Adherence to adjuvant endocrine therapy in estrogen receptor-positive breast cancer patients with regular follow-up

Psychosomatic mechanisms of heart failure symptoms on quality of life in patients with chronic heart failure: A multi-centre cross-sectional study

AIMS

To determine the contributions of different kinds of symptoms to the quality of life and mediating effect of psychological and physical symptoms between heart failure symptoms and quality of life.

DESIGN

A multi-centre cross-sectional study.

METHODS

2006 chronic heart failure patients from four cities were recruited in China from January 2021 to December 2022. Patients' symptoms and quality of life were self-reported, and data were analysed using correlation analysis, dominance analysis and mediating effects analysis.

RESULTS

The dominance analysis revealed that the overall mean contributions of heart failure, psychological and physical symptoms were .083, .085 and .111; 29.5%, 30.2% and 39.5% of the known variance. And heart failure symptoms could negatively affect quality of life through psychological and physical symptoms, accounting for 28.39% and 22.95% of the total effect. Heart failure symptoms could also affect quality of life through the chain-mediated effect of physical and psychological symptoms, accounting for 16.74%.

CONCLUSIONS

Physiological symptoms had the strongest effect on quality of life and heart failure symptoms had the weakest. Most of the effect for heart failure symptoms on quality of life in chronic heart failure patients was mediated by psychological and physiological symptoms.

RELEVANCE TO CLINICAL PRACTICE

It is important to design non-pharmacological intervention plans for the enhancement of physical and psychological symptoms' management skills, to reduce the adverse impact of heart failure symptoms on quality of life.

REPORTING METHOD

Study methods and results reported in adherence to the STROBE checklist.

NO PATIENT OR PUBLIC CONTRIBUTION

No patients or members of the public were involved in the study.

Relations Between Posttraumatic Growth and Fear of Progression Among Young and Middle-Aged Primary Brain Tumor Patients: The Parallel Mediating Role of Perceived Social Support and Illness Uncertainty

OBJECTIVE

This study aimed to investigate the mediating role of perceived social support and illness uncertainty in posttraumatic growth (PTG) and fear of progression (FoP) among young and middle-aged primary brain tumor (PBT) patients.

METHODS

A total of 252 young and middle-aged benign PBT patients were investigated. Data were collected by using self-designed general and disease-related data questionnaires, PTG Inventory, FoP Questinaire-Short Form, Mischel Uncertainty in Illness Scale, and Perceived Social Support Scale. Parallel mediation effect models were used to explore the relationship between PTG and FoP mediation effects. Bootstrap analysis was conducted to examine the mediation effect of PTG on FoP.

RESULTS

The total FoP and PTG scores were 35.15 ± 4.85 and 55.04 ± 7.86. Furthermore, mediation effect analyses revealed that perceived social support and illness uncertainty were partially associated with the mediated relationship between PTG and FoP. (std.β = -0.026, P-value = 0.001, std. β = -0.393, P value ＜0.001, respectively).

CONCLUSIONS

Illness uncertainty and perceived social support were identified as partially parallel mediators between PTG and FoP. Thus, we should ensure adequate social support and improve the enthusiasm and input of family members for better patient recovery. Strengthening the nursing support, reducing the uncertainty of young and middle-aged PBT patients, and improving the patients' PTG can help reduce the fear of disease progression.

Stellate ganglion block with procaine in breast cancer survivors with hot flashes and sleep disturbances undergoing Endocrine Therapy

Breast cancer survivors under endocrine therapy (ET) suffer from side effects such as hot flashes and sleep disturbance accompanied by poor quality of life. Many quit ET early and reduce their survival rate. Guidelines recommend gabapentin next to yoga or acupuncture. The role of side effects related to compliance with ET over years require new and effective therapies. Stellate ganglion block (SGB) has shown evidence of safety and efficacy and was found to be more effective than pregabalin without side effects. However, practical guidelines for the long-term use of SGB are still missing. We primarily used procaine instead of bupivacaine presuming effectiveness paired with lower toxic risks. Twenty-nine breast cancer survivors with severe hot flashes and sleep disturbance under ET received SGB with Procaine. Diaries recorded hot flashes and sleep quality scores up to week 24. All patients took part and none refused SGB. Each Patient received one SGB every 4 weeks without any side effects observed. Weekly scores were reduced from baseline by -33.6% (P < .01) (hot flashes) and -22.3% (P < .01) (sleep disturbances) after 4, and by -58.8% (P < .01) (hot flashes) and -50.8% (P < .01) (sleep disturbances) after twenty-for weeks. A wavelike reduction indicated a limited effect of a single SGB during continuous ET. We showed, that procaine in SGB is as effective as bupivacaine with lower risks and costs. High significant reductions in hot flashes and sleep disturbances after 1 and 6 months were found. We conclude that breast cancer survivors need individual treatment with SGB due to her personal impact. Hence, SGB should find its way to guidelines and daily routines as a valuable method for treating side effects in breast cancer survivors undergoing ET.

Exploring adherence in patients with advanced breast cancer: focus on CDK4/6 inhibitors

Treatment adherence is crucial for optimal outcomes in advanced breast cancer, but can be challenging due to various factors, i.e. patients' attitudes and behavior upon diagnosis, and complex therapies with high adverse effect rates. Our aim was to explore the adherence to oral anticancer medications (OAM) in women with advanced breast cancer, focusing on cyclin-dependent kinase 4 and 6 inhibitors (CDKI), and identify factors associated with the adherence. We conducted a cross-sectional study at the University Hospital Centre Zagreb, Croatia, involving women with stage IV advanced breast cancer receiving OAM. Data collection included a questionnaire assessing socio-demographic and clinical information, Beck Depression Inventory-II for depressive symptoms, Medication Adherence Report Scale (MARS-5) for adherence to OAM, and Beliefs about Medicines Questionnaire. Plasma concentrations of CDKI were confirmed by LC-MS/MS in three randomly selected participants. A total of 89 women were included. The most prescribed OAMs were anti-estrogen (71.3 %) and CDKI (60.9 %). MARS-5 scores (mean: 24.1 ± 1.6) correlated with CDKI plasma concentrations. Forgetfulness was the primary reason for non-adherence (25.9 %). Women receiving CDKI (p = 0.018), without depressive symptomatology (p = 0.043), and with more positive beliefs about medicines were more adherent (p < 0.05). This study enhances understanding of medication adherence in advanced breast cancer and identifies influential factors.

The effect of health literacy, self-efficacy, social support and fear of disease progression on the health-related quality of life of patients with cancer in China: a structural equation model

BACKGROUND

Health literacy (HL), self-efficacy (SE), social support (SS) and fear of disease progression (FOP) are all important factors affecting health-related quality of life (HRQoL) in cancer patients. However, their synergistic effects and underlying mechanisms on HRQoL in cancer patients remain unclear. Therefore, the purpose of this study was to construct a structural equation model (SEM) to explore the underlying mechanism of factors affecting HRQoL. It is hoped that this study will provide a theoretical basis for future interventions.

METHODS

A cross-sectional design and convenience sampling method were used to investigate cancer inpatients in two general hospitals in Chongqing and Chengdu. Data were collected using structured scales, including HL, SE, SS, FOP and HRQoL. Finally, the SEM was constructed, and P ≤ 0.05 was considered significant.

RESULTS

There were 1749 participants included in this study. Correlation analysis showed that all variables were significantly correlated with one another except for symptoms, physical health (PD) and social family (SF) (p < 0.01). The SEM of the HRQoL had a good overall fit (GFI = 0.943, AGFI = 0.917, NFI = 0.950, RFI = 0.936, CFI = 0.955, IFI = 0.955, RMSEA = 0.072). The model indicated that HL had the strongest correlation with HRQoL (β = 0.398, p < 0.01), followed by FOP (β = -0.364, p < 0.01), SE (β = 0.347, p < 0.01) and SS (β = 0.184, p < 0.01).

CONCLUSIONS

The HRQoL of cancer patients is correlated with HL, SS, SE and FOP. HL can directly affect HRQoL and mediate HRQoL through SS and SE. Future programs should consider HL promotion, SE improvement and SS expansion as the breakthrough point when designing targeted intervention strategies. At the same time, the importance of the impact of FOP on the HRQoL of patients with cancer should not be ignored.

A Review of Endocrine Therapy in Early-stage Breast Cancer: The Journey From Crudeness to Precision

Endocrine therapy (ET) is the standard of care for hormone receptor-positive early-stage breast cancer in the adjuvant setting. However, response to ET can vary across patient subgroups. Historically, hormone receptor expression and clinical stage are the main predictors of the benefit of ET. A "window of opportunity" trials has raised significant interest in recent years as a means of assessing the sensitivity of a patient's cancer to short-term neoadjuvant ET, which provides important prognostic information, and helps in decision-making regarding treatment options in a time-efficient and cost-efficient manner. In the era of genomics, molecular profiling has led to the discovery and evaluation of the prognostic and predictive abilities of new molecular profiles. To realize the goal of personalized medicine, we are in urgent need to explore reliable biomarkers or genomic signatures to accurately predict the clinical response and long-term outcomes associated with ET. Validation of these biomarkers as reliable surrogate endpoints can also lead to a revolution in the clinical trial designs, and potentially avoid the need for repeated tissue biopsies in the surveillance of disease response. The clinical potential of tumor genomic profiling marks the beginning of a new era of precision medicine in breast cancer treatment.

Treatment-related side effects among Hispanic and non-Hispanic white long-term breast cancer survivors by tamoxifen use and duration

PURPOSE

To determine the associations between ethnicity, age at diagnosis, obesity, multimorbidity, and odds of experiencing breast cancer (BC) treatment-related side effects among long-term Hispanic and non-Hispanic white (NHW) survivors from New Mexico and explore differences by tamoxifen use.

METHODS

Lifestyle and clinical information including self-reported tamoxifen use and presence of treatment- related side effects were collected at follow-up interviews (12-15 years) for 194 BC survivors. Multivariable logistic regression models were used to examine associations between predictors and odds of experiencing side effects overall and by tamoxifen use.

RESULTS

Women ranged in age at diagnosis (30-74, M = 49.3, SD = 9.37), most were NHW (65.4%) and had in-situ or localized BC (63.4%). Less than half reportedly used tamoxifen (44.3%), of which 59.3% reported using > 5 years. Overall, survivors who were overweight/obese at follow-up were 5.42 times more likely to experience treatment-related pain (95% CI 1.40-21.0) compared to normal weight survivors. Survivors with multimorbidity, compared to survivors without, were more likely to report treatment-related sexual health issues (aOR 6.90, 95% CI 1.43-33.2) and poorer mental health (aOR 4.51, 95% CI 1.06-19.1). The statistical interactions between ethnicity and overweight/obese with tamoxifen use were significant (p-interaction < 0.05) for treatment-related sexual health issues.

CONCLUSION

Our results demonstrate that survivors with overweightness/obesity or multimorbidity may be more likely to experience BC treatment-related side effects. Tamoxifen use modifies associations between ethnicity, being overweight/obese, and sexual health issues following treatment. The likelihood of experiencing treatment-related side effects were more favorable for those on tamoxifen or those who had used tamoxifen for longer durations. These findings highlight the importance of fostering side effect awareness and applying appropriate interventions to assist with disease management throughout BC survivorship care.

Adherence to adjuvant hormonal therapy in localised breast cancer

BACKGROUND

Hormonal therapies are the cornerstone of systemic adjuvant treatment of oestrogen receptor (ER) positive breast cancer. The full benefit of this treatment is obtained with long-term adherence. However, discontinuation of hormonal therapy is common. Factors associated with non-compliance to therapy are complex and worth of detailed evaluation.

PATIENTS AND METHODS

A retrospective analysis of medical records of 284 early ER-positive breast cancer patients prescribed adjuvant hormonal therapy during a 5-year period in a single centre was undertaken. Characteristics of the patients and their disease as well as adherence to therapy and continuation at 1 and 3 years were recorded. The group of patients that were on treatment at 3 years and the group that had discontinued therapy before 3 years were compared to identify differences predicting lack of adherence.

RESULTS

The discontinuation rate of hormonal therapy at 1 year was 13%, and the discontinuation rate at 3 years was 21.2%. Patient age and menopause status were not associated with hormone therapy adherence at 3 years. The type of hormonal therapy (aromatase inhibitor or tamoxifen) was also not associated with adherence. In contrast, patients that received adjuvant chemotherapy before starting hormonal therapy had a higher adherence to hormonal therapy (86.9% at 3 years vs. 75.7% in patients that had not received adjuvant chemotherapy, χ² p = 0.04). Among co-morbidities, patients with a concomitant diagnosis of psychiatric disease at the time of breast cancer diagnosis were at increased risk of hormone therapy non-adherence. Progression-free survival and overall survival were inferior in the non-adherent group compared with the patients who continued their hormonal therapy at 3 years.

CONCLUSION

Adjuvant chemotherapy is associated with better subsequent adherence to hormonal therapy in early breast cancer patients. On the other hand, psychiatric co-morbidities are associated with worse adherence. De-escalation of adjuvant therapy guided by genomic tests leads to a significant percentage of early ER-positive breast cancer patients not receiving chemotherapy. Non-adherence to hormonal therapy would leave a subset of these patients with no adjuvant systemic therapy. The current results will guide efforts to increase compliance to hormonal therapies in specific groups of patients.

Medication Non-Adherence in Rheumatology, Oncology and Cardiology: A Review of the Literature of Risk Factors and Potential Interventions

Medication adherence is directly associated with health outcomes. Adherence has been reviewed extensively; however, most studies provide a narrow scope of the problem, covering a specific disease or treatment. This project's objective was to identify risk factors for non-adherence in the fields of rheumatology, oncology, and cardiology as well as potential interventions to improve adherence and their association with the risk factors. The project was developed in three phases and carried out by a Steering Committee made up of experts from the fields of rheumatology, oncology, cardiology, general medicine, and hospital and community pharmacy. In phase 1, a bibliographic review was performed, and the articles/reviews were classified according to the authors' level of confidence in the results and their clinical relevance. In phase 2, 20 risk factors for non-adherence were identified from these articles/reviews and agreed upon in Steering Committee meetings. In phase 3, potential interventions for improving adherence were also identified and agreed upon. The results obtained show that adherence is a dynamic concept that can change throughout the course of the disease, the treatments, and other factors. Educational interventions are the most studied ones and have the highest level of confidence in the authors' opinion. Information and education are essential to improve adherence in all patients.

Adherence to Hormonal Therapy in Breast Cancer Patients in Saudi Arabia: A Single-Center Study

Breast cancer is one of the most common types of cancer in women. Approximately three-quarters of all breast cancer patients have estrogen and/or progesterone receptor positivity. As a result, the majority of patients receive hormonal treatment for between five and 10 years. Long-term use of hormonal therapy reduces the recurrence rate and the risk of death. In Saudi patients, adherence to hormonal therapy is not adequately assessed. The primary objective of this study is to determine the clinical outcomes associated with hormonal therapy adherence in breast cancer patients.

This is a retrospective cohort study of patients who received adjuvant hormonal therapy for hormone-receptor-positive breast cancer. Patients were included if they had received at least two prescription refills following their breast cancer diagnosis. The primary outcome measure was mortality and disease progression in relation to hormonal therapy adherence. Progression of disease is defined as local recurrence or radiographic evidence of metastatic disease. The secondary outcome measure was the study population's adherence to hormonal therapy. The proportion of days covered during hormonal therapy was used to assess adherence (PDC). PDC was calculated as the number of days in the prescription period divided by the total number of days in the prescription period. Patients are considered adherent if their PDC value is greater than 0.8. The mortality and disease progression curves were generated using the Kaplan-Meier method. The proportion of patients adhering to hormonal therapy was determined using descriptive analysis. The IRB granted approval. A total of 121 patients were included in the study from the 380 patients screened. Tamoxifen, letrozole, and anastrozole were administered to 58%, 27%, and 14% of patients, respectively. The median age was 53 years. Women who were postmenopausal constituted 52.3% of the study population. The majority of patients were in Stages II and I (56.2% and 16.53%, respectively). The majority of the tumors were Grade II (58.68 %). Adherence was not associated with disease progression (HR, 0.66; 95% CI, 0.25-1.72) or mortality (HR, 1.391; 95 percent CI, 0.33-5.82). Disease progression and mortality were not found to be significantly associated with hormonal therapy adherence in this study. A larger study is required to confirm the findings of our study.

Assessment of compliance with hormonal therapy in early breast cancer patients with positive hormone receptor phenotype: A single institution study

Background

Adherence to long-term adjuvant hormonal therapy in hormonal receptors (HR)-positive breast cancer is really challenging and can affect the survival outcome. The present study aims to assess rate of compliance with hormonal therapy and possible predictive factors in a single institute in Saudi Arabia.

Patients &methods

We recruited patients with HR-positive breast cancer who presented to oncology outpatient clinics. Patients were assessed for compliance using a study questionnaire. Compliance was defined as taking ≥80% of prescribed doses of oral hormonal therapy. Different epidemiological, clinical, pathological and treatment data were checked in patients’ medical records and correlated with compliance/interruption of hormonal therapy.

Results

Among the 203 recruited patients, 95.1% were compliant with hormonal therapy, while it was interrupted in 16.7% of patients, and 58.1% reported missing intake of hormonal pills. Age >50 years, having permanent job and higher education level were significantly associated with non-compliance in univariate analysis. On multivariate analysis, job status was the only independent predictor of non-compliance. The following parameters were significantly related to hormonal therapy interruption: marital status (single: 28.8% vs married patients: 12.6%, p = 0.01) and residence location (Makkah: 11.7% vs. outside Makkah: 25.3%, p = 0.019), lymphovascular invasion (LVI) (No: 20.9%, Yes: 7.8%, p = 0.025) and N0 tumours (compared to node-positive patients, p = 0.008). On multivariate analysis, marital status, residence location and N-stage, maintained significance relation with hormonal therapy interruption.

Conclusion

Compliance with hormonal therapy was high in the study cohort. Marital status, residence location, job status and N-stage may be related to interruption/compliance with hormonal therapy.

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Compliance rate to adjuvant hormonal therapy was high in Saudi patients.

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Job status was significantly associated to hormonal therapy compliance.

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Marital status, residence location and N0-stage were linked with hormonal therapy interruption.

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Side effects were related to hormonal therapy interruption in a minority of patients.

OUP accepted manuscript

Introduction

Many women in rural Ethiopia do not receive adjuvant therapy following breast cancer surgery despite the majority being diagnosed with estrogen-receptor-positive breast cancer and tamoxifen being available in the country. We aimed to compare a breast nurse intervention to improve adherence to tamoxifen therapy for breast cancer patients.

Methods and Materials

The 8 hospitals were randomized to intervention and control sites. Between February 2018 and December 2019, patients with breast cancer were recruited after their initial surgery. The primary outcome of the study was adherence to tamoxifen therapy by evaluating 12-month medication-refill data with medication possession ratio (MPR) and using a simplified medication adherence scale (SMAQ) in a subjective assessment.

Results

A total of 162 patients were recruited (87 intervention and 75 control). Trained nurses delivered education and provided literacy material, gave additional empathetic counselling, phone call reminders, and monitoring of medication refill at the intervention hospitals. Adherence according to MPR at 12 months was high in both the intervention (90%) and control sites (79.3%) (P = .302). The SMAQ revealed that adherence at intervention sites was 70% compared with 44.8% in the control sites (P = .036) at 12 months. Persistence to therapy was found to be 91.2% in the intervention and 77.8% in the control sites during the one-year period (P = .010).

Conclusion

Breast nurses can improve cost-effective endocrine therapy adherence at peripheral hospitals in low-resource settings. We recommend such task sharing to overcome the shortage of oncologists and distances to central cancer centers.

Development of a Prognostic Application to Predict Survival for Chinese Women with Breast Cancer (Preprint)

Background

Objective

Methods

Results

Conclusions

Adherence to Newly Implemented Tamoxifen Therapy for Breast Cancer Patients in Rural Western Ethiopia

INTRODUCTION

Endocrine therapy for breast cancer (BC) patients is highly underutilized in rural Ethiopia and other African countries.

OBJECTIVE

This study aims to assess the feasibility of and adherence to tamoxifen therapy in rural Ethiopia.

METHODS

We ascertained the hormone receptor (HR) status in 101 women diagnosed with BC from January 2010 to December 2015 and who had surgery in Aira Hospital, in rural Ethiopia. From 2013, tamoxifen was offered to patients with HR-positive (HR+) tumors. Prescription refill records and a structured questionnaire were used to assess receipt of and adherence to tamoxifen.

RESULTS

Of the 101 BC patients tested for HR status during the study period, 66 (65%) patients were HR+ and were eligible for tamoxifen treatment. However, 15 of the HR+ patients died before tamoxifen became available in 2013. Of the remaining 51 HR+ patients, 26 (51%) initiated tamoxifen but only 9 of them (35%) adhered to therapy (medication possession rate ≥80%, median observation 16.2 months). After 1 year, 52% of the patients were still adherent, and 9 patients had discontinued therapy. The reasons for non-initiation of tamoxifen included patient factors (n = 5), including financial hardship or lack of transportation, and health care provider factors (n = 12).

CONCLUSIONS

Endocrine therapy for BC patients seems feasible in rural Western Ethiopia, although non-adherence due to financial hardship and a less developed health care infrastructure remains a major challenge. We postulate that the implementation of breast nurses could reduce patient and health system barriers and improve initiation of and adherence to endocrine treatment.

Adjuvant endocrine therapy for premenopausal women with breast cancer: Patient adherence and physician prescribing practices in Mexico

BACKGROUND

In resource-constrained settings, data regarding breast cancer patients' adherence to endocrine therapy (ET) and physicians' prescribing practices is limited. This study aims to decrease this knowledge gap in a real-world clinical practice.

METHODS

Premenopausal women with stage 0-III hormone-sensitive breast cancer and receiving adjuvant ET during the past 1-5 years were identified in three Mexican referral centers. Participants' self-reported ET compliance, clinicopathologic characteristics, ET-related knowledge and beliefs, experienced adverse effects, social support, and patient-physician relationships were evaluated. Physician ET prescribing practices were compared with the gold standard according to international and national guidelines to assess clinicians' adherence to standard-of-care prescription.

RESULTS

In total, 95/132 (72%) and 35/132 (27%) participants reported complete and acceptable adherence, respectively. Incomplete adherence was mainly attributed to forgetfulness, adverse effects, and unwillingness to take ET. Being employed/studying (p = 0.042), worrying about long-term ET use (p = 0.031), and experiencing >7 ET-related symptoms (p = 0.018) were associated with incomplete adherence. Guideline-endorsed regimens were prescribed in 84/132 (64%) patients, while the rest should have undergone ovarian function suppression (OFS) but instead received tamoxifen monotherapy.

CONCLUSIONS

Premenopausal Mexican women self-report remarkably high rates of adequate ET adherence. However, a considerable proportion misses ≥1 doses/month, usually because of forgetfulness. Notably, only 64% receive standard-of-care ET due to suboptimal prescription of OFS. Interventions that remind patients to take their ET, refine physicians' knowledge on the importance of OFS in high-risk patients, and increase access to OFS could prove pivotal to enhance optimal ET implementation and adherence, which could translate into improved patient outcomes.

Longitudinal Trends in Illness Perception and Depression during Adjuvant Breast Cancer Endocrine Therapy: A Prospective Observational Study

This study aimed to identify the changes in the illness perceptions and depression of women with breast cancer, undergoing AET, at three time points (i.e., before initiating AET, 3 months follow-up, and 12 months follow-up). We investigated the interaction effects of their demographic and clinical characteristics on illness perception changes over time. Furthermore, factors including the patient’s characteristics and illness perceptions associated with depressive symptoms 1 year after starting AET were explored. Illness perception and depressive symptoms were assessed with the brief illness perception questionnaire and the Center for Epidemiologic Studies Depression Scale, in a prospective study of 150 women. The changes in illness perceptions and depression between the three time points were analyzed using repeated measures ANOVA. The factors associated with depressive symptoms were identified using regression analysis. Illness perception improved overall over the 12 months. However, more patients perceived their illness as chronic, experienced more symptoms, and developed negative beliefs that treatment could not control their disease. Patients’ depressive symptoms decreased significantly. Depression at the baseline, cancer stage, and the perception of personal control were highly associated with depression after 12 months. These findings suggest that healthcare providers should offer appropriate interventions to patients, for managing symptoms, having a positive belief that treatment can control their disease, and preventing long-term depressive symptoms.

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

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

Is patient participation in multidisciplinary tumor conferences associated with their fear of progression?

PURPOSE

Previous studies found that some breast cancer patients in Germany are invited to participate in a multidisciplinary tumor conference (MTC) during the discussion of their own case. MTCs are regular meetings of a treatment team in which the diagnosis and treatment plan of cancer patients are discussed. Psychological consequences concerning the patients' participation in an MTC have not been examined yet. This study examines the association between patients' participation in MTC and patients' fear of progression (FoP).

METHODS

This analysis is part of a larger project named "Patient participation in multidisciplinary tumor conferences in Breast Cancer Care" (PINTU) which is a multicenter observational mixed-methods study. The study was conducted in six breast and gynecological cancer centers in North Rhine-Westphalia, Germany. Data were collected from 2018 to 2020 by patient survey at three time points. Patients with (n = 81) and without (n = 120) MTC participation were compared. FoP was measured with a 12-item short form of the FoP Questionnaire (FoP-Q-SF) at all three measurement time points. Data analysis included descriptive statistics, a one-way repeated variance analysis (ANOVA), and a one-way repeated ANCOVA using the propensity score as a covariate.

RESULTS

Data of n = 201 patients were included in the analysis. In general, FoP scores decreased in both groups from T0 to T2 (F = 36.539, p < 0.001, η²  = 0.155). Non-participating patients did not differ with regard to their FoP from patients who participated in an MTC before and after participation. The results of AN(C)OVA revealed no significant effects concerning the influence of patient participation in an MTC on FoP (F = 0.014, p = 0.907, η² = <0.001 and (F = 0.013, p = 0.909, η² = <0.001).

CONCLUSION

Since the FoP is not influenced by participation, the findings do not support recommendations for or against patient participation in an MTC. Further research should focus on the question of which patient groups might benefit from participation in an MTC with regard to which outcome variables.

Breast cancer patients' insurance status and residence zip code correlate with early discontinuation of endocrine therapy: An analysis of the ECOG-ACRIN TAILORx trial

BACKGROUND

Early discontinuation is a substantial barrier to the delivery of endocrine therapies (ETs) and may influence recurrence and survival. The authors investigated the association between early discontinuation of ET and social determinants of health, including insurance coverage and the neighborhood deprivation index (NDI), which was measured on the basis of patients' zip codes, in breast cancer.

METHODS

In this retrospective analysis of a prospective randomized clinical trial (Trial Assigning Individualized Options for Treatment), women with hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer who started ET within a year of study entry were included. Early discontinuation was calculated as stopping ET within 4 years of its start for reasons other than distant recurrence or death via Kaplan-Meier estimates. A Cox proportional hazards joint model was used to analyze the association between early discontinuation of ET and factors such as the study-entry insurance and NDI, with adjustments made for other variables.

RESULTS

Of the included 9475 women (mean age, 55.6 years; White race, 84%), 58.0% had private insurance, whereas 11.7% had Medicare, 5.8% had Medicaid, 3.8% were self-pay, and 19.1% were treated at international sites. The early discontinuation rate was 12.3%. Compared with those with private insurance, patients with Medicaid (hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.23-1.92) and self-pay patients (HR, 1.65; 95% CI, 1.25-2.17) had higher early discontinuation. Participants with a first-quartile NDI (highest deprivation) had a higher probability of discontinuation than those with a fourth-quartile NDI (lowest deprivation; HR, 1.34; 95% CI, 1.11-1.62).

CONCLUSIONS

Patients' insurance and zip code at study entry play roles in adherence to ET, with uninsured and underinsured patients having a high rate of treatment nonadherence. Early identification of patients at risk may improve adherence to therapy.

LAY SUMMARY

In this retrospective analysis of 9475 women with breast cancer participating in a clinical trial (Trial Assigning Individualized Options for Treatment), Medicaid and self-pay patients (compared with those with private insurance) and those in the highest quartile of neighborhood deprivation scores (compared with those in the lowest quartile) had a higher probability of early discontinuation of endocrine therapy. These social determinants of health assume larger importance with the expected increase in unemployment rates and loss of insurance coverage in the aftermath of the coronavirus disease 2019 pandemic. Early identification of patients at risk and enrollment in insurance optimization programs may improve the persistence of therapy.

Adherence to endocrine therapy and its relation to disease-free survival among breast cancer patients visiting an out-patient clinic at Khartoum Oncology Hospital, Sudan

RATIONALE

Adherence to endocrine therapy provides substantial reduction in breast cancer (BC) relapses and improve survival. Hence, non-adherence remains an under reported issue mainly in developing countries.

AIMS AND OBJECTIVES

The aim of this study is to evaluate the adherence to endocrine therapy (tamoxifen [TAM] and aromatase inhibitors [AIs]) among BC patients visiting an out-patient clinic (2015-2016) in Khartoum Oncology Hospital, Sudan.

METHODS

Adherence was assessed using pills count and self-reporting methods. A total of 172 patients were interviewed. Also, records were reviewed for demographic and other cancer characteristics.

RESULTS

The patients' mean age at diagnosis was 53 years, with the highest frequency at (41-60) years. Invasive ductal carcinoma 69.2% formed the main pathological diagnosis. T2 tumour size (51.2%) and lymph node involvement (N1) (31.4%) were most evident. Also, the majority of patients were stage III (45.9%) and grade II (48%). The studied women were postmenopausal (49.4%) and premenopausal (47.7%). Regarding hormonal receptors, about 68% were oestrogen (ER)+/progesterone (PR)+ and 23.3% were ER+/PR-. Studying adherence, almost (93%) of the studied group were ≥80% adherent to TAM and AIs. The hormonal therapy persistence mean was 27.2 ± 22.5 months (40-96). While adherence percentage mean was 93.7 ± 13.6% (0%-100%). Also disease-free survival (DFS) mean was 36.3 ± 32.7 months (4-312). Adherence to hormonal therapy and persistence were significantly correlated (P < .000). Also, statistically significant association was found between hormonal therapy adherence (≥80%) and patient poor to average economic status (P = .006), and the marital status "married" (P = .008).

CONCLUSIONS

A high rate of adherence (93%) to endocrine therapy was estimated in the present study. Also, a positive association was found between the hormonal therapy persistence, and the DFS year's groups (P = .000), and the hormonal therapy types (P = .000). Adherence to hormonal therapy and persistence were significantly correlated (P < .000).

The Patient's Voice: Adherence, Symptoms, and Distress Related to Adjuvant Endocrine Therapy After Breast Cancer

BACKGROUND

While adjuvant endocrine therapy (AET) for early-stage, hormone-sensitive breast cancer confers a 40-50% reduction in recurrence risk, adherence to AET is suboptimal, and no efficacious interventions exist to improve adherence. A qualitative study was conducted to understand patient experiences on AET, motivators and barriers to adherence, side effects, and distress, with the goal of developing a patient-centered, evidence-based intervention.

METHOD

From November 2017 to November 2018, female patients with early-stage, hormone receptor-positive breast cancer taking AET were recruited. Patients with low and high medication adherence of varying ages, levels of distress, and years taking AET were purposefully enrolled. In-depth semi-structured interviews were conducted, audio recorded, and transcribed. Study staff created a thematic framework, and three independent researchers coded interviews using NVivo 11, achieving high inter-coder agreement (Kappa = .96).

RESULTS

Thirty interviews were conducted with patients who were, on average, 55.13 years old (SD = 12.37) and had been taking AET for a mean of 1.76 years (SD = 0.75). The sample was stratified by adherence level (low = 20; high = 10). Recurrent themes related to adherence included a commitment to AET to prevent recurrence despite distressing side effects, lack of strategies to cope with symptoms and distress, and desire for emotional support from others taking AET. Patients were highly accepting of a proposed psychosocial intervention to manage AET.

CONCLUSION

Patients are committed to taking AET to prevent breast cancer recurrence, but need and desire psychosocial support and skills training. Themes from this study are modifiable targets for a psychosocial, evidence-based intervention to promote adherence, coping with side effects, and distress management.

Predictors of increased risk for early treatment non-adherence to oral anti-estrogen therapies in early-stage breast cancer patients

PURPOSE

Non-adherence to the oral anti-estrogen therapies (AET) tamoxifen and aromatase inhibitors in early-stage hormone receptor-positive breast cancer is associated with numerous negative clinical outcomes. Prior studies have identified that non-adherence is associated with psychological and menopause-related factors which are present during AET, but the presence of these characteristics prior to AET initiation has not been investigated.

METHODS

Psychological and menopause symptoms (depression, generalized anxiety, insomnia, somatosensory amplification, hot flash frequency, and hot flash-related interference) were assessed pre-AET initiation as predictors of subsequent non-adherence in 73 participants (M_age = 55.0, SD = 10.1 years). Participants self-reported treatment adherence after three and 6 weeks on AET. Participants who did not initiate treatment were excluded from the analysis.

RESULTS

Discriminant function analyses revealed that the hypothesized set of psychological and menopause symptoms at baseline (pre-AET) together statistically distinguished between those who were non-adherent (n = 19; 26.0%) from adherent (n = 54; 74.0%) at 6 weeks. Model classification accuracy was statistically significant (Wilks' ƛ = 0.782, χ²(6) = 15.50, p = 0.017) at the 6-week timepoint. Results were consistent at 3 weeks. Pre-AET psychological and menopause symptoms correctly classified 6-week treatment adherence 77.9% of the time. Depression contributed most to distinguishing between adherers and non-adherers.

CONCLUSIONS

The presence of a composite profile of psychological and menopause symptoms prior to AET initiation may help to identify early treatment non-adherence. Results can be used to identify patients at risk for non-adherence and to guide psychological and symptom management interventions.

Survival Outcomes of Early-Stage Hormone Receptor-Positive Breast Cancer in Elderly Women

BACKGROUND

Elderly women (≥ 70 years old) form a significant proportion of patients affected by breast cancer (BC); however, the treatment decisions for this patient population are complicated, owing to the presence of comorbidities, limited life expectancy, reduced tolerability of therapy, and limited enrollment in clinical trials. A growing body of evidence suggests equivalent outcomes in elderly patients with hormone receptor-positive early-stage breast cancer receiving primary endocrine therapy only or surgery with subsequent endocrine therapy. Whether these results are reproduced in the larger BC population outside of a clinical trial currently remains unclear.

PATIENTS AND METHODS

Women ≥ 70 years old diagnosed with early-stage invasive breast cancer between January 2008 and December 2013 with tumor size T1 or T2, minimal nodal involvement (N0 and N1), and estrogen and/or progesterone receptor positivity who started endocrine therapy within a year of diagnosis were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked datasets. Endocrine therapy was identified using outpatient prescription fills for anastrozole, exemestane, fulvestrant, letrozole, raloxifene, tamoxifen, and toremifene; the first fill date was used as the treatment initiation date. Surgical intervention included either breast-conserving surgery or mastectomy. Women who received chemotherapy were excluded. Trends in the use of primary endocrine therapy only were assessed using Poisson regression. Multivariable Cox proportional hazard regression was used to estimate the association between undergoing surgery within a year of diagnosis and 5-year all-cause mortality, after adjusting for patient demographics, comorbidities, and clinical cancer characteristics. Similar methods were used to assess 5-year cancer-specific mortality, where noncancer mortality was treated as a competing risk.

RESULTS

Overall, 8784 women were included in the analysis: 8006 (91%) received surgery with endocrine therapy and 778 (9%) received primary endocrine therapy alone. The proportion of women not receiving surgery remained consistent between 2008 and 2013 (p = 0.10). The 5-year mortality was 11% (n = 619), and 19% of all deaths were due to cancer causes (n = 117). After adjustment, 5-year mortality was lower among women undergoing surgery (HR 0.59, 95% CI 0.47-0.74, p < 0.0001). Similar results were found when looking at 5-year cancer-specific mortality (HR 0.52, 95% CI 0.30-0.90, p < 0.0001).

CONCLUSIONS

Elderly breast cancer patients with early-stage hormone-receptor-positive disease receiving primary surgical intervention plus endocrine therapy may have significantly improved survival than those receiving primary endocrine therapy alone. This study suggests the importance of surgical intervention for elderly breast cancer patients and warrants further investigation and comprehensive geriatric assessment to identify subsets of elderly breast cancer patients who may benefit significantly from surgical intervention.

Factors influencing adherence to adjuvant endocrine therapy in breast cancer-treated women: using real-world data to inform a switch from acute to chronic disease management

PURPOSE

Adjuvant endocrine therapy (AET) for ≥ 5 years is generally recommended for women with hormone receptor-positive breast cancer to reduce cancer recurrence/mortality; however, adherence can be suboptimal. We tested determinants of AET adherence using patient characteristics, treatment pathways, AET initiation timing, and multiple healthcare facility use. An underlying objective was to explore how oncological pathways mirror chronic disease management to monitor adherence and target improvement interventions using administrative datasets.

METHODS

Using patient-linked administrative health data from the Italian Lombardy Region, we identified 33.291 surviving patients starting AET in 2010-2016, with two (22.939 patients) or five years (8400 patients) follow-up, using a ≥ 80% prescription refill approach to measure adherence and logistic regression to test determinants of adherence.

RESULTS

AET crude adherence falls significantly during follow-up, from 94% at 1 Year to 58% at 5 Years. At 5 Years, patients who were older (>70), prescribed tamoxifen-only (OR 0.69; 95% CI 0.57-0.83; p = 0.0001) vs. aromatase inhibitors-only or therapy switches, treated for depression (OR 0.68; 95% CI 0.60-0.78; p < 0.0001), with surgery performed in high-volume hospitals (OR 0.85; 95% CI 0.75-0.97; p = 0.0116) showed lower adherence. Loyalty, or continued care in the surgical hospital (OR 1.73; 95% CI 1.51-2.00; p < 0.0001), undergoing chemotherapy before AET (OR 2.65; 95% CI 2.02-3.48; p < 0.0001), and earlier AET initiation, positively influenced adherence.

CONCLUSIONS

Chronic disease monitoring using administrative data can help oncologists focus efforts to ensure AET adherence. Results suggest addressing mental health, age, disease severity patient perceptions, timely AET initiation and therapy switches, and encouraging continued follow-up in the same hospital or better care coordination with outside follow-up specialists.

Adherence status to Adjuvant Endocrine Therapy in Chinese Women with Early Breast Cancer and its influencing factors: A cross-sectional survey

OBJECTIVE

Despite the proven benefits of adjuvant endocrine therapy, adherence to oral endocrine therapy in breast cancer treatment is a substantial problem. The aim of this study was to assess adherence to adjuvant endocrine therapy by women in China for the first 5 years, and to identify its influencing factors.

METHODS

Stratified sampling method was adopted to select 1875 cases of breast cancer patients for cross-sectional telephone follow-up. Compliance to medications was assessed using the Morisky Medication Adherence Scale. Status of endocrine therapy was assessed using nine additional questions. Binomial regression was used when assessing the factors associated with persistence, multinomial regression models were used to assess factors associated with compliance.

RESULTS

Of 888 patients who started adjuvant endocrine therapy, 769(86.6%) persisted and 119 (13.4%) discontinued. 760 patients who completed Morisky Medication Adherence Scale, the compliance was 7.4% low, 42% medium, and 50.6% high. The type of medication, duration of medication and side effects had an impact both on persistence and compliance. Age, history of radiotherapy and caregivers only had an impact on persistence.

CONCLUSIONS

Medication adherence was affected by many factors. Special attention and interventions should be given to women taking tamoxifen in the 2nd to 3rd year of medication, and aromatase inhibitors in the 1st to 2nd year. Further prospective design studies are needed to explore effective measures to improve medication adherence of women with breast cancer treated by endocrine therapy.

Symptom Care at Home: A Comprehensive and Pragmatic PRO System Approach to Improve Cancer Symptom Care

INTRODUCTION

There is growing recognition that systematically obtaining the patient's perspective on their health experience, using patient-reported outcomes (PRO), can be used to improve patient care in real time. Few PRO systems are designed to monitor and provide symptom management support between visits. Patients are instructed to contact providers between visits with their concerns, but they rarely do, leaving patients to cope with symptoms alone at home. We developed and tested an automated system, Symptom Care at Home (SCH), to address this gap in tracking and responding to PRO data in-between clinic visits. The purpose of this paper is to describe SCH as an example of a comprehensive PRO system that addresses unmet need for symptom support outside the clinic.

METHODS FOR PRO SCORE INTERPRETATION

SCH uses pragmatic, single-item measures for assessing symptoms, which are commonly used and readily interpretable for both patients and providers. We established alerting values for PRO symptom data, which was particularly important for conserving oncology providers' time in responding to daily PRO data.

METHODS FOR DEVELOPING RECOMMENDATIONS FOR ACTING ON PRO RESULTS

The SCH system provides automated, just-in-time self-management coaching tailored to the specific symptom pattern and severity levels reported in the daily call. In addition, the SCH system includes a provider decision support system for follow-up symptom assessment and intervention strategies.

DISCUSSION

SCH provides PRO monitoring, tailored automated self-management coaching, and alerts the oncology team of poorly controlled symptoms with a provider dashboard that includes evidence-based decision support for follow-up to improve individual patients' symptom care. We particularly emphasize our process for PRO selection, rationale for determining alerting thresholds, and the design of the provider dashboard and decision support. Currently, we are in the process of updating the SCH system, developing both web-based and app versions in addition to interactive voice response phone access and integrating the SCH system in the electronic health record.

Symptom Clusters in Women With Breast Cancer During the First 18 Months of Adjuvant Therapy

CONTEXT

Women with breast cancer treated with aromatase inhibitor (AI) therapy experience multiple concurrent symptoms or symptom clusters. Understanding of the symptom experience and identifying symptom clusters before and during AI therapy are important for the development of interventions to improve clinical outcomes.

OBJECTIVES

The aim of this study was to identify symptom clusters experienced by women with breast cancer treated with AI therapy from pre-adjuvant therapy up to 18 months of adjuvant therapy using a broad scope of symptoms assessment.

METHODS

Forty-seven symptoms were evaluated in postmenopausal women with breast cancer (N = 354) who received AI therapy or chemotherapy followed by AI therapy. Symptoms were assessed at four semiannual time points with the Breast Cancer Prevention Trial Symptom Checklist, Patient's Assessment of Own Functioning Inventory, Beck Depression Inventory-II, and Profile of Mood States Tension/Anxiety and Fatigue/Inertia subscales. Exploratory factor analyses were conducted at each time point to identify symptom clusters.

RESULTS

Four stable symptom clusters (i.e., musculoskeletal, vasomotor, urinary, sexual) and three relatively stable symptom clusters (i.e., psychological, neurocognitive, weight) were identified across the 18-month follow-up period. The gastrointestinal symptom cluster only appeared at after six months of adjuvant therapy (postchemotherapy).

CONCLUSION

This study helps us to better understand the most common symptom clusters over the first 18 months of adjuvant therapy among postmenopausal women with early-stage breast cancer. It is critical for health care providers to know the symptom clusters commonly experienced by women receiving AI therapy with or without chemotherapy and manage them properly over time.

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

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.

Providers' Perspectives on Adherence to Hormonal Therapy in Breast Cancer Survivors. Is there a Role for the Digital Health Feedback System?

Objective

Despite the benefits of hormonal therapy (HT) adherence remains suboptimal in ER positive breast cancer patients. Medication adherence is challenging to assess and tends to be overestimated. The Digital Health Feedback System (DHFS) consists of an ingestible sensor attached to a pill that sends intake date and time to a smart phone or computer. Patients can share this information with health care providers and other persons. The DHFS can also send reminders. This mixed methods study examined providers' perceptions of HT medication adherence. The potential role of the DHFS in enhancing medication tracking and adherence was also explored.

Methods

We conducted semi-structured interviews with key informants (N=10). Questions examined perceptions about adherence barriers and facilitators, challenges tracking adherence, and views on the DHFS. Findings informed the development of a survey that was administered online (N=19).

Results

Providers emphasized the importance of fostering open and trustful communication around adherence. The most mentioned challenges to assessing adherence were the patient not disclosing discontinuation immediately (78.9%) and over-reporting adherence (57.9%). The perceived potential benefits of DHFS were the ability to track adherence better (94.7%) and reminders to take the medication (68.4%). Safety to ingest a sensor was as a major perceived barrier (8 4.2%).

Conclusion

Interventions that target providers and doctor-patient communication are warranted to enhance adherence and reduce communication delays around HT discontinuation.

Practice Implications

DHFS has the potential to enhance HT adherence by directly targeting barriers. Future studies should also examine the feasibility of adopting the DHFS with cancer patients.

Invasive lobular breast cancer: A review of pathogenesis, diagnosis, management, and future directions of early stage disease

Invasive lobular carcinoma (ILC) is the second most common type of invasive breast cancer after invasive ductal carcinoma (IDC). Invasive lobular carcinoma has unique clinical, pathologic, and radiographic features which suggest that it is a distinct clinical entity; however, it is treated with the same treatment paradigms as IDC. Information regarding the specific treatment of ILC, including response to standard therapy, is sparse. Neoadjuvant treatment considerations are of great importance in this space as ILC is often found at a locally advanced stage. In this review, we summarize the classic features of ILC and the available data regarding efficacy of both endocrine therapy and chemotherapy in curative treatment of breast cancer.

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.

Cognitive effects of adjuvant endocrine therapy in older women treated for early-stage breast cancer: a 1-year longitudinal study

PURPOSE

Evidence suggests endocrine therapy (ET) for breast cancer (BC) has adverse cognitive effects, but its specific effects on older women are unknown. This is despite the fact that older women are at increased risk of both breast cancer (BC) and cognitive decline relative to younger women. This study prospectively examined the cognitive effects of ET in a cohort of older BC patients. Our primary outcome measure was change in verbal memory, the cognitive domain most consistently affected by estrogen deprivation.

METHODS

Forty-two chemotherapy-naïve women age 60+, without dementia and recently diagnosed with hormone receptor-positive BC, completed neuropsychological tests at the time of ET initiation and after 1 year of treatment. Change in age-standardized verbal memory performance was examined using paired t tests. To assess a broader range of potential cognitive effects, we also examined changes in visual memory, processing speed, frontal executive function, and perceptual reasoning.

RESULTS

Participants exhibited significant decline from baseline to 1 year in verbal memory (p = 0.01). This decline was small to moderate in effect size (d = - 0.40). Performance on other domains did not change significantly over the year (all p > 0.05).

CONCLUSIONS

Our findings suggest potentially detrimental effects of ET on verbal memory in older women after just 1 year of treatment. Given that ET is prescribed for courses of 5 to 10 years, additional studies examining longer-term effects of treatment in older women are critical.

Adjuvant endocrine therapy side-effects among postmenopausal breast cancer patients in Malaysia

OBJECTIVE

This study was conducted to determine the prevalence and severity of menopausal symptoms and their associated risk factors among postmenopausal breast cancer patients receiving adjuvant endocrine therapy.

METHODS

Postmenopausal breast cancer patients on endocrine therapy were recruited at three hospitals in Malaysia. Presence and severity of menopausal symptoms were determined using the Menopause Rating Scale. Sociodemographic and clinical data were collected from medical records.

RESULTS

A total of 192 patients participated in this study. Commonly reported symptoms were musculoskeletal pain (59.9%), physical and mental exhaustion (59.4%), and hot flushes (41.1%). Multivariate analyses indicated that increasing number of years after menopause until the start of endocrine therapy was significantly associated with less likelihood of reporting menopausal symptoms and musculoskeletal pain. Patients with primary or secondary education levels reported significantly less menopausal urogenital symptoms compared to patients with a tertiary education level. Patients using aromatase inhibitors were twice as likely to experience musculoskeletal pain compared to patients using tamoxifen (odds ratio, 2.18; 95% confidence interval, 1.06-4.50; p < 0.05).

CONCLUSION

Menopausal symptoms and musculoskeletal pain are common problems encountered by postmenopausal breast cancer patients receiving adjuvant endocrine therapy and should be closely monitored for successful treatment.

Oral Endocrine Therapy Nonadherence, Adverse Effects, Decisional Support, and Decisional Needs in Women With Breast Cancer

BACKGROUND

Oral endocrine therapy (OET) such as tamoxifen or aromatase inhibitors reduces recurrence and mortality for the 75% of breast cancer survivors (BCSs) with a diagnosis of estrogen receptor-positive breast cancer. Because many BCSs decide not take OET as recommended because of adverse effects, understanding BCSs' decisional supports and needs is foundational to supporting quality OET decision making about whether to adhere to OET.

OBJECTIVE

The aim of this study was to examine literature pertaining to OET nonadherence and adverse effects using the Ottawa Decision Support Framework categories of decisional supports and decisional needs because these factors potentially influence OET use.

METHODS

A systematic literature search was performed in PubMed and CINAHL using combined search terms "aromatase inhibitors and adherence" and "tamoxifen and adherence." Studies that did not meet criteria were excluded. Relevant data from 25 publications were extracted into tables and reviewed by 2 authors.

RESULTS

Findings identified the impact of adverse effects on OET nonadherence, an absence of decisional supports provided to or available for BCSs who are experiencing OET adverse effects, and the likelihood of unmet decisional needs related to OET.

CONCLUSIONS

Adverse effects contribute to BCSs decisions to stop OET, yet there has been little investigation of the process through which that occurs. This review serves as a call to action for providers to provide support to BCSs experiencing OET adverse effects and facing decisions related to nonadherence.

IMPLICATIONS FOR PRACTICE

Findings suggest BCSs prescribed OET have unmet decisional needs, and more decisional supports are needed for BCSs experiencing OET adverse effects.

Osteoporosis and musculoskeletal complications related to therapy of breast cancer

Aromatase inhibitors (AIs) are the treatment of choice for the majority of postmenopausal women with estrogen receptor (ER) positive breast cancers in early and advanced stage settings. One of most frequent side effects of AIs is bone loss that is of sufficient magnitude to increase risk of osteoporotic fractures. Osteoporosis is primarily a complex genetic disease with few modifiable risk factors. As the lifespan increases, and breast mortality decreases, more women with breast cancer will be at risk of osteoporotic fractures, or falls that result in fractures. The screening, prevention, and treatment of osteoporosis do not differ in women with or without breast cancer. Rather, breast cancer treatments, including AIs, chemotherapy-induced ovarian failure, and gonadotropin-releasing hormone (GnRH) agonists, all decrease estrogen, which causes net bone resorption, leading some women to experience fracture. Occurring in about fifty-percent of women, AI-induced arthralgia is one of the most common side effects, and causes of nonadherence and discontinuation. Registry studies show that nonadherence and discontinuation may contribute to higher breast cancer mortality. Thus, understanding the mechanisms, risk factors, and interventions to mitigate symptoms of AI-induced arthralgia is a high priority.

Use of a web-based app to improve breast cancer symptom management and adherence for aromatase inhibitors: a randomized controlled feasibility trial

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.

Interventions to improve endocrine therapy adherence in breast cancer survivors: what is the evidence?

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.

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.

Improving Cancer Care Through the Patient Experience: How to Use Patient-Reported Outcomes in Clinical Practice

Poorly controlled symptoms are common and debilitating during cancer treatment and can affect functional status and quality of life, health care resource utilization, treatment adherence, and cancer survivorship. Historically, the patient experience, including symptoms during treatment, has not been tracked or documented in the patient health record. Measurement of patient-reported outcomes (PROs), including symptoms, is an essential component to cancer care focused on the illness impact to the patient and family. PROs can be useful at the individual level for monitoring and promoting symptom care both in the clinic and remotely and at the population level for aggregating population data for use in research and quality improvement initiatives. Implementation of PROs in cancer clinical care requires a carefully thought out process to overcome challenges related to integrating PROs into existing electronic health records and clinical work flow. Issues with implementing PRO collection may include making decisions about measurement tools, modes of delivery, frequency of measurement, and interpretation that are guided by a clarification of the purpose for collecting PROs. We focus on three aspects of PRO use: (1) improving care for individual patients, (2) analyzing aggregated data to improve care and outcomes overall, and (3) considerations in implementing PRO collection.

Understanding tamoxifen adherence in women with breast cancer: A qualitative study

OBJECTIVE

Non-adherence to tamoxifen is common in breast cancer survivors and is associated with poor clinical outcomes. This study aimed to understand womens' experiences of taking tamoxifen and to identify factors which may be associated with non-adherence.

DESIGN

A qualitative study using semi-structured interviews.

METHODS

Thirty-two breast cancer survivors who had been prescribed tamoxifen took part in interviews conducted face to face or over the telephone. They were transcribed verbatim and analysed using inductive thematic analysis with elements of grounded theory.

RESULTS

A key theme identified in the data was weighing up costs and benefits of treatment, which resulted in women falling into three groups; tamoxifen is keeping me alive, tamoxifen is not worth the reduced risk of recurrence, or conflicting beliefs about the harms and benefits of treatment. Additional themes were living with risk of recurrence and information & support.

CONCLUSIONS

Women who believed that the necessity of tamoxifen outweighed its costs were more likely to be adherent, whereas women who thought that the benefits did not outweigh the side effects were more likely to have discontinued. A third more ambivalent group believed strongly in the importance of treatment, but were struggling with side effects and were often non-adherent. Patients sometimes felt unsupported and discussed a need for more comprehensive information. To increase adherence, future research needs to explore ways to increase beliefs around tamoxifen necessity and how to help women cope with side effects. Statement of contribution What is already known on this subject? Non-adherence to tamoxifen is associated with increased risk of recurrence and mortality. Up to 50% of patients are non-adherent to tamoxifen by the fifth year of treatment Few consistent predictors of tamoxifen non-adherence have been identified. What does this study add? Many women report not knowing how to manage their side effects. Non-adherence is related to how women weigh up their side effects against their medication beliefs. Interventions aiming to increase necessity beliefs and improve symptom management may be effective.

Current treatment trends and the need for better predictive tools in the management of ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) of the breast represents a group of heterogeneous non-invasive lesions the incidence of which has risen dramatically since the advent of mammography screening. In this review we summarise current treatment trends and up-to-date results from clinical trials studying surgery and adjuvant therapy alternatives, including the recent consensus on excision margin width and its role in decision-making for post-excision radiotherapy. The main challenge in the clinical management of DCIS continues to be the tailoring of treatment to individual risk, in order to avoid the over-treatment of low-risk lesions or under-treatment of DCIS with higher risk of recurring or progressing into invasion. While studies estimate that only about 40% of DCIS would become invasive if untreated, heterogeneity and complex natural history have prevented adequate identification of these higher-risk lesions. Here we discuss attempts to develop prognostic tools for the risk stratification of DCIS lesions and their limitations. Early results of a UK-wide audit of DCIS management (the Sloane Project) have also demonstrated a lack of consistency in treatment. In this review we offer up-to-date perspectives on current treatment and prediction of DCIS, highlighting the pressing clinical need for better prognostic indices. Tools integrating both clinical and histopathological factors together with molecular biomarkers may hold potential for adequate stratification of DCIS according to risk. This could help develop standardised practices for optimal management of patients with DCIS, improving clinical outcomes while providing only the amount of therapy required for each individual patient.

Investigating Associations Between Health-Related Quality of Life and Endocrine Therapy Underuse in Women With Early-Stage Breast Cancer

PURPOSE

Endocrine therapy (ET) underuse puts women at increased risk for breast cancer (BC) recurrence. Our objective was to determine if health-related quality of life (HRQOL) subgroups were associated with underuse.

METHODS

Data came from the third phase of the Carolina Breast Cancer Study. We included 1,599 women with hormone receptor-positive BC age 20 to 74 years. HRQOL was measured, on average, 5 months postdiagnosis. Subgroups were derived using latent profile (LP) analysis. Underuse was defined as not initiating or adhering to ET by 36 months postdiagnosis. Multivariable logistic regression models estimated adjusted odds ratios (ORs) between HRQOL LPs and underuse. The best HRQOL LP was the reference. Chemotherapy- and race-stratified models were estimated, separately.

RESULTS

Initiation analyses included 953 women who had not begun ET by their 5-month survey. Of these, 154 never initiated ET. Adherence analyses included 1,114 ET initiators, of whom 211 were nonadherent. HRQOL was not significantly associated with noninitiation, except among nonchemotherapy users, with membership in the poorest LP associated with increased odds of noninitiation (adjusted OR, 5.5; 95% CI, 1.7 to 17.4). Membership in the poorest LPs was associated with nonadherence (LP1: adjusted OR, 2.2; 95% CI, 1.2 to 4.0 and LP2: adjusted OR,1.9; 95% CI, 1.1 to 3.6). Membership in the poorest LP was associated with nonadherence among nonchemotherapy users (adjusted OR, 2.1; 95% CI, 1.2 to 5.1).

CONCLUSION

Our results suggest women with poor HRQOL during active treatment may be at increased risk for ET underuse. Focusing on HRQOL, a modifiable factor, may improve targeting of future interventions early in the BC continuum to improve ET initiation and adherence and prevent BC recurrence.

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.

Oral Endocrine Therapy Nonadherence, Adverse Effects, Decisional Support, and Decisional Needs in Women With Breast Cancer

BACKGROUND

Oral endocrine therapy (OET) such as tamoxifen or aromatase inhibitors reduces recurrence and mortality for the 75% of breast cancer survivors (BCSs) with a diagnosis of estrogen receptor-positive breast cancer. Because many BCSs decide not take OET as recommended because of adverse effects, understanding BCSs' decisional supports and needs is foundational to supporting quality OET decision making about whether to adhere to OET.

OBJECTIVE

The aim of this study was to examine literature pertaining to OET nonadherence and adverse effects using the Ottawa Decision Support Framework categories of decisional supports and decisional needs because these factors potentially influence OET use.

METHODS

A systematic literature search was performed in PubMed and CINAHL using combined search terms "aromatase inhibitors and adherence" and "tamoxifen and adherence." Studies that did not meet criteria were excluded. Relevant data from 25 publications were extracted into tables and reviewed by 2 authors.

RESULTS

Findings identified the impact of adverse effects on OET nonadherence, an absence of decisional supports provided to or available for BCSs who are experiencing OET adverse effects, and the likelihood of unmet decisional needs related to OET.

CONCLUSIONS

Adverse effects contribute to BCSs decisions to stop OET, yet there has been little investigation of the process through which that occurs. This review serves as a call to action for providers to provide support to BCSs experiencing OET adverse effects and facing decisions related to nonadherence.

IMPLICATIONS FOR PRACTICE

Findings suggest BCSs prescribed OET have unmet decisional needs, and more decisional supports are needed for BCSs experiencing OET adverse effects.