Factors associated to persistence with hormonal therapy in women with breast cancer

Impact of hormone therapy side effects on health-related quality of life, distress, and well-being of breast cancer survivors

To explore the modulatory role of Adjuvant Hormone Therapy (AHT) on health-related quality of life (QoL), subjective well-being and distress prevalence in Breast Cancer (BC) survivors, considering the survival phase. Cross-sectional study with control group. 616 BC survivors participated. Examination of interaction effect between AHT and time since end of primary treatment showed that many of the positive changes observed through the survival phases were experienced exclusively by survivors without AHT. When AHT was not prescribed, longer time elapsed was associated with a decrease in distress prevalence and an improvement in subjective well-being and QoL. It seems there is a turning point around the fifth year after finalization of primary treatment, from which the survivors without AHT significantly improve in several areas and those with AHT do so to a lesser extent. It is expected that the improvement in QoL throughout the different survival phases will have a significant impact on the adherence and maintenance of AHT and, consequently, the likelihood of survival. Thus, AHT side-effects should be routinely assessed by health care providers to gain accurate knowledge that allows improving the QoL of BC survivors.

Persistence with tamoxifen and aromatase inhibitors in Germany: a retrospective cohort study with 284,383 patients

PURPOSE

The aim of this study was to analyze the persistence of women on tamoxifen (TAM) and aromatase inhibitors (AIs) in Germany, and to investigate possible determinants of non-persistence.

METHODS

The present retrospective cohort study was based on the IQVIA longitudinal prescription database (LRx). The study included women with an initial prescription of TAM or AIs (anastrozole, letrozole, and exemestane) between January 2016 and December 2020 (index date). Kaplan-Meier analyses were performed to show the persistence for TAM and AI, using a therapy gap of 90 or 180 days, respectively. A multivariable Cox proportional hazards regression model was further used to estimate the relationship between non-persistence and drug prescription (AI versus TAM), age, and the specialty of the physician initiating therapy (gynecologist, oncologist, or general practitioner).

RESULTS

Up to 5 years after the index date, only 35.1% of AI and 32.5% of TAM patients were continuing therapy when therapy discontinuation was defined as at least 90 days without therapy. Using a 180-day therapy gap, 51.9% of AI and 50.4% of TAM patients remained on therapy after 5 years. Cox regression models reveal that initial therapy with TAM (HR 1.06, 95% CI 1.04-1.07), therapy initiation by oncologists (HR 1.09, 95% CI 1.07-1.11), or general practitioners (HR 1.24, 95% CI 1.21-1.27) and age ≤ 50 (HR 1.08, 95% CI 1.06-1.10) were significantly associated with an increased risk of therapy discontinuation.

CONCLUSION

Overall, the present study indicates that persistence rates are low in all age groups for both TAM and AI treatment. We found several factors (e.g., physician specialty, younger age, and type of endocrine therapy) to be associated with an increased risk for non-persistence.

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.

The impact of medication side effects on adherence and persistence to hormone therapy in breast cancer survivors: A qualitative systematic review and thematic synthesis

BACKGROUND

Hormone Therapy (HT) reduces the risk of breast cancer recurrence and mortality in women with breast cancer. Despite these clinical benefits, rates of HT non-adherence and non-persistence are high. Research suggests this may be due to the impact of HT side effects. However, little research has explored the individual contribution of side effects to non-adherence and non-persistence behaviours, thereby hindering the implementation of targeted intervention strategies. Our aim is to review the published literature on breast cancer survivors' lived experiences of HT side effects and explore how these may be related to non-adherence and non-persistence behaviour.

METHODS

Electronic searches were conducted from inception to May 2020, utilising Cochrane CENTRAL, Medline, Embase, Web of Science and PsycINFO databases. Searches included a combination of terms related to breast cancer, adherence, hormone therapy and side effects.

RESULTS

Sixteen eligible papers were identified, and study quality was high. Data were thematically synthesised into four analytical themes, which encompassed 13 descriptive sub-themes: 'Daily impact of side-effects', 'Role of Health Care Professionals', 'Managing HT side-effects', and 'Weighing up the pros and cons'.

CONCLUSIONS

HT side effects significantly impact breast cancer survivor's quality of life. A lack of support from healthcare providers leads to self-management strategies, which negatively affects adherence and persistence behaviour.

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.

Oncologists' perspectives on adherence/non-adherence to adjuvant endocrine therapy and management strategies in women with breast cancer

PURPOSE

Adherence to adjuvant endocrine therapy (AET) is suboptimal, and a range of variables have been explored for understanding patients' experiences and motivations for medication-taking. However, oncologists' views on adherence are poorly understood. The aim of this study was to explore oncologists' perspectives on adherence/non-adherence and their strategies to ensure patients continue with treatments to inform the development of potential modifiable interventions.

METHODS

A qualitative study using in-depth, semi-structured interviews with 16 oncologists was conducted in Argentina. A stratified purposive sampling was used to recruit female and male participants from 3 health subsystems (private, social security, and public). Data were analyzed using the Framework approach.

RESULTS

Oncologists believed patients' adherence was overall high and associated it with good tolerance of AET in comparison to chemotherapy, information provided, and patients feeling reassured (fear of recurrence). Non-adherence was not perceived as a major source of concern, and it was related to rare cases of severe side effects, young age, refusing treatment, losing the insurance plan, lack of education, and social circumstances. Patients' complaints of bothersome side effects were not identified as a main reason to discontinuation. Public and private sector patients, however, were perceived as having different attitudes toward side effects. Management strategies included medicine change, referral to support services, and a supportive relationship with the oncologist.

CONCLUSION

Oncologists' perspectives on adherence/non-adherence to AET show similarities and significant differences with those in the literature based on patient-reported factors. Overall adherence was considered high, but the likelihood of unintentional non-adherence seems important in public sector patients. Information to patients should provide clear explanations on both severe and unpleasant side effects. Interventions to improve communication skills in oncologists and specialists responsible for survivorship care should be considered to strengthen patients' self-efficacy and effective medication-taking. Reliable data on adherence are needed.

Origin-destination flows in chemotherapy for breast cancer in Brazil: implications for pharmaceutical services

Abstract This study maps and analyzes patient flows for breast cancer chemotherapy in order to identify the potential implications for organization of pharmaceutical services in the cancer care network. An ecological study design sought to correlate the place of residence with place of care for breast cancer patients. All chemotherapy procedures financed by Brazil’s Unified Health System (SUS) and performed from January to December 2013 were included. Flows were mapped using TerraView® software. A total of 1 347 803 outpatient chemotherapy procedures were delivered by 243 cancer care units located in 156 municipalities. Seventeen cities concentrated approximately 50.0 % of the procedures. A total of 8 538 origin-destination flows were generated and 49.2% of procedures were performed in services located outside the municipality in which the patient resided. Context challenges, related to inequality of access to chemotherapy and hindrances in planning and management of pharmaceutical services, were discussed.

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.

First-line treatment disruption among post-menopausal women with HR+/HER2- metastatic breast cancer: a retrospective US claims study

OBJECTIVE

This study assessed disruption of first-line treatments initiated after the approval of the first CDK 4/6 inhibitor, palbociclib, among post-menopausal women with HR+/HER2- metastatic breast cancer (mBC) in the US.

METHODS

Post-menopausal women with HR+/HER2- mBC who initiated first-line endocrine therapy or chemotherapy (index therapy) between February 3, 2015 (palbociclib approval date) and February 29, 2016 (end of data) were identified from the Symphony Source Lx database. Patients were required to have continuous quarterly activity (defined as ≥1 pharmacy or medical claim) for 12 months prior to and 1 month after the initiation of the index therapy (index date). Treatment disruption was defined as a treatment gap of ≥60 days or adding an agent after the original therapy. Kaplan-Meier analyses were conducted to estimate treatment disruption rates during the 6 months following the index date. Patients without treatment disruption were censored at the end of continuous quarterly activity or end of data.

RESULTS

A total of 8,160 and 2,153 eligible patients initiated endocrine therapy or chemotherapy as their first-line mBC treatment, with a median follow-up of 6.7 and 7.6 months, respectively. The three most prevalent metastatic sites were bone (28.1-42.2%), liver (8.8-17.3%), and lung (8.6-9.5%). Overall, 37.7% (n = 3,074) of patients receiving endocrine therapy and 86.1% (n = 1,852) of patients receiving chemotherapy encountered treatment disruption at 6 months (log-rank test p < .05).

CONCLUSIONS

Treatment disruption rates of first-line therapies were sub-optimal among post-menopausal women with HR+/HER2- mBC, primarily driven by chemotherapy users. New therapies or interventions are needed to reduce treatment disruption in this patient population.

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.

Estudo do tempo entre o diagnóstico e início do tratamento do câncer de mama em idosas de um hospital de referência em São Paulo, Brasil

Resumo Objetivou-se analisar o tempo entre o diagnóstico e o início do tratamento e conhecer o perfil sociodemográfico e clínico de mulheres com 60 ou mais anos de idade, diagnosticadas com câncer de mama entre os anos de 2001 a 2006, no Hospital Pérola Byington, São Paulo. Trata-se de um estudo descritivo, com dados secundários e amostra de 1299 casos. Coletou-se variáveis sociodemográficas, clínicas e temporais. Formou-se dois grupos de mulheres utilizando a variável tempo, sendo o tempo entre o diagnóstico e o início do tratamento: “até e maior que 60 dias”. A média do tempo entre o diagnóstico e o início do tratamento foi de 74,7 dias (DP = 212,6), e o tempo mediano de 45 dias. As idosas sem o diagnóstico e sem o tratamento anterior levaram menos tempo para dar início ao tratamento (p = 0,001), bem como as mulheres com estadiamento do tumor na fase inicial, in situ e I (p = 0,001). O tempo foi significante para os desfechos de recidiva (p = 0,004) e metástase (p = 0,038). O diagnóstico e o tratamento estabelecidos garantiu às idosas menor tempo para o início da assistência devida. Melhorar a estruturação e o funcionamento dos serviços de saúde constitui fator imprescindível para o atendimento dos casos da doença de forma eficiente, um importante desafio para o Sistema Único de Saúde.