and not living alone (p = 0.579). The adherence rate from this study was significantly higher than the adherence from metastatic settings. Adherence-enhancing interventions for capecitabine in XELOX treatment as adjuvant therapy comprised management of nausea/vomiting and diarrhea.

Adherence to oral cancer therapy in older adults: The International Society of Geriatric Oncology (SIOG) taskforce recommendations

There is an increasing trend towards using oral systemic therapy in patients with cancer. Compared to parenteral therapy, oral cancer agents offer convenience, have similar efficacy, and are preferred by patients, consequently making its use appealing in older adults. However, adherence is required to ensure its efficacy and to avoid compromising treatment outcomes, especially when the treatment goal is curative, or in case of symptomatic/rapidly progressing disease, where dose-intensity is important. This opens a new challenge for clinicians, as optimizing patient adherence is challenging, particularly due to lack of consensus and scarcity of available clinical evidence. This manuscript aims to review the impact of age-related factors on adherence, summarize the evidence on adherence, recommend methods for selecting patients suitable for oral cancer agents, and advise monitoring interventions to promote adherence to treatment.

Assessment and measurement of medication adherence: oral agents for cancer

BACKGROUND

Clinicians are challenged to find ways to assess and measure adherence to oral agents for cancer (OACs).

OBJECTIVES

The purpose of this article is to report on available ways to assess and measure medication adherence by patients with cancer.

METHODS

Tools examined include the Morisky Medication Adherence Scale (MMAS) and the Adherence Estimator, which are able to predict risk of nonadherence. Adherence Starts With Knowledge (ASK®)-12 and the Brief Adherence Rating Scale (BARS) are likely to be effective for predicting nonadherence and measuring adherence rates.

FINDINGS

Additional research needs to focus on the testing of reliable and valid tools that are sensitive and specific to patients with cancer who are prescribed OACs. The authors found that the MMAS and Adherence Estimator tools may be useful at predicting risk of medication nonadherence, and the ASK-12 and BARS may be useful for measuring rates of adherence. Tools could be modified to a specific clinical setting and used in a standardized format so that nurses can assess risk of medication nonadherence and measure adherence rates of OACs.

Factors influencing oral adherence: qualitative metasummary and triangulation with quantitative evidence

BACKGROUND

Concern about adherence to oral agents among patients with cancer has grown as more oral agents are being used for cancer treatment. Knowledge of common factors that facilitate or inhibit adherence to oral medication regimens can be beneficial to clinicians in identifying patients at risk for nonadherence, in planning care to address barriers to adherence, and in educating patients about ways to improve adherence.

OBJECTIVES

The focus of this review is to synthesize the evidence about factors that influence adherence and identify implications for practice.

METHODS

Literature was searched via PubMed and CINAHL®. Evidence regarding factors influencing adherence was synthesized using a metasummary of qualitative research and triangulated with findings from quantitative research.

FINDINGS

Forty-four factors influencing adherence were identified from 159 research studies of patients with and without cancer. Factors associated with adherence in oncology and non-oncology cases included provider relations, side effects, forgetfulness, beliefs about medication necessity, establishing routines for taking medication, social support, ability to fit medications in lifestyle, cost, and medication knowledge. Among patients with cancer, depression and negative expectations of results also were shown to have a negative relationship to adherence.

Barriers and facilitators of adjuvant hormone therapy adherence and persistence in women with breast cancer: a systematic review

PURPOSE

Nonadherence to hormone therapy in breast cancer survivors is common and associated with increased risk of mortality. Consistent predictors of nonadherence and nonpersistence are yet to be identified, and little research has examined psychosocial factors that may be amenable to change through intervention. This review aimed to identify predictors of nonadherence and nonpersistence to hormone therapy in breast cancer survivors in order to inform development of an intervention to increase adherence rates.

METHODS

Studies published up to April 2016 were identified through MEDLINE, Embase, Web of Science, PsycINFO, CINAHL and gray literature. Studies published in English measuring associations between adherence or persistence and any predictor variables were included. Eligible studies were assessed for methodological quality, data were extracted and a narrative synthesis was conducted.

RESULTS

Sixty-one eligible articles were identified. Most studies focused on clinical and demographic factors with inconsistent results. Some evidence suggested that receiving specialist care and social support were related to increased persistence, younger age and increased number of hospitalizations were associated with nonadherence, and good patient-physician relationship and self-efficacy for taking medication were associated with better adherence. A small amount of evidence suggested that medication beliefs were associated with adherence, but more high-quality research is needed to confirm this.

CONCLUSION

Some psychosocial variables were associated with better adherence and persistence, but the results are currently tentative. Future high-quality research should be carried out to identify psychosocial determinants of nonadherence or nonpersistence that are modifiable through intervention.

Treatment Adherence and Its Impact on Disease-Free Survival in the Breast International Group 1-98 Trial of Tamoxifen and Letrozole, Alone and in Sequence

PURPOSE

To investigate adherence to endocrine treatment and its relationship with disease-free survival (DFS) in the Breast International Group (BIG) 1-98 clinical trial.

METHODS

The BIG 1-98 trial is a double-blind trial that randomly assigned 6,193 postmenopausal women with hormone receptor-positive early breast cancer in the four-arm option to 5 years of tamoxifen (Tam), letrozole (Let), or the agents in sequence (Let-Tam, Tam-Let). This analysis included 6,144 women who received at least one dose of study treatment. Conditional landmark analyses and marginal structural Cox proportional hazards models were used to evaluate the relationship between DFS and treatment adherence (persistence [duration] and compliance with dosage). Competing risks regression was used to assess demographic, disease, and treatment characteristics of the women who stopped treatment early because of adverse events.

RESULTS

Both aspects of low adherence (early cessation of letrozole and a compliance score of < 90%) were associated with reduced DFS (multivariable model hazard ratio, 1.45; 95% CI, 1.09 to 1.93; P = .01; and multivariable model hazard ratio, 1.61; 95% CI, 1.08 to 2.38; P = .02, respectively). Sequential treatments were associated with higher rates of nonpersistence (Tam-Let, 20.8%; Let-Tam, 20.3%; Tam 16.9%; Let 17.6%). Adverse events were the reason for most trial treatment early discontinuations (82.7%). Apart from sequential treatment assignment, reduced adherence was associated with older age, smoking, node negativity, or prior thromboembolic event.

CONCLUSION

Both persistence and compliance are associated with DFS. Toxicity management and, for sequential treatments, patient and physician awareness, may improve adherence.

Concordance between two methods in measuring treatment adherence in patients with type 2 diabetes

OBJECTIVE

We analyzed the concordance between two methods for measuring treatment adherence (TA) and studied the determinants of TA in patients with type 2 diabetes mellitus.

METHODS

We conducted a cross-sectional descriptive study in a primary care center, involving 320 diabetic patients. TA was measured using the Haynes-Sackett (H-S) adherence test during the patient interview and based on pharmacy refill data. TA was calculated globally and by drug groups (antihypertensive, lipid-lowering, and antidiabetic drugs).

RESULTS

Poor TA as measured by the H-S test was observed in 11.2% of the patients. Based on pharmacy refill data, there was a poor global TA rate of 30.3%, which was 33.3%, 26.6%, and 34.2% for oral antidiabetic, antihypertensive, and lipid-lowering drugs, respectively. Concordance between the two methods was poor. There was no relationship between the degree of disease control and TA as measured by the H-S test. Good TA measured based on pharmacy refill data for antidiabetic and antihypertensive drugs was associated with lower glycosylated hemoglobin and diastolic blood pressure values, respectively. Patients with good global TA showed lower glycosylated hemoglobin, diastolic blood pressure, and low-density lipoprotein cholesterol values. The multivariate analysis found good oral antidiabetic adherence to be associated to free pharmacy service; good antihypertensive drug adherence to the existence of comorbidities; and good lipid-lowering drug adherence to a history of ischemic heart disease, and a more experienced physician and/or female physician.

CONCLUSION

Concordance between the two methods in assessing TA was low. Approximately one-third of the patients with type 2 diabetes mellitus presented poor TA in relation to antihypertensive, lipid-lowering, and antidiabetic medication. An improved TA was associated with a better control of the studied parameters. Comorbidities, such as ischemic heart disease and access to free pharmacy service, were identified as determinants of good TA.

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

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

A Systematic Review of Adherence to Oral Antineoplastic Therapies

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.

Utility of the Morisky Medication Adherence Scale in gout: a prospective study

BACKGROUND

The outcomes of any chronic illness often depend on patients' adherence with their treatment. A tool is lacking to assess adherence in gout that is standardized, allows real-time feedback, and is easy to understand.

OBJECTIVE

We set out to evaluate the utility of the 8-item Morisky Medication Adherence Scale (MMAS-8) in monitoring medication adherence in a multiethnic Asian gout cohort on urate-lowering therapy (ULT).

METHODS

This cohort study recruited patients with gout where baseline and 6-monthly clinical data, self-report of adherence, and health status by Gout Impact Scale (GIS) and EuroQoL-5 dimension 3 levels were collected. Those who received at least 9 months of ULT were analyzed. Convergent and construct validities of MMAS-8 were evaluated against medication possession ratio (MPR) and known groups, clinical outcomes, and patient-reported outcomes. Internal consistency and test-retest reliability were assessed using Cronbach's alpha and intraclass correlation coefficient (ICC), respectively.

RESULTS

Of 91 patients, 92.3% were male, 72.5% Chinese with mean age 53.5 years. MMAS-8 (mean 6.17) and MPR (mean 96.3%) were poorly correlated (r=0.069, P=0.521). MMAS-8 did not differ between those who did or did not achieve target serum urate (SU) <360 µmol/L (P=0.852); or among those whose SU improved, stagnated, or worsened during follow-up (P=0.777). Adherence was associated with age (β=0.256, P=0.015) and education level (P=0.011) but not comorbidities, polypharmacy, or flare frequency. Concerns for medication side effects and anxiety or depression were associated with lower MMAS-8 (P<0.005). Internal consistency was acceptable (α=0.725) and test-retest reliability was satisfactory (ICC =0.70, 95% confidence interval [CI] 0.36-0.88).

CONCLUSION

MMAS-8 had limited construct validity in assessing medication adherence to ULT in our gout patients. Nevertheless, it identified patients bothered or worried about ULT side effects, and those with underlying anxiety or depression, for whom targeted education and coping support may be useful.

Skeletal adverse effects with aromatase inhibitors in early breast cancer: evidence to date and clinical guidance

Aromatase inhibitors (AIs) are routinely used in the adjuvant treatment of women with hormone receptor-positive early breast cancer. Patients who receive AIs have an increased risk of bone loss and arthralgia compared with those treated with tamoxifen. In addition to the effects of AIs, the population of women with early breast cancer has a high prevalence of 25-hydroxyvitamin D (25(OH)D) insufficiency. In our experience 88% of patients had concentrations lower than 30 ng/ml. Vitamin D supplementation should be adapted to the baseline concentration. Another relevant finding in our research program was the close relationship between 25(OH)D levels and intensity of AI-related arthralgia (AIrA). A target concentration of 40 ng/ml 25(OH)D may prevent development of AIrA. We also demonstrate that AIrA is genetically determined: single nucleotide polymorphisms located in genes encoding key factors for the metabolism of estrogens and vitamin D (CYP17A1, VDR, and CYP27B1) are associated with self-reported arthralgia during AI therapy. We recommend establishing an individualized protocol of bone-health surveillance based on baseline and evolutionary clinical variables.

Comparative adherence to oral hormonal agents in older women with breast cancer

We aim to (1) compare compliance of anastrozole, letrozole, exemestane, and tamoxifen in women and (2) identify clinical factors associated with medication non-adherence and non-persistence. Female Medicare beneficiaries who were new users of anastrozole, letrozole, exemestane, or tamoxifen between 2007 and 2010 were analyzed. Multivariate-modified Poisson and Cox regression models were constructed to compare non-adherence and non-persistence, respectively, across the different oral agents. A total of 5,150 women were included: mean age was 76.4 years, 2352 initiated anastrozole, 1401 letrozole, 248 exemestane, and 1149 tamoxifen. Non-adherence and non-persistence were 41 and 49% respectively, with exemestane being associated with the worst non-adherence and non-persistence (RR 1.57, 95% CI 1.37-1.80, p < 0.001; HR 1.93, 95% CI 1.63-2.30, respectively, p < 0.001), followed by letrozole (RR 1.39, 95% CI 1.26-1.53, p < 0.001; HR 1.47, 95% CI 1.32-1.64, respectively, p < 0.001), and anastrozole (RR 1.16, 95% CI 1.05-1.27, p = 0.003; HR 1.14, 95%CI 1.03-1.27, respectively, p = 0.011), whereas tamoxifen was associated with the best compliance. Use of statins and osteoporosis medications was correlated with improved adherence (RR 0.89, 95 % CI 0.82-0.96, p = 0.002 and RR 0.84, 95 % CI 0.76-0.92, p < 0.001, respectively, for non-adherence) and persistence (HR 0.86, 95 % CI 0.79-0.94, p < 0.001 and HR 0.86, 95 % CI 0.78-0.96, p = 0.005, respectively, for non-persistence), but chronic kidney disease was correlated with worse non-persistence (HR 1.15, 95 % CI 1.04-1.33, p = 0.04). Age ≥ 70 years was also associated with worse compliance. Compliance to oral hormonal therapy varied depending on the type of agent, age, and concurrent medications, highlighting specific opportunities to improve adherence and persistence in older women with breast cancer.

Population-based analysis of the impact and generalizability of the NSABP-B24 study on endocrine therapy for patients with ductal carcinoma in situ of the breast

BACKGROUND

In 1999, the National Surgical Adjuvant Breast and Bowel Project (NSABP)-B24 trial demonstrated that tamoxifen reduced relapse risk in women with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS) and radiotherapy (RT). In 2002, Allred's subgroup analysis showed that tamoxifen mainly benefitted estrogen receptor (ER)-positive disease. This study evaluates the impact and generalizability of these trial findings at the population level.

PATIENTS AND METHODS

From 1989 to 2009, 2061 women with DCIS underwent BCS + RT in British Columbia. The following cohorts were analyzed: (1) pre-NSABP-B24 era (1989-1998, N = 417); (2) post-NSABP-B24 era (2000-2009, N = 1548). Cohort 2 was further divided into pre- and post-Allred eras.

RESULTS

Endocrine therapy (ET) was used in 404/2061 (20%) patients. Median age of patients treated with compared with without ET, was 53 versus 57 years, (P < 0.0005). One of 417 (0.2%) versus 399/1548 (26%) patients took ET before versus after NSABP-B24. Among the post-Allred era cohort treated with ET (N = 227), tumors were ER-positive in 65%, ER-negative in 1%, and ER-unknown in 33%; whereas of those treated without ET (N = 801), ER was positive in 43%, negative in 15%, and unknown in 42% (P < 0.0005). On multivariable analysis of the post-NSABP-B24 era, ET was associated with improved event-free survival (EFS) (hazard ratio 0.6; P = 0.02); 5-year EFS were 96.9% with ET versus 94.5% without ET.

CONCLUSIONS

ET use in DCIS patients treated with BCS + RT increased significantly after the NSABP-B24 study. ER+ disease and younger age were associated with increased ET use. ET was associated with improved EFS, confirming the generalizability of trial data at a population level.

Identifying the determinants of adjuvant hormonal therapy medication taking behaviour in women with stages I-III breast cancer: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to identify the modifiable determinants of adjuvant hormonal therapy medication taking behaviour (MTB) in women with stage I-III breast cancer in clinical practice settings.

METHODS

We searched PubMed EMBASE, PsycINFO and CINAHL for articles investigating determinants of adjuvant hormonal therapy. Potentially modifiable determinants were identified and mapped to the 14 domains of the Theoretical Domains Framework (TDF), an integrative framework of theories of behavioural change. Meta-analysis was used to calculate pooled odds ratios for selected determinants.

RESULTS

Potentially modifiable determinants were identified in 42 studies and mapped to 9 TDF domains. In meta-analysis treatment side-effects (Domain: Beliefs about Capabilities) and follow-up care with a general practitioner (vs. oncologist) (Social Influences) were significantly negatively associated with persistence (p<0.001) and number of medications (Behaviour Regulation) was significantly positively associated with persistence (p<0.003). Studies did not examine several domains (including Beliefs about Consequences, Intentions, Goals, Social Identity, Emotion and Knowledge) which have been reported to influence MTB in other disease groups.

CONCLUSIONS

There is some evidence that the domains Beliefs about Capabilities, Behaviour Regulation and Social Influences influence hormonal therapy MTB.

PRACTICE IMPLICATIONS

Further research is needed to develop effective interventions to improve hormonal therapy MTB.

Endocrine therapy adherence: a cross-sectional study of factors affecting adherence and discontinuation of therapy

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.

Rethinking agency and medical adherence technology: applying Actor Network Theory to the case study of Digital Pills

Much literature surrounding medical technology and adherence posits that technology is a mechanism for social control. This assumes that the medical establishment can take away patients' agency. Although power relationships and social control can play a key role, medical technology can also serve as an agentive tool to be utilized. We (1) offer the alternative framework of Actor Network Theory to view medical technology, (2) discuss the literature on medication adherence and technology, (3) delve into the ramifications of looking at adherence as a network and (4) use Digital Pills as a case study of dispersed agency.

Patients' self-reported adherence to capecitabine on XELOX treatment in metastatic colorectal cancer: findings from a retrospective cohort analysis

BACKGROUND

Capecitabine plus oxaliplatin (XELOX) has been established as a first-line treatment for metastatic colorectal cancer. Adherence is particularly important with capecitabine to maintain appropriate curative effect. In this study, we monitored the adherence to capecitabine on XELOX treatment and investigated which factors might decrease compliance.

METHODS

The study included 242 consecutive patients who received XELOX treatment for metastatic colorectal cancer between October 2009 and March 2012. Adherence to capecitabine was checked by pharmacists with a patient-reported treatment diary at a pharmaceutical outpatient clinic. Adherence rate was defined as the number of times that a patient took capecitabine in a 14-day cycle/28 prescribed doses. We retrospectively surveyed median relative dose intensities of capecitabine and the factors deteriorating adherence across eight cycles from electronic patient records and examined differences in compliance rates according to age.

RESULTS

The study included 144 male and 98 female patients. The overadherence rate was 1.5% (n=23). The median adherence rate was 93.5% (n=242) in the first cycle of XELOX treatment, which gradually rose to 96.1% (n=148) in the eighth cycle. The median relative dose intensity of capecitabine was 79.2%. The main factors contributing to decreased adherence to capecitabine were diarrhea (22.5%, 352 instances) and nausea/vomiting (13.8%, 215 instances). The rate of missed dose was 12.1%. Analysis of adherence issues in relation to patient age showed a trend toward worse adherence to capecitabine therapy in the group of patients aged ≥80 years (hazard ratio =3.83; 95% confidence interval 2.48-5.91, P<0.001 versus 70-80 years group and versus <70 years group, chi-square test).

CONCLUSION

Patient-reported adherence to capecitabine on XELOX treatment in clinical practice is high but adversely affected by side effects. Patients aged 80 years or more exhibit a significant decrease in compliance compared with younger patients.

Adherence and patients' attitudes to oral anticancer drugs: a prospective series of 201 patients focusing on targeted therapies

OBJECTIVES

Patient adherence is a challenge in oncology and hematology practice. Hormone therapy data in breast cancer suggest insufficient adherence and poor persistence. Limited data are available for targeted therapies (TT) including tyrosine kinase and mammalian target of rapamycin inhibitors.

METHODS

We performed a prospective survey using a 15-item questionnaire in patients with solid tumors and hematologic malignancies receiving oral anticancer therapy. Treatment duration, setting (adjuvant vs. metastatic), cancer type, age, and comedication were recorded.

RESULTS

201 patients (median age 65.5 years) participated, 102 with TT and 99 with hormone therapy or chemotherapy (HC). The median time of drug intake was 11.0 months. Written information was more frequently given to TT patients (68.6 vs. 23.2%, p < 0.0001). TT and HC patients showed equal adherence to therapy (72.5 vs. 69.6%, p = n.s.) despite TT patients experiencing more side effects (p < 0.0001) and taking more concomitant oral medication (p = 0.0042). Forgotten doses were the leading cause of nonadherence in HC patients (83%, as compared to 54% in the TT group), whereas dose reduction by the patient was higher in the TT group (32 vs. 17%).

CONCLUSIONS

Despite advances in providing information to patients leading to better adherence among TT patients, efforts towards better patient education are warranted including dedicated staff for monitoring outpatient anticancer oral therapy.

Interventions for adherence with oral chemotherapy in hematological malignancies: A systematic review

BACKGROUND

Poor adherence to treatment for chronic diseases including some hematological malignancies impedes health outcomes and increases costs. Oral chemotherapy is an emerging trend that raises concern about nonadherence problems in these targeted patients.

OBJECTIVES

This systematic literature review explores evidence and gaps in the literature regarding interventions to enhance adherence with prescribed oral chemotherapy in patients with hematological malignancies.

METHODS

Searches of databases and abstracts from conferences were performed for 1987 to January 2013 using a modified Cochrane method. Studies measuring interventions to improve adherence alone or together with clinical, humanistic, and economic outcomes were included. Assessment of methodological quality was performed for each retained study.

RESULTS

The literature search generated 6 studies that met inclusion criteria. Four of these reported a statistically significant increase in the adherence outcome, compared with baseline. Tailored and educational interventions were widely used among the retained studies. Post-intervention adherence rates were 41-96.1%; intervention groups yielded higher rates than comparison groups. Two studies reported statistically significant improvement in clinical outcomes (cytogenetic response and survival time). One study reported that severity of illness was associated with survival time but not with adherence. Studies that used both tailored and educational interventions showed significant relationship between adherence and clinical outcomes; however, the study that used dosage simplification did not. None of the studies explored humanistic or economic outcomes.

CONCLUSIONS

Interventions to improve adherence with oral chemotherapies in hematological malignancies remain limited. Though they were heterogeneous in nature, interventions tested in the retained studies suggested a positive impact on the adherence outcome; some established a significant relationship between adherence and clinical outcomes. The results yielded limited evidences regarding characteristics of a specific intervention, but supported a general structure for methods to improve adherence and other outcomes in real-life settings. Further rigorous methodological studies are needed to fully examine impact on adherence and clinical outcomes.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Low adherence to upfront and extended adjuvant letrozole therapy among early breast cancer patients in a clinical practice setting

OBJECTIVE

The aim of this study was to investigate the prevalence and causes of early discontinuation and non-adherence to upfront and extended adjuvant letrozole therapy in breast cancer patients.

METHODS

Adherence was assessed using medical charts and longitudinal pharmacy records of 609 patients who initiated adjuvant letrozole between January 2002 and April 2011. A Cox proportional hazards regression model was adopted to identify potential predictors of non-adherence.

RESULTS

The overall adherence rate after 1 year of therapy was 79.5%, with cumulative rates declining to 63.7% after 3 years and 57.1% after 5 years. A significantly lower rate of adherence in the extended adjuvant group was observed compared with the upfront adjuvant group (49.0 vs. 72.5%, p < 0.001). Adverse events (50.4%) were the major cause of early discontinuation, with musculoskeletal pain (73.2%) being the single most cited reason. Additional factors correlating with non-adherence in the upfront adjuvant group included a delay in initiation of adjuvant hormone therapy, breast-conserving surgery, calcium supplements, bisphosphonate therapy and concomitant medication for co-morbidity.

CONCLUSIONS

We observed that approximately 57% of patients fully adhered to letrozole therapy over a 5-year treatment period, and that the adherence to extended letrozole was meaningfully lower than the upfront adjuvant letrozole in a clinical practice setting.

Current nursing practice for patients on oral chemotherapy: a multicenter survey in Japan

BACKGROUND

With a paradigm shift toward a chronic care model in cancer, the issue of adherence is becoming increasingly important in oncology.

METHODS

We mailed two self-reported surveys on current nursing practices for patients on oral chemotherapy to all 309 designated cancer centers and 141 large general hospitals in Japan. The first survey was based on a nurse-based questionnaire containing 40 items concerning nurse's characteristics, nurse staffing at workplace, general nursing care for new patients on oral chemotherapy and those with refilled prescriptions, follow-up, and system-based approach. The second survey was based on a patient-based questionnaire containing 10 items about patient characteristics and adherence-related nursing practice for 249 patients taking oral chemotherapy of 903 systematically sampled. We used multivariate logistic regression to identify factors that were associated with adherence-related nursing practices.

RESULTS

A total of 62 nurses (mean age: 41.5 years) from 62 hospitals who consented participated in the both nurse-based survey and patient-based survey about 249 patients. The results of nurse-based survey indicated that practices varied, but nurses were less likely to ask adherence-related questions of patients with refilled prescriptions than of new patients. The results of patient-based survey found that questions on side effects, discussions about barriers to achieving balance between treatment and daily life activities, and medication management were all significantly related to the question about unused medicines. Logistic regression revealed that adherence-related nursing practices were associated with the nurse's background, type of treatment, and healthcare system-related factors. Patient orientation on oral chemotherapy, interdisciplinary learning, and having a system-based approach for detecting prescription errors were identified as healthcare system-related factors.

CONCLUSIONS

A more systematic approach must be developed to ensure patients receive safe and effective oral chemotherapy, while nurses should play significant roles in patient education and monitoring.