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Lobo CL, Shetty A, M M, Dubey A, El-Zahaby SA. Non-systemic Approaches for Ductal Carcinoma In Situ: Exploring the Potential of Ultra-flexible Combisomes as a Novel Drug Delivery Strategy-a Review. AAPS PharmSciTech 2023; 24:119. [PMID: 37173545 DOI: 10.1208/s12249-023-02574-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
Ductal carcinoma in situ (DCIS) is currently treated through breast-conserving surgery (lumpectomy), radiation therapy, breast-removing surgery (mastectomy), and hormone therapy to prevent further progression into invasive breast cancer and recurrence. Discrepancies concerning the prognosis of DCIS have sparked controversy about adequate treatment. Considering the severe medical and psychological consequences of mastectomy, developing a treatment approach that arrests the progression of DCIS to the invasive stage without affecting the non-cancerous cells is of utmost importance. In the current review, the problems associated with the diagnosis and management of DCIS have been thoroughly discussed. A summary of the route of administration and drug delivery systems to manage DCIS was also provoked. Innovative ultra-flexible combisomes were also proposed for the effective management of DCIS. Prevention is essential in managing the risk of DCIS and reducing the risk of progression to invasive breast cancer. While prevention is vital, it is not always possible to prevent DCIS, and in some cases, treatment may be necessary. Hence, this review recommends that ultra-flexible combisomes administered as a topical gel provide a non-systemic approach for managing DCIS and thus significantly minimize the side effects and costs associated with existing therapies.
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Affiliation(s)
- Cynthia Lizzie Lobo
- Nitte (Deemed to be University), NGSM Institute of Pharmaceutical Sciences, Department of Pharmaceutics, Deralakatte, Mangalore, 575018, India
| | - Amitha Shetty
- Nitte (Deemed to be University), NGSM Institute of Pharmaceutical Sciences, Department of Pharmaceutics, Deralakatte, Mangalore, 575018, India
| | - Manohar M
- Nitte (Deemed to be University), NGSM Institute of Pharmaceutical Sciences, Department of Pharmaceutics, Deralakatte, Mangalore, 575018, India
| | - Akhilesh Dubey
- Nitte (Deemed to be University), NGSM Institute of Pharmaceutical Sciences, Department of Pharmaceutics, Deralakatte, Mangalore, 575018, India.
| | - Sally A El-Zahaby
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, King Salman International University, South Sinai, Egypt
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Risk management recommendations and patient acceptance vary with high-risk breast lesions. Am J Surg 2021; 223:94-100. [PMID: 34325908 DOI: 10.1016/j.amjsurg.2021.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/07/2021] [Accepted: 07/16/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Lobular carcinoma in situ (LCIS), atypical ductal and lobular hyperplasia (AH) increase breast cancer risk. We examined risk management recommendations (RMR) and acceptance in AH/LCIS. METHODS All patients with AH/LCIS on core needle biopsy from 2013 to 2016 at our institution were identified; cancer patients were excluded. Univariate and multivariate analysis examined factors associated with management. RESULTS 98 % of patients were evaluated by breast surgeons and 53 % underwent risk model calculation (RC). 77 % had new RMR. RMR of MRI screening (MRI), genetic counselling (GC) and medical oncology (MO) referral were 41 %, 18 %, 77 %, respectively. MRI screening was more likely recommended in those with strong family history (p = 0.01), and high RC (p < 0.001). Uptake of at least one RMR did not occur in 84 % of patients. Use of RC correlated with MO acceptance (p = 0.049). CONCLUSIONS Diagnosis of atypia has the potential to change risk management for most, however only 16 % of patients accepted all RMR.
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Jahan N, Jones C, Rahman RL. Endocrine prevention of breast cancer. Mol Cell Endocrinol 2021; 530:111284. [PMID: 33882282 DOI: 10.1016/j.mce.2021.111284] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 01/01/2023]
Abstract
Breast cancer (BC) is the most common non-cutaneous malignancy among women worldwide and is a significant cause of morbidity, mortality, and national health care expenditure. Unfortunately, with few exceptions like alcohol consumption, obesity, and physical activity, most BC risk factors are unmodifiable. Antiestrogen endocrine therapy, commonly known as BC chemoprevention, is an effective method of BC prevention. In multiple randomized trials, two selective estrogen receptor modulators - tamoxifen and raloxifene, and two aromatase inhibitors - exemestane and anastrozole have reduced BC incidence by 50%-65% in high-risk women. An estimated 15% of the US women between 35 and 79 years of age may qualify as high risk for BC, yet a small percentage of these women will ever have a formal BC risk assessment or a discussion of endocrine prevention options. The etiology of underutilization of endocrine prevention of BC is multifactorial - infrequent use of BC risk assessment tools in the primary care settings, insufficient knowledge of BC risk assessment tools and antiestrogen agents among primary care providers, concerns of side effects, inadequate time for counseling during primary care visit, and lack of predictive biomarkers may play significant roles. Many small studies incorporating risk assessment tools and decision-making aids showed minimal success in enhancing endocrine prevention. One critical factor for underutilization of endocrine prevention is low uptake of endocrine prevention by high-risk women even when appropriately recommended. Furthermore, adherence to BC endocrine prevention is unsatisfactorily low. Despite the current infrequent usage, endocrine prevention has the potential to reduce the public health burden of BC significantly. Innovative approaches like finding new agents, alternative dosing and schedule of currently available agents, transdermal medication delivery, increased public and professional awareness, and policymakers' commitments may bring the desired changes.
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Affiliation(s)
- Nusrat Jahan
- Division of Hematology-Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA.
| | - Catherine Jones
- Division of Hematology-Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA
| | - Rakhshanda Layeequr Rahman
- Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA
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Jones T, Guzman A, Silverman T, Freeman K, Kukafka R, Crew K. Perceptions of Racially and Ethnically Diverse Women at High Risk of Breast Cancer Regarding the Use of a Web-Based Decision Aid for Chemoprevention: Qualitative Study Nested Within a Randomized Controlled Trial. J Med Internet Res 2021; 23:e23839. [PMID: 34100769 PMCID: PMC8262666 DOI: 10.2196/23839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/12/2020] [Accepted: 04/13/2021] [Indexed: 01/17/2023] Open
Abstract
Background Chemopreventive agents such as selective estrogen receptor modulators and aromatase inhibitors have proven efficacy in reducing breast cancer risk by 41% to 79% in high-risk women. Women at high risk of developing breast cancer face the complex decision of whether to take selective estrogen receptor modulators or aromatase inhibitors for breast cancer chemoprevention. RealRisks is a patient-centered, web-based decision aid (DA) designed to promote the understanding of breast cancer risk and to engage diverse women in planning a preference-sensitive course of decision making about taking chemoprevention. Objective This study aims to understand the perceptions of women at high risk of developing breast cancer regarding their experience with using RealRisks—a DA designed to promote the uptake of breast cancer chemoprevention—and to understand their information needs. Methods We completed enrollment to a randomized controlled trial among 300 racially and ethnically diverse women at high risk of breast cancer who were assigned to standard educational materials alone or such materials in combination with RealRisks. We conducted semistructured interviews with a subset of 21 high-risk women enrolled in the intervention arm of the randomized controlled trial who initially accessed the tool (on average, 1 year earlier) to understand how they interacted with the tool. All interviews were audio recorded, transcribed verbatim, and compared with digital audio recordings to ensure the accuracy of the content. We used content analysis to generate themes. Results The mean age of the 21 participants was 58.5 (SD 10.1) years. The participants were 5% (1/21) Asian, 24% (5/21) Black or African American, and 71% (15/21) White; 10% (2/21) of participants were Hispanic or Latina. All participants reported using RealRisks after being granted access to the DA. In total, 4 overarching themes emerged from the qualitative analyses: the acceptability of the intervention, specifically endorsed elements of the DA, recommendations for improvements, and information needs. All women found RealRisks to be acceptable and considered it to be helpful (21/21, 100%). Most women (13/21, 62%) reported that RealRisks was easy to navigate, user-friendly, and easily accessible on the web. The majority of women (18/21, 86%) felt that RealRisks improved their knowledge about breast cancer risk and chemoprevention options and that RealRisks informed their (17/21, 81%) decision about whether or not to take chemoprevention. Some women (9/21, 43%) shared recommendations for improvements, as they wanted more tailoring based on user characteristics, felt that the DA was targeting a narrow population of Hispanic or Latina by using graphic novel–style narratives, wanted more understandable terminology, and felt that the tool placed a strong emphasis on chemoprevention drugs. Conclusions This qualitative study demonstrated the acceptability of the RealRisks web-based DA among a diverse group of high-risk women, who provided some recommendations for improvement.
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Affiliation(s)
- Tarsha Jones
- Florida Atlantic University, Boca Raton, FL, United States
| | | | | | | | - Rita Kukafka
- Columbia University, New York, NY, United States
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Macdonald C, Saunders CM, Keogh LA, Hunter M, Mazza D, McLachlan SA, Jones SC, Nesci S, Friedlander ML, Hopper JL, Emery JD, Hickey M, Milne RL, Phillips KA. Breast Cancer Chemoprevention: Use and Views of Australian Women and Their Clinicians. Cancer Prev Res (Phila) 2020; 14:131-144. [PMID: 33115784 DOI: 10.1158/1940-6207.capr-20-0369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/27/2020] [Accepted: 10/15/2020] [Indexed: 11/16/2022]
Abstract
Guidelines endorse the use of chemoprevention for breast cancer risk reduction. This study examined the barriers and facilitators to chemoprevention use for Australian women at increased risk of breast cancer, and their clinicians. Surveys, based on the Theoretical Domains Framework, were mailed to 1,113 women at ≥16% lifetime risk of breast cancer who were enrolled in the Kathleen Cuningham Foundation Consortium for Research into Familial Breast Cancer cohort study (kConFab), and their 524 treating clinicians. Seven hundred twenty-five women (65%) and 221 (42%) clinicians responded. Only 10 (1.4%) kConFab women had ever taken chemoprevention. Three hundred seventy-eight (52%) kConFab women, two (3%) breast surgeons, and 51 (35%) family physicians were not aware of chemoprevention. For women, the strongest barriers to chemoprevention were side effects (31%) and inadequate information (23%), which operate in the Theoretical Domains Framework domains of "beliefs about consequences" and "knowledge," respectively. Strongest facilitators related to tamoxifen's long-term efficacy (35%, "knowledge," "beliefs about consequences," and "goals" domains), staying healthy for family (13%, "social role" and "goals" domains), and abnormal breast biopsy (13%, "environmental context" domain). The strongest barrier for family physicians was insufficient knowledge (45%, "knowledge" domain) and for breast surgeons was medication side effects (40%, "beliefs about consequences" domain). The strongest facilitators for both clinician groups related to clear guidelines, strong family history, and better tools to select patients ("environmental context and resources" domain). Clinician knowledge and resources, and beliefs about the side-effect consequences of chemoprevention, are key domains that could be targeted to potentially enhance uptake. PREVENTION RELEVANCE: Despite its efficacy in reducing breast cancer incidence, chemoprevention is underutilised. This survey study of Australian women and their clinicians used behavioural change theory to identify modifiable barriers to chemoprevention uptake, and to suggest interventions such as policy change, educational resources and public campaigns, that may increase awareness and use.See related Spotlight by Vogel, p. 1.
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Affiliation(s)
- Courtney Macdonald
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | | | - Louise A Keogh
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Morgan Hunter
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Danielle Mazza
- Department of General Practice, Monash University, Melbourne, Australia
| | - Sue-Anne McLachlan
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia.,Department of Medical Oncology, St Vincent's Hospital, Fitzroy, Melbourne, Australia
| | - Sandra C Jones
- ACU Engagement, Australian Catholic University, Melbourne, Australia
| | - Stephanie Nesci
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Michael L Friedlander
- Prince of Wales Clinical School University of New South Wales, Sydney, Australia.,Department of Medical Oncology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - John L Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Jon D Emery
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Australia.,School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
| | - Martha Hickey
- Department of Obstetrics and Gynaecology, University of Melbourne and the Royal Women's Hospital, Melbourne, Australia
| | - Roger L Milne
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia.,Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Melbourne, Australia
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6
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Crew KD, Silverman TB, Vanegas A, Trivedi MS, Dimond J, Mata J, Sin M, Jones T, Terry MB, Tsai WY, Kukafka R. Study protocol: Randomized controlled trial of web-based decision support tools for high-risk women and healthcare providers to increase breast cancer chemoprevention. Contemp Clin Trials Commun 2019; 16:100433. [PMID: 31497674 PMCID: PMC6722284 DOI: 10.1016/j.conctc.2019.100433] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/11/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Chemoprevention using selective estrogen receptor modulators and aromatase inhibitors has been shown to reduce invasive breast cancer incidence in high-risk women. Despite this evidence, few high-risk women who are eligible for chemoprevention utilize it as a risk-reducing strategy. Reasons for low uptake include inadequate knowledge about chemoprevention among patients and healthcare providers, concerns about side effects, time constraints during the clinical encounter, and competing comorbidities. METHODS/DESIGN We describe the study design of a randomized controlled trial examining the effect of two web-based decision support tools on chemoprevention decision antecedents and quality, referral for specialized counseling, and chemoprevention uptake among women at an increased risk for breast cancer. The trial is being conducted at a large, urban medical center. A total of 300 patients and 50 healthcare providers will be recruited and randomized to standard educational materials alone or in combination with the decision support tools. Patient reported outcomes will be assessed at baseline, one and six months after randomization, and after their clinic visit with their healthcare provider. DISCUSSION We are conducting this trial to provide evidence on how best to support personalized breast cancer risk assessment and informed and shared decision-making for chemoprevention. We propose to integrate the decision support tools into clinical workflow, which can potentially expand quality decision-making and chemoprevention uptake. TRIAL REGISTRATION NCT03069742.
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Affiliation(s)
- Katherine D. Crew
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Thomas B. Silverman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Alejandro Vanegas
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Meghna S. Trivedi
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Jill Dimond
- Sassafras Tech Collective, Ann Arbor, MI, USA
| | - Jennie Mata
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Margaret Sin
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Tarsha Jones
- Christine E Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL, USA
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Wei-Yann Tsai
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rita Kukafka
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
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7
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Conley CC, Agnese DM, Vadaparampil ST, Andersen BL. Factors associated with intentions for breast cancer risk management: Does risk group matter? Psychooncology 2019; 28:1119-1126. [PMID: 30889627 DOI: 10.1002/pon.5066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/05/2019] [Accepted: 03/12/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE National guidelines provide breast cancer (BC) risk management recommendations based on estimated lifetime risk. Despite this specificity, it is unclear if women's risk management intentions are or are not guideline concordant. To address this knowledge gap, women at varying risk levels reported intentions for risk-reducing behaviors. Factors associated with intentions, informed by the Health Beliefs Model, were also studied. METHODS Women with elevated BC risk (N = 103) were studied and categorized by risk level: moderate (15%-20%), high (greater than or equal to 20%), or very high (BRCA1/2 positive). Participants self-reported BC susceptibility, self-efficacy, and benefits, barriers, and intentions for risk-reducing mastectomy (RRM), risk-reducing salpingo-oophorectomy (RRSO), chemoprevention, improving diet or physical activity, and reducing alcohol use. RESULTS Groups significantly differed in RRSO intentions (P < .01); BRCA1/2 positive women had greater intentions for RRSO. Groups did not differ in intentions for RRM, chemoprevention, or lifestyle changes (Ps > .28). In hierarchical linear regression models examining Health Belief Model (HBM) factors, perceived susceptibility was associated with intentions for RRM (β = .169, P = .08). Perceived benefits was associated with intentions for RRM (β = .237, P = .02) and chemoprevention (β = .388, P < .01). Self-efficacy was associated with intentions for physical activity (β = .286, P < .01). CONCLUSIONS Consistent with guidelines, BRCA1/2 positive women reported greater intentions for RRSO, and risk groups did not differ in intentions for lifestyle changes. Notably, women's intentions for RRM and chemoprevention were guideline discordant; groups did not differ in intentions for these behaviors. Accounting for the effects of risk group, modifiable health beliefs were also associated with risk management intentions; these may represent targets for decision support interventions.
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Affiliation(s)
- Claire C Conley
- Department of Psychology, The Ohio State University, Columbus, Ohio.,Health Outcomes and Behavior Program, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Doreen M Agnese
- Department of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Susan T Vadaparampil
- Health Outcomes and Behavior Program, H. Lee Moffitt Cancer Center, Tampa, Florida
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8
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Pilot study of decision support tools on breast cancer chemoprevention for high-risk women and healthcare providers in the primary care setting. BMC Med Inform Decis Mak 2018; 18:134. [PMID: 30558581 PMCID: PMC6296071 DOI: 10.1186/s12911-018-0716-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 12/03/2018] [Indexed: 02/08/2023] Open
Abstract
Background Breast cancer chemoprevention can reduce breast cancer incidence in high-risk women; however, chemoprevention is underutilized in the primary care setting. We conducted a pilot study of decision support tools among high-risk women and their primary care providers (PCPs). Methods The intervention included a decision aid (DA) for high-risk women, RealRisks, and a provider-centered tool, Breast Cancer Risk Navigation (BNAV). Patients completed validated surveys at baseline, after RealRisks and after their PCP clinical encounter or at 6-months. Referral for high-risk consultation and chemoprevention uptake were assessed via the electronic health record. The primary endpoint was accuracy of breast cancer risk perception at 6-months. Results Among 40 evaluable high-risk women, median age was 64.5 years and median 5-year breast cancer risk was 2.19%. After exposure to RealRisks, patients demonstrated an improvement in accurate breast cancer risk perceptions (p = 0.02), an increase in chemoprevention knowledge (p < 0.01), and 24% expressed interest in taking chemoprevention. Three women had a high-risk referral, and no one initiated chemoprevention. Decisional conflict significantly increased from after exposure to RealRisks to after their clinical encounter or at 6-months (p < 0.01). Accurate breast cancer risk perceptions improved and was sustained at 6-months or after clinical encounters. We discuss the side effect profile of chemoprevention and the care pathway when RealRisks was introduced to understand why patients experienced increased decision conflict. Conclusion Future interventions should carefully link the use of a DA more proximally to the clinical encounter, investigate timed measurements of decision conflict and improve risk communication, shared decision making, and chemoprevention education for PCPs. Additional work remains to better understand the impact of decision aids targeting both patients and providers. Trial registration ClinicalTrials.gov Identifier: NCT02954900 November 4, 2016 Retrospectively registered.
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Rainey L, van der Waal D, Wengström Y, Jervaeus A, Broeders MJ. Women's perceptions of the adoption of personalised risk-based breast cancer screening and primary prevention: a systematic review. Acta Oncol 2018; 57:1275-1283. [PMID: 29882455 DOI: 10.1080/0284186x.2018.1481291] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Increased knowledge of breast cancer risk factors may enable a paradigm shift from the current age-based mammographic screening programmes to a personalised risk-based approach. This would warrant a significant change in practice, yet the acceptability from a woman's perspective has never been systematically explored. In this systematic review, we inventoried and appraised studies of women's perceptions of risk-based breast cancer screening and prevention to identify factors associated with adopting this new paradigm. METHODS We searched Medline, Embase and PsycInfo to identify original articles in English containing perceptions of risk-based breast cancer screening and/or primary prevention of women with an average to above average risk of developing breast cancer. Qualitative data were systematically extracted and referenced against four theoretical models of preventative health behaviour adoption. RESULTS When considering the adoption of this novel screening and prevention programme, women carefully review their perceived susceptibility to breast cancer. Their decisions are based on a cost-benefit analysis of adopting lifestyle changes, chemoprevention, or prophylactic surgery, taking into account their perceived competence, individual autonomy, relatedness to others, and personal preference. The role of intent is limited when considering behavioural change. CONCLUSIONS Implementing risk-based breast cancer screening and prevention will require a multifactorial approach. The transition from theory to practice can be supported by developing evidence-based shared decision aids and family-oriented (genetic) counselling programmes.
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Affiliation(s)
- Linda Rainey
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Daniëlle van der Waal
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne Wengström
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Huddinge, Sweden
- Theme Cancer, Karolinska University Hospital, Huddinge, Sweden
| | - Anna Jervaeus
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Huddinge, Sweden
| | - Mireille J.M. Broeders
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Dutch Expert Center for Screening, Nijmegen, The Netherlands
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Abstract
In this review, we address selected areas that are central to the state-of-the-art of cancer prevention science. The emphasis on prevention as a viable and critical approach to decreasing cancer mortality has gained traction in recent years, evidenced by its inclusion in the US Vice President's Cancer Initiative (also termed 'Moonshot'). Cancer prevention occurs by arresting, slowing down, or reversing the carcinogenic process before invasion into surrounding tissue or by avoiding or blocking causative exposure. An important challenge is to identify individuals who will benefit most from preventive interventions with the least possible harm. Preventive interventions range from avoiding known carcinogens (e.g., tobacco or asbestos) to intervening with anticarcinogenic strategies (behavioral modifications , such as diet and exercise; medications; nutritional agents; and vaccination against causative agents). Here, we focus on active intervention with measures involving pharmaceutical and immunological agents.
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Affiliation(s)
- Barbara K Dunn
- National Cancer Institute, Division of Cancer Prevention, 9609 Medical Center Drive, MSC 9787, Bethesda, MD 20892-9787, USA
| | - Barnett S Kramer
- National Cancer Institute, Division of Cancer Prevention, 9609 Medical Center Drive, MSC 9787, Bethesda, MD 20892-9787, USA
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11
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Meiser B, Wong WKT, Peate M, Julian-Reynier C, Kirk J, Mitchell G. Motivators and barriers of tamoxifen use as risk-reducing medication amongst women at increased breast cancer risk: a systematic literature review. Hered Cancer Clin Pract 2017; 15:14. [PMID: 28943990 PMCID: PMC5607482 DOI: 10.1186/s13053-017-0075-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 09/14/2017] [Indexed: 12/02/2022] Open
Abstract
Background Selective estrogen receptor modulators, such as tamoxifen, reduce breast cancer risk by up to 50% in women at increased risk for breast cancer. Despite tamoxifen’s well-established efficacy, many studies show that most women are not taking up tamoxifen. This systematic literature review aimed to identify the motivators and barriers to tamoxifen use ‘s amongst high-risk women. Methods Using MEDLINE, PsycINFO, and Embase plus reviewing reference lists of relevant articles published between 1995 and 2016, 31 studies (published in 35 articles) were identified, which addressed high-risk women’s decisions about risk-reducing medication to prevent breast cancer and were peer-reviewed primary clinical studies. Results A range of factors were identified as motivators of, and barriers to, tamoxifen uptake including: perceived risk, breast-cancer-related anxiety, health professional recommendation, perceived drug effectiveness, concerns about side-effects, knowledge and access to information about side-effects, beliefs about the role of risk-reducing medication, provision of a biomarker, preference for other forms of breast cancer risk reduction, previous treatment experience, concerns about randomization in clinical trial protocols and finally altruism. Conclusions Results indicate that the decision for high-risk women regarding tamoxifen use or non-use as a risk-reducing medication is not straightforward. Support of women making this decision is essential and needs to encompass the full range of factors, both informational and psychological.
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Affiliation(s)
- B Meiser
- Prince of Wales Clinical School, UNSW, Level 4, Lowy Cancer Research Centre C25, Sydney, NSW 2052 Australia
| | - W K T Wong
- Prince of Wales Clinical School, UNSW, Level 4, Lowy Cancer Research Centre C25, Sydney, NSW 2052 Australia.,School of Social Sciences and Prince of Wales Clinical School, UNSW Sydney, Kensington, NSW 2052 Australia
| | - M Peate
- Prince of Wales Clinical School, UNSW, Level 4, Lowy Cancer Research Centre C25, Sydney, NSW 2052 Australia.,Department of Obstetrics and Oncology, Royal Women's Hospital, University of Melbourne, Melbourne, VIC 3052 Australia
| | | | - J Kirk
- Familial Cancer Service, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145 Australia.,Westmead Millennium Institute for Medical Research at the University of Sydney, PO Box 412, Westmead, NSW 2145 Australia
| | - G Mitchell
- Sir Peter MacCallum Dept of Oncology, University of Melbourne, Parkville, VIC 3010 Australia.,Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC 8006 Australia
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12
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Crew KD, Albain KS, Hershman DL, Unger JM, Lo SS. How do we increase uptake of tamoxifen and other anti-estrogens for breast cancer prevention? NPJ Breast Cancer 2017. [PMID: 28649660 PMCID: PMC5460136 DOI: 10.1038/s41523-017-0021-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Several randomized controlled trials of anti-estrogens, such as tamoxifen and aromatase inhibitors, have demonstrated up to a 50–65% decrease in breast cancerincidence among high-risk women. Approximately 15% of women, age 35–79 years, in the U.S. meet criteria for breast cancer preventive therapies, but uptake of these medications remain low. Explanations for this low uptake includelack of awareness of breast cancer risk status, insufficient knowledge about breast cancer preventive therapies among patients and physicians, and toxicity concerns. Increasing acceptance of pharmacologic breast cancer prevention will require effective communication of breast cancer risk, accurate representation about the potential benefits and side effects of anti-estrogens, targeting-specific high-risk populations most likely to benefit from preventive therapy, and minimizing the side effects of current anti-estrogens with novel administration and dosing options. One strategy to improve the uptake of chemoprevention strategies is to consider lessons learned from the use of drugs to prevent other chronic conditions, such as cardiovascular disease. Enhancing uptake and adherence to anti-estrogens for primary prevention holds promise for significantly reducing breast cancer incidence, however, this will require a significant change in our current clinical practice and stronger advocacy and awareness at the national level.
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Affiliation(s)
- Katherine D Crew
- Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY USA
| | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL USA
| | - Dawn L Hershman
- Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY USA
| | - Joseph M Unger
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Shelly S Lo
- Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL USA
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13
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Martinez KA, Fagerlin A, Witteman HO, Holmberg C, Hawley ST. What Matters to Women When Making Decisions About Breast Cancer Chemoprevention? PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2017; 9:149-59. [PMID: 26115846 DOI: 10.1007/s40271-015-0134-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Despite the effectiveness of chemoprevention (tamoxifen and raloxifene) in preventing breast cancer among women at high risk for the disease, uptake is low. The objective of this study was to determine the tradeoff preferences for various attributes associated with chemoprevention among women not currently taking the drugs. METHODS We used rating-based conjoint analysis to evaluate the relative importance of a number of attributes associated with chemoprevention, including risk of side effects, drug effectiveness, time needed to take the drugs, and availability of a blood test to see if the drugs were working in an Internet sample of women. We generated mean importance values and part-worth utilities for all attribute levels associated with taking chemoprevention. We then used multivariable linear regression to examine attribute importance scores controlling for participant age, race, Hispanic ethnicity, educational level, and a family history of breast cancer. RESULTS Overall interest in taking chemoprevention was low among the 1094 women included in the analytic sample, even for the scenario in which participants would receive the greatest benefit and fewest risks associated with taking the drugs. Time needed to take the pill for it to work and 5-year risk of breast cancer were the most important attributes driving tradeoff preferences between the chemoprevention scenarios. CONCLUSIONS Interest in taking chemoprevention among this sample of women at average risk was low. Addressing women's concerns about the time needed to take chemoprevention for it to work may help clinicians improve uptake of the drugs among those likely to benefit.
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Affiliation(s)
- Kathryn A Martinez
- Ann Arbor VA Center for Clinical Management Research, Building 16, 4th Floor, 2800 Plymouth Road, Ann Arbor, MI, 48105, USA.
| | - Angela Fagerlin
- Ann Arbor VA Center for Clinical Management Research, Building 16, 4th Floor, 2800 Plymouth Road, Ann Arbor, MI, 48105, USA.,Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Holly O Witteman
- Department of Family and Emergency Medicine and Office of Education and Continuing Professional Development, Laval University, Quebec City, QC, Canada.,Population Health and Optimal Health Practices Research Unit, CHU de Québec Research Centre, Quebec City, QC, Canada
| | | | - Sarah T Hawley
- Ann Arbor VA Center for Clinical Management Research, Building 16, 4th Floor, 2800 Plymouth Road, Ann Arbor, MI, 48105, USA.,Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
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14
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Hoerger M, Scherer LD, Fagerlin A. Affective forecasting and medication decision making in breast-cancer prevention. Health Psychol 2016; 35:594-603. [PMID: 26867042 PMCID: PMC4868645 DOI: 10.1037/hea0000324] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Over 2 million American women at elevated risk for breast cancer are eligible to take chemoprevention medications such as tamoxifen and raloxifene, which can cut in half the risk of developing breast cancer, but which also have a number of side effects. Historically, very few at-risk women have opted to use chemoprevention medications. Affective forecasting theory suggests that people may avoid these medications if they expect taking them to increase their health-related stress. METHOD After receiving an individually tailored decision aid that provided personalized information about the risks and benefits of these medications, 661 women at elevated risk of breast cancer were asked to make 3 affective forecasts, predicting what their level of health-related stress would be if they took tamoxifen, raloxifene, or neither medication. They also completed measures of decisional preferences and intentions, and at a 3-month follow-up, reported on whether or not they had decided to use either medication. RESULTS On the affective forecasting items, very few women (<10%) expected the medications to reduce their health-related stress, relative to no medication at all. Participants with more negative affective forecasts about taking a chemoprevention medication expressed lower preferences and intentions for using the medications (Cohen's ds from 0.74 to 0.79) and were more likely to have opted against using medication at follow-up (OR range = 1.34-2.66). CONCLUSION These findings suggest that affective forecasting may explain avoidance of breast-cancer chemoprevention medications. They also highlight the need for more research aimed at integrating emotional content into decision aids. (PsycINFO Database Record
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Affiliation(s)
| | | | - Angela Fagerlin
- University of Michigan and Ann Arbor VA Center for Clinical Management Research
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15
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Brewster AM, Davidson NE, McCaskill-Stevens W. Chemoprevention for breast cancer: overcoming barriers to treatment. Am Soc Clin Oncol Educ Book 2016:85-90. [PMID: 24451714 DOI: 10.14694/edbook_am.2012.32.152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Evidence from placebo-controlled, randomized clinical trials supports the use of chemoprevention in women at high risk for developing breast cancer, and two agents-tamoxifen and raloxifene-are U.S. Food and Drug Administration (FDA)-approved for the indication. Despite clinical guidelines that recommend physicians counsel high-risk women about the use of chemoprevention and the estimated 2.4 million women in the United States who meet eligibility criteria for net benefit, the uptake of breast cancer chemoprevention has been exceedingly low. Assessments of the risks and benefits of chemoprevention are aided by the availability of models that can be used to estimate of the risk-benefit ratio. However, many physicians remain unaware of these resources to determine patient eligibility for chemoprevention and lack the time to provide informed counseling to their patients. The barriers for patients' acceptance of chemoprevention treatment include fear of side effects and the perception that chemoprevention will not substantially lower their risk of developing breast cancer. Despite these challenges, there are substantial opportunities to increase the utilization of chemoprevention. These strategies include education, dissemination of user-friendly risk-benefit models, and the support of research efforts focused on identifying biomarkers that can more accurately select women most likely to develop breast cancer and predict responsiveness of treatment.
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Affiliation(s)
- Abenaa M Brewster
- From the University of Texas M. D. Anderson Cancer Center, Houston, TX; University of Pittsburgh Cancer Institute, Pittsburgh, PA; and National Cancer Institute, Bethesda, MD
| | - Nancy E Davidson
- From the University of Texas M. D. Anderson Cancer Center, Houston, TX; University of Pittsburgh Cancer Institute, Pittsburgh, PA; and National Cancer Institute, Bethesda, MD
| | - Worta McCaskill-Stevens
- From the University of Texas M. D. Anderson Cancer Center, Houston, TX; University of Pittsburgh Cancer Institute, Pittsburgh, PA; and National Cancer Institute, Bethesda, MD
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16
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Crew KD. Addressing barriers to uptake of breast cancer chemoprevention for patients and providers. Am Soc Clin Oncol Educ Book 2016:e50-8. [PMID: 25993215 DOI: 10.14694/edbook_am.2015.35.e50] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Breast cancer is the most common malignancy among women in the United States, and the primary prevention of this disease is a major public health issue. Because there are relatively few modifiable breast cancer risk factors, pharmacologic interventions with antiestrogens have the potential to significantly affect the primary prevention setting. Breast cancer chemoprevention with selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene, and with aromatase inhibitors (AIs) exemestane and anastrozole, is underutilized despite several randomized controlled trials demonstrating up to a 50% to 65% relative risk reduction in breast cancer incidence among women at high risk. An estimated 10 million women in the United States meet high-risk criteria for breast cancer and are potentially eligible for chemoprevention, but less than 5% of women at high risk who are offered antiestrogens for primary prevention agree to take it. Reasons for low chemoprevention uptake include lack of routine breast cancer risk assessment in primary care, inadequate time for counseling, insufficient knowledge about antiestrogens among patients and providers, and concerns about side effects. Interventions designed to increase chemoprevention uptake, such as decision aids and incorporating breast cancer risk assessment into clinical practice, have met with limited success. Clinicians can help women make informed decisions about chemoprevention by effectively communicating breast cancer risk and enhancing knowledge about the risks and benefits of antiestrogens. Widespread adoption of chemoprevention will require a major paradigm shift in clinical practice for primary care providers (PCPs). However, enhancing uptake and adherence to breast cancer chemoprevention holds promise for reducing the public health burden of this disease.
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Affiliation(s)
- Katherine D Crew
- From the Department of Medicine, College of Physicians and Surgeons, Department of Epidemiology, Mailman School of Public Health, and Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
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17
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Gorini A, Masiero M, Pravettoni G. Patient decision aids for prevention and treatment of cancer diseases: are they really personalised tools? Eur J Cancer Care (Engl) 2016; 25:936-960. [DOI: 10.1111/ecc.12451] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2015] [Indexed: 11/27/2022]
Affiliation(s)
- A. Gorini
- Department of Oncology and Hemato-Oncology; University of Milan; Milano Italy
- European Institute of Oncology; Milan Italy
| | - M. Masiero
- Department of Oncology and Hemato-Oncology; University of Milan; Milano Italy
- European Institute of Oncology; Milan Italy
| | - G. Pravettoni
- Department of Oncology and Hemato-Oncology; University of Milan; Milano Italy
- European Institute of Oncology; Milan Italy
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18
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DeCensi A, Thorat MA, Bonanni B, Smith SG, Cuzick J. Barriers to preventive therapy for breast and other major cancers and strategies to improve uptake. Ecancermedicalscience 2015; 9:595. [PMID: 26635899 PMCID: PMC4664508 DOI: 10.3332/ecancer.2015.595] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Indexed: 12/31/2022] Open
Abstract
The global cancer burden continues to rise and the war on cancer can only be won if improvements in treatment go hand in hand with therapeutic cancer prevention. Despite the availability of several efficacious agents, utilisation of preventive therapy has been poor due to various barriers, such as the lack of physician and patient awareness, fear of side effects, and licensing and indemnity issues. In this review, we discuss these barriers in detail and propose strategies to overcome them. These strategies include improving physician awareness and countering prejudices by highlighting the important differences between preventive therapy and cancer treatment. The importance of the agent-biomarker-cohort (ABC) paradigm to improve effectiveness of preventive therapy cannot be overemphasised. Future research to improve therapeutic cancer prevention needs to include improvements in the prediction of benefits and harms, and improvements in the safety profile of existing agents by experimentation with dose. We also highlight the role of drug repurposing for providing new agents as well as to address the current imbalance between therapeutic and preventive research. In order to move the field of therapeutic cancer prevention forwards, engagement with policymakers to correct research imbalance as well as to remove practical obstacles to implementation is also urgently needed.
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Affiliation(s)
- Andrea DeCensi
- Division of Medical Oncology, E.O. Ospedali Galliera, Mura delle Cappuccine 14, Genoa 16128, Italy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
| | - Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
- Breast Services, Division of Surgery and Interventional Science, Whittington Hospital, Magdala Avenue, London N19 5NF, UK
| | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Via Ripamonti 435, Milan 20141, Italy
| | - Samuel G Smith
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
- Health Behaviour Research Centre, University College London, London WC1E 7HB, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
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19
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Fabian CJ, Kimler BF, Zalles CM, Phillips TA, Metheny T, Petroff BK, Havighurst TC, Kim K, Bailey HH, Heckman-Stoddard BM. Clinical Trial of Acolbifene in Premenopausal Women at High Risk for Breast Cancer. Cancer Prev Res (Phila) 2015; 8:1146-55. [PMID: 26391916 DOI: 10.1158/1940-6207.capr-15-0109] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 09/07/2015] [Indexed: 12/31/2022]
Abstract
The purpose of this study was to assess the feasibility of using the selective estrogen receptor modulator (SERM) acolbifene as a breast cancer prevention agent in premenopausal women. To do so, we assessed change in proliferation in benign breast tissue sampled by random periareolar fine-needle aspiration (RPFNA) as a primary endpoint, along with changes in other risk biomarkers and objective and subjective side effects as secondary endpoints. Twenty-five women with cytologic hyperplasia ± atypia and ≥2% of breast epithelial cells staining positive for Ki-67, received 20 mg acolbifene daily for 6-8 months, and then had benign breast tissue and blood risk biomarkers reassessed. Ki-67 decreased from a median of 4.6% [interquartile range (IQR), 3.1%-8.5%] at baseline to 1.4% (IQR, 0.6%-3.5%) after acolbifene (P < 0.001; Wilcoxon signed-rank test), despite increases in bioavailable estradiol. There were also significant decreases in expression (RT-qPCR) of estrogen-inducible genes that code for pS2, ERα, and progesterone receptor (P ≤ 0.026). There was no significant change in serum IGF1, IGFBP3, IGF1:IGFBP3 ratio, or mammographic breast density. Subjective side effects were minimal with no significant increase in hot flashes, muscle cramps, arthralgias, or fatigue. Objective measures showed a clinically insignificant decrease in lumbar spine bone density (DEXA) and an increase in ovarian cysts but no change in endometrial thickness (sonography). In summary, acolbifene was associated with favorable changes in benign breast epithelial cell proliferation and estrogen-inducible gene expression but minimal side effects, suggesting a phase IIB placebo-controlled trial evaluating it further for breast cancer prevention.
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Affiliation(s)
- Carol J Fabian
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Bruce F Kimler
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas.
| | | | - Teresa A Phillips
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Trina Metheny
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Brian K Petroff
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Thomas C Havighurst
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison, Madison, Wisconsin
| | - KyungMann Kim
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison, Madison, Wisconsin
| | - Howard H Bailey
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
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20
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Lee O, Page K, Ivancic D, Helenowski I, Parini V, Sullivan ME, Margenthaler JA, Chatterton RT, Jovanovic B, Dunn BK, Heckman-Stoddard BM, Foster K, Muzzio M, Shklovskaya J, Skripkauskas S, Kulesza P, Green D, Hansen NM, Bethke KP, Jeruss JS, Bergan R, Khan SA. A randomized phase II presurgical trial of transdermal 4-hydroxytamoxifen gel versus oral tamoxifen in women with ductal carcinoma in situ of the breast. Clin Cancer Res 2015; 20:3672-82. [PMID: 25028506 DOI: 10.1158/1078-0432.ccr-13-3045] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE Local transdermal therapy to the breast may achieve effective target-organ drug delivery, while diminishing systemic effects. We conducted a randomized, double-blind, placebo-controlled phase II trial comparing transdermal 4-hydroxytamoxifen gel (4-OHT) to oral tamoxifen (oral-T) in women with ductal carcinoma in situ (DCIS). METHODS Twenty-seven pre- and postmenopausal women were randomized to 4-OHT (4 mg/day) or oral-T (20 mg/day) for 6 to 10 weeks before surgery. Plasma, nipple aspirate fluid, and breast adipose tissue concentrations of tamoxifen and its major metabolites were determined by liquid chromatography/tandem mass spectrometry. The primary endpoint was Ki67 labeling in DCIS lesions, measured by immunohistochemistry. In plasma, insulin-like growth factor-1 (IGFI), sex hormone-binding globulin (SHBG), and coagulation protein concentrations were determined. RESULTS Posttherapy Ki67 decreased by 3.4% in the 4-OHT and 5.1% in the oral-T group (P ≤ 0.03 in both, between-group P = 0. 99). Mean plasma 4-OHT was 0.2 and 1.1 ng/mL in 4-OHT and oral groups, respectively (P = 0.0003), whereas mean breast adipose tissue concentrations of 4-OHT were 5.8 ng/g in the 4-OHT group and 5.4 ng/g in the oral group (P = 0.88). There were significant increases in plasma SHBG, factor VIII, and von Willebrand factor and a significant decrease in plasma IGFI with oral-T, but not with 4-OHT. The incidence of hot flashes was similar in both groups. CONCLUSIONS The antiproliferative effect of 4-OHT gel applied to breast skin was similar to that of oral-T, but effects on endocrine and coagulation parameters were reduced. These findings support the further evaluation of local transdermal therapy for DCIS and breast cancer prevention.
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Affiliation(s)
- Oukseub Lee
- Authors' Affiliations: Departments of Surgery
| | - Katherine Page
- The Robert H. Lurie Cancer Center of Northwestern University
| | | | | | | | | | - Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Barbara K Dunn
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland; and
| | | | - Kathleen Foster
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland; and
| | | | | | | | | | | | - Nora M Hansen
- Authors' Affiliations: Departments of Surgery, The Robert H. Lurie Cancer Center of Northwestern University
| | - Kevin P Bethke
- Authors' Affiliations: Departments of Surgery, The Robert H. Lurie Cancer Center of Northwestern University
| | - Jacqueline S Jeruss
- Authors' Affiliations: Departments of Surgery, The Robert H. Lurie Cancer Center of Northwestern University
| | - Raymond Bergan
- Medicine, Division of Hematology/Oncology; The Robert H. Lurie Cancer Center of Northwestern University
| | - Seema A Khan
- Authors' Affiliations: Departments of Surgery, The Robert H. Lurie Cancer Center of Northwestern University;
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21
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Mazor KM, Rubin DL, Roblin DW, Williams AE, Han PKJ, Gaglio B, Cutrona SL, Costanza ME, Wagner JL. Health literacy-listening skill and patient questions following cancer prevention and screening discussions. Health Expect 2015. [PMID: 26202787 PMCID: PMC4723284 DOI: 10.1111/hex.12387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective Patient question‐asking is essential to shared decision making. We sought to describe patients' questions when faced with cancer prevention and screening decisions, and to explore differences in question‐asking as a function of health literacy with respect to spoken information (health literacy–listening). Methods Four‐hundred and thirty‐three (433) adults listened to simulated physician–patient interactions discussing (i) prophylactic tamoxifen for breast cancer prevention, (ii) PSA testing for prostate cancer and (iii) colorectal cancer screening, and identified questions they would have. Health literacy–listening was assessed using the Cancer Message Literacy Test‐Listening (CMLT‐Listening). Two authors developed a coding scheme, which was applied to all questions. Analyses examined whether participants scoring above or below the median on the CMLT‐Listening asked a similar variety of questions. Results Questions were coded into six major function categories: risks/benefits, procedure details, personalizing information, additional information, decision making and credibility. Participants who scored higher on the CMLT‐Listening asked a greater variety of risks/benefits questions; those who scored lower asked a greater variety of questions seeking to personalize information. This difference persisted after adjusting for education. Conclusion Patients' health literacy–listening is associated with distinctive patterns of question utilization following cancer screening and prevention counselling. Providers should not only be responsive to the question functions the patient favours, but also seek to ensure that the patient is exposed to the full range of information needed for shared decision making.
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Affiliation(s)
- Kathleen M Mazor
- Meyers Primary Care Institute, Worcester, MA, USA.,Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Douglas W Roblin
- Health Management and Policy, Georgia State University, Atlanta, GA, USA.,Kaiser Permanente Georgia, Atlanta, GA, USA
| | | | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - Bridget Gaglio
- Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Sarah L Cutrona
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Mary E Costanza
- University of Massachusetts Medical School, Worcester, MA, USA
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22
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Holmberg C, Waters EA, Whitehouse K, Daly M, McCaskill-Stevens W. My Lived Experiences Are More Important Than Your Probabilities: The Role of Individualized Risk Estimates for Decision Making about Participation in the Study of Tamoxifen and Raloxifene (STAR). Med Decis Making 2015; 35:1010-22. [PMID: 26183166 DOI: 10.1177/0272989x15594382] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 06/07/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Decision-making experts emphasize that understanding and using probabilistic information are important for making informed decisions about medical treatments involving complex risk-benefit tradeoffs. Yet empirical research demonstrates that individuals may not use probabilities when making decisions. OBJECTIVES To explore decision making and the use of probabilities for decision making from the perspective of women who were risk-eligible to enroll in the Study of Tamoxifen and Raloxifene (STAR). METHODS We conducted narrative interviews with 20 women who agreed to participate in STAR and 20 women who declined. The project was based on a narrative approach. Analysis included the development of summaries of each narrative, and thematic analysis with developing a coding scheme inductively to code all transcripts to identify emerging themes. RESULTS Interviewees explained and embedded their STAR decisions within experiences encountered throughout their lives. Such lived experiences included but were not limited to breast cancer family history, a personal history of breast biopsies, and experiences or assumptions about taking tamoxifen or medicines more generally. CONCLUSIONS Women's explanations of their decisions about participating in a breast cancer chemoprevention trial were more complex than decision strategies that rely solely on a quantitative risk-benefit analysis of probabilities derived from populations In addition to precise risk information, clinicians and risk communicators should recognize the importance and legitimacy of lived experience in individual decision making.
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Affiliation(s)
- Christine Holmberg
- Berlin School of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany (CH, KW)
| | - Erika A Waters
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA (EAW)
| | - Katie Whitehouse
- Berlin School of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany (CH, KW)
| | - Mary Daly
- Fox Chase Cancer Center, Philadelphia, PA, USA (MD)
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23
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Reimers LL, Sivasubramanian PS, Hershman D, Terry MB, Greenlee H, Campbell J, Kalinsky K, Maurer M, Jayasena R, Sandoval R, Alvarez M, Crew KD. Breast Cancer Chemoprevention among High-risk Women and those with Ductal Carcinoma In Situ. Breast J 2015; 21:377-86. [PMID: 25879521 DOI: 10.1111/tbj.12418] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Chemoprevention with the anti-estrogens, tamoxifen, raloxifene, and aromatase inhibitors, reduce breast cancer incidence in high-risk women; however, uptake has been poor (<5%) in the prevention setting. We assessed use of anti-estrogens for breast cancer prevention, among high-risk women seen at an academic breast center, to observe how uptake rates compare in this setting. We collected data on demographics, breast cancer risk factors, and health behaviors via self-administered questionnaires and medical chart abstraction. Women eligible for chemoprevention with anti-estrogens had a 5-year predicted breast cancer risk according to the Gail model of ≥1.67%, history of lobular or ductal carcinoma in situ (LCIS/DCIS), and/or BRCA mutation. We dichotomized anti-estrogen use as ever or never. Predictors of use were evaluated using multivariable log-binomial regression. Of 412 high-risk women enrolled, 316 (77%) were eligible for chemoprevention. Among eligible women, 55% were non-Hispanic white, 29% Hispanic, 8% non-Hispanic black, and 7% Asian. Women were grouped based upon their highest category of breast cancer risk (in descending order): BRCA mutation carriers (3%), DCIS (40%), LCIS (22%), and 5-year Gail risk ≥1.67% (36%). Among those eligible for chemoprevention, 162 (51%) had ever initiated anti-estrogen therapy (71% tamoxifen, 23% raloxifene, 5% aromatase inhibitor). Anti-estrogen use was highest among women with DCIS (73%). In multivariable analysis, women with a 5-year Gail risk ≥1.67% had approximately a 20% lower likelihood of anti-estrogen use compared to women with DCIS (p = 0.01). In the primary prevention setting, excluding women diagnosed with DCIS, anti-estrogen use was 37%. Multivariable analysis showed differences in uptake by education and potentially by race/ethnicity. Among high-risk women seen at a breast center, anti-estrogen use for chemoprevention was relatively high as compared to the published literature. Clinicians can support high-risk women by effectively communicating breast cancer risk and enhancing knowledge about the risks and benefits of chemoprevention.
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Affiliation(s)
- Laura L Reimers
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | | | - Dawn Hershman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Heather Greenlee
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Julie Campbell
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York
| | - Kevin Kalinsky
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Matthew Maurer
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Ramona Jayasena
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Rossy Sandoval
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Maria Alvarez
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Katherine D Crew
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
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Roetzheim RG, Lee JH, Fulp W, Matos Gomez E, Clayton E, Tollin S, Khakpour N, Laronga C, Lee MC, Kiluk JV. Acceptance and adherence to chemoprevention among women at increased risk of breast cancer. Breast 2014; 24:51-6. [PMID: 25491191 DOI: 10.1016/j.breast.2014.11.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 10/28/2014] [Accepted: 11/07/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Chemoprevention is an option for women who are at increased risk of breast cancer (five year risk ≥1.7%). It is uncertain, however, how often women accept and complete five years of therapy and whether clinical or demographic factors predict completion. METHODS Medical records were abstracted for 219 women whose five year risk of breast cancer was ≥1.7% and who were offered chemoprevention while attending a high risk breast clinic at the Moffitt Cancer Center. We examined the likelihood of accepting chemoprevention and completing five years of therapy, and potential clinical and demographic predictors of these outcomes, using multivariable logistic regression and survival analysis models. RESULTS There were 118/219 women (54.4%) who accepted a recommendation for chemoprevention and began therapy. The likelihood of accepting chemoprevention was associated with lifetime breast cancer risk and was higher for women with specific high risk conditions (lobular carcinoma in situ and atypical ductal hyperplasia). Women with osteoporosis and those that consumed alcohol were also more likely to accept medication. There were 58/118 (49.2%) women who stopped medication at least temporarily after starting therapy. Based on survival curves, an estimated 60% of women who begin chemoprevention will complete five years of therapy. CONCLUSIONS A substantial percentage of women at increased risk of breast cancer will decline chemoprevention and among those that accept therapy, approximately 40% will not be able to complete five years of therapy because of side effects.
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Affiliation(s)
- Richard G Roetzheim
- H. Lee Moffitt Cancer Center & Research Institute, USA; U. of South Florida, Department of Family Medicine, USA.
| | | | - William Fulp
- H. Lee Moffitt Cancer Center & Research Institute, USA
| | | | | | - Sharon Tollin
- H. Lee Moffitt Cancer Center & Research Institute, USA
| | | | | | | | - John V Kiluk
- H. Lee Moffitt Cancer Center & Research Institute, USA
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Nichols HB, DeRoo LA, Scharf DR, Sandler DP. Risk-benefit profiles of women using tamoxifen for chemoprevention. J Natl Cancer Inst 2014; 107:354. [PMID: 25475563 DOI: 10.1093/jnci/dju354] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Tamoxifen has been US Food and Drug Administration-approved for primary prevention of breast cancer since 1998 but has not been widely adopted, in part because of increased risk of serious side effects. Little is known about the risk-benefit profiles of women who use chemoprevention outside of a clinical trial. We examined characteristics associated with initiation and discontinuation of tamoxifen for primary prevention of breast cancer within a large cohort of women with a first-degree family history of breast cancer. METHODS This research was conducted within The Sister Study, a cohort of 50884 US and Puerto Rican women age 35 to 74 years enrolled from 2003 to 2009. Eligible women were breast cancer-free at enrollment and had a sister who had been diagnosed with breast cancer. Participants reported tamoxifen use, ages started and stopped taking tamoxifen, and total duration of use at enrollment. We identified 788 tamoxifen users and 3131 nonusers matched on age and year of enrollment who had no history of contraindicating factors (stroke, transient ischemic attack, cataract, endometrial or uterine cancer). Characteristics associated with tamoxifen initiation were evaluated with multivariable conditional logistic regression. All statistical tests were two-sided. RESULTS Based on published risk-benefit indices, 20% of women who used tamoxifen had insufficient evidence that the benefits of tamoxifen outweigh the risk of serious side effects. After 4.5 years, 46% of women had discontinued tamoxifen. CONCLUSIONS While the majority of women who used tamoxifen for primary prevention of breast cancer were likely to benefit, substantial discontinuation of tamoxifen before five years and use by women at risk of serious side effects may attenuate benefits for breast cancer prevention.
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Affiliation(s)
- Hazel B Nichols
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC (HBN); Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (LAD); Westat, Durham, NC (DS); Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC (DPS).
| | - Lisa A DeRoo
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC (HBN); Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (LAD); Westat, Durham, NC (DS); Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC (DPS)
| | - Daniel R Scharf
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC (HBN); Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (LAD); Westat, Durham, NC (DS); Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC (DPS)
| | - Dale P Sandler
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC (HBN); Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (LAD); Westat, Durham, NC (DS); Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC (DPS)
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Korfage IJ, Fuhrel-Forbis A, Ubel PA, Zikmund-Fisher BJ, Greene SM, McClure JB, Smith DM, Alford SH, Fagerlin A. Informed choice about breast cancer prevention: randomized controlled trial of an online decision aid intervention. Breast Cancer Res 2014; 15:R74. [PMID: 24004815 PMCID: PMC3978729 DOI: 10.1186/bcr3468] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 05/08/2013] [Accepted: 09/03/2013] [Indexed: 11/26/2022] Open
Abstract
Introduction Tamoxifen and raloxifene are chemopreventive drugs that can reduce women's relative risk of primary breast cancer by 50%; however, most women eligible for these drugs have chosen not to take them. The reasons for low uptake may be related to women's knowledge or attitudes towards the drugs. We aimed to examine the impact of an online breast cancer chemoprevention decision aid (DA) on informed intentions and decisions of women at high risk of breast cancer. Methods We conducted a randomized clinical trial, assessing the effect of a DA about breast cancer chemoprevention on informed choices about chemoprevention. Women (n = 585), 46- to 74-years old old, completed online baseline, post-test, and three-month follow-up questionnaires. Participants were randomly assigned to either an intervention group, a standard control group that answered questions about chemoprevention at baseline, or a three-month control group that did not answer questions about chemoprevention at baseline. The main outcome measures were whether women's intentions and decisions regarding chemoprevention drugs were informed, and whether women who viewed the DA were more likely to make informed decisions than women who did not view the DA, using a dichotomous composite variable 'informed choice' (yes/no) to classify informed decisions as those reflecting sufficient knowledge and concordance between a woman's decision and relevant attitudes. Results Analyses showed that more intervention than standard control participants (52.7% versus 5.9%) made informed decisions at post-test, P <0.001. At the three-month follow-up, differences in rates of informed choice between intervention (16.9%) and both control groups (11.8% and 8.0%) were statistically non-significant, P = 0.067. Conclusions The DA increased informed decision making about breast cancer chemoprevention, although the impact on knowledge diminished over time. This study was not designed to determine how much knowledge decision makers must retain over time. Examining informed decisions increases understanding of the impact of DAs. A standard for defining and measuring sufficient knowledge for informed decisions is needed. Trial registration ClinicalTrials.gov: NCT00967824
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Donnelly LS, Evans DG, Wiseman J, Fox J, Greenhalgh R, Affen J, Juraskova I, Stavrinos P, Dawe S, Cuzick J, Howell A. Uptake of tamoxifen in consecutive premenopausal women under surveillance in a high-risk breast cancer clinic. Br J Cancer 2014; 110:1681-7. [PMID: 24594998 PMCID: PMC3974072 DOI: 10.1038/bjc.2014.109] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/31/2014] [Accepted: 02/01/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Randomised trials of tamoxifen versus placebo indicate that tamoxifen reduces breast cancer risk by approximately 33%, yet uptake is low. Approximately 10% of women in our clinic entered the IBIS-I prevention trial. We assess the uptake of tamoxifen in a consecutive series of premenopausal women not in a trial and explore the reasons for uptake through interviews. METHODS All eligible women between 33 and 46 years at ≥17% lifetime risk of breast cancer and undergoing annual mammography in our service were invited to take a 5-year course of tamoxifen. Reasons for accepting (n=15) or declining (n=15) were explored using semi-structured interviews. RESULTS Of 1279 eligible women, 136 (10.6%) decided to take tamoxifen. Women >40 years (74 out of 553 (13.4%)) and those at higher non-BRCA-associated risk were more likely to accept tamoxifen (129 out of 1109 (11.6%)). Interviews highlighted four themes surrounding decision making: perceived impact of side effects, the impact of others' experience on beliefs about tamoxifen, tamoxifen as a 'cancer drug', and daily reminder of cancer risk. CONCLUSIONS Tamoxifen uptake was similar to previously ascertained uptake in a randomised controlled trial (IBIS-I). Concerns were similar in women who did or did not accept tamoxifen. Decision making appeared to be embedded in the experience of significant others.
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Affiliation(s)
- L S Donnelly
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester M23 9LT, UK
| | - D G Evans
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester M23 9LT, UK
- Department of Genomic Medicine, MAHSC, St Mary's Hospital, Manchester M13 9WL, UK
| | - J Wiseman
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester M23 9LT, UK
| | - J Fox
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester M23 9LT, UK
| | - R Greenhalgh
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester M23 9LT, UK
| | - J Affen
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester M23 9LT, UK
| | - I Juraskova
- Centre for Medical Psychology and Evidence-based Decision-Making (CeMPED), School of Psychology, University of Sydney, Sydney, NSW 2006, Australia
| | - P Stavrinos
- Manchester Academic Health Science Centre, University Hospital of South Manchester, University of Manchester, Manchester M23 9LT, UK
| | - S Dawe
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester M23 9LT, UK
| | - J Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
| | - A Howell
- Nightingale and Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester M23 9LT, UK
- Department of Medical Oncology, Christie Hospital, Manchester M20 4BX, UK
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Gridchyna I, Cloutier AM, Nkeng L, Craig C, Frise S, Moride Y. Methodological gaps in the assessment of risk minimization interventions: a systematic review. Pharmacoepidemiol Drug Saf 2014; 23:572-9. [PMID: 24616240 DOI: 10.1002/pds.3596] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 01/17/2014] [Accepted: 01/20/2014] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Since the introduction of therapeutic risk management regulatory guidance, an increase in the number of risk minimization interventions (RMIs) published in the literature has been observed. Methods used to evaluate their effectiveness remain, however, poorly examined. OBJECTIVE This paper aimed to conduct a literature review on the methods of evaluation of effectiveness of RMIs and to identify methodological gaps. METHODS The search was conducted using MEDLINE and Embase between 1 January 2000 and 31 December 2010, and updated on 1 April 2013. The following characteristics were extracted from each study: target population for the RMI, target population for the assessment of effectiveness, study design, data sources, and effectiveness outcome(s). RESULTS A total of 188 unique RMIs were identified in the literature, of which effectiveness was evaluated in only 65 (34.6%) at the time of publication. The largest proportion of studies reviewed (n = 49, 75.4%) attempted to evaluate changes in behavior through prescribing or laboratory test practices. One quarter of studies evaluated the effect of RMIs on the occurrence of adverse events. Only a minority of studies used robust designs, such as randomized controlled trials (n = 6, 9.2%) or a quasi-experimental design with a parallel comparison group (n = 8, 12.3%). CONCLUSION Lack of robust methodological design used in published studies on RMI effectiveness evaluation is an important methodological gap in the evaluation of RMI effectiveness. © 2014 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Inna Gridchyna
- Faculty of Pharmacy, Université de Montreal, Montreal, Quebec, Canada
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29
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Rahman RL, Pruthi S. Chemoprevention of Breast Cancer: The Paradox of Evidence versus Advocacy Inaction. Cancers (Basel) 2012; 4:1146-60. [PMID: 24213502 PMCID: PMC3712728 DOI: 10.3390/cancers4041146] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 09/23/2012] [Accepted: 10/19/2012] [Indexed: 02/03/2023] Open
Abstract
Women who are at high risk of breast cancer can be offered chemoprevention. Chemoprevention strategies have expanded over the past decade and include selective receptor modulator inhibitors and aromatase inhibitors. Physicians are expected to provide individualized risk assessments to identify high risk women who may be eligible for chemoprevention. It is prudent that physicians utilize a shared decision approach when counseling high risk women about their preventive options. Barriers and misperceptions however exist with patient and physician acceptance of chemoprevention and continue to impede uptake of chemoprevention as a strategy to reduce breast cancer risk. Programs to increase awareness and elucidate the barriers are critical for women to engage in cancer prevention and promote chemoprevention adherence.
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Affiliation(s)
- Rakhshanda Layeequr Rahman
- Division of Surgical Oncology, Texas Tech University Health Sciences Center, Amarillo Breast Center of Excellence, 1400 Coulter, Amarillo, TX 79106, USA
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-806-354-5563; Fax: +1-806-354-5561
| | - Sandhya Pruthi
- Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; E-Mail:
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Kaplan CP, Kim SE, Wong ST, Sawaya GF, Walsh JME, Pérez-Stable EJ. Willingness to use tamoxifen to prevent breast cancer among diverse women. Breast Cancer Res Treat 2012; 133:357-66. [PMID: 22315131 DOI: 10.1007/s10549-012-1960-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 01/16/2012] [Indexed: 10/14/2022]
Abstract
Use of chemoprevention to prevent development of breast cancer among high-risk women has been limited despite clinical evidence of its benefit. Our goals were to determine whether knowledge of the benefits and risks of tamoxifen affects a woman's willingness to take it to prevent breast cancer, to define factors associated with willingness to take tamoxifen, and to evaluate race/ethnic differences. Women, ages 50-80, who identified as African American, Asian, Latina, or White, and who had at least one visit to a primary care physician in the previous 2 years, were recruited from ambulatory practices. After a screening telephone survey, women completed an in-person interview in their preferred language. Multivariate regression models were constructed to examine the associations of demographic characteristics, numeracy, breast cancer history, and health knowledge with willingness to take tamoxifen. Over 40% of the women reported they would likely take tamoxifen if determined to be at high risk, and 31% would be somewhat likely to do so. Asian women, those with no insurance, and those with less than high school education were significantly more likely to be willing to take tamoxifen. Higher scores on numeracy and on breast cancer knowledge were also associated with willingness to take tamoxifen. A higher tamoxifen knowledge score was inversely related to willingness to take the drug. Factors affecting women's willingness to take breast cancer chemoprevention drugs vary and are not determined solely by knowledge of risk/benefit or risk perception.
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Affiliation(s)
- Celia Patricia Kaplan
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, 3333 California Street, San Francisco, CA 94143-0856, USA
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Waters EA, McNeel TS, Stevens WM, Freedman AN. Use of tamoxifen and raloxifene for breast cancer chemoprevention in 2010. Breast Cancer Res Treat 2012; 134:875-80. [PMID: 22622807 PMCID: PMC3771085 DOI: 10.1007/s10549-012-2089-2] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 05/02/2012] [Indexed: 10/28/2022]
Abstract
Two selective estrogen receptor modulators, tamoxifen and raloxifene, have been shown in randomized clinical trials to reduce the risk of developing primary invasive breast cancer in high-risk women. In 1998, the U.S. Food and Drug Administration (FDA) used these studies as a basis for approving tamoxifen for primary breast chemoprevention in both premenopausal and postmenopausal women at high risk. In 2007, the FDA approved raloxifene for primary breast cancer chemoprevention for postmenopausal women. Data from the year 2010 National Health Interview Survey were analyzed to estimate the prevalence of tamoxifen and raloxifene use for chemoprevention of primary breast cancers among U.S. women. Prevalence of use of chemopreventive agents for primary tumors was 20,598 (95 % CI, 518-114,864) for U.S. women aged 35-79 for tamoxifen. Prevalence was 96,890 (95 % CI, 41,277-192,391) for U.S. women aged 50-79 for raloxifene. Use of tamoxifen and raloxifene for prevention of primary breast cancers continues to be low. In 2010, women reporting medication use for breast cancer chemoprevention were primarily using the more recently FDA approved drug raloxifene. Multiple possible explanations for the low use exist, including lack of awareness and/or concern about side effects among primary care physicians and patients.
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Affiliation(s)
- Erika A Waters
- Department of Surgery (Division of Public Health Sciences), Washington University School of Medicine, Campus Box 8100, 660 S. Euclid Avenue, Saint Louis, MO 63110, USA.
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Reimers L, Crew KD. Tamoxifen vs Raloxifene vs Exemestane for Chemoprevention. CURRENT BREAST CANCER REPORTS 2012; 4:207-215. [PMID: 23956815 DOI: 10.1007/s12609-012-0082-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Clinical trial data on selective estrogen receptor modulators (SERMs) and aromatase inhibitors (AIs) have demonstrated reduced breast cancer incidence in the prevention setting among high-risk women. We conducted an extensive review of clinical trials and recent published reports of barriers to uptake of breast cancer chemoprevention, to provide health care professionals with information to improve decision-making regarding chemoprevention. Despite the positive results of these trials, uptake of chemoprevention has been low due to barriers in identifying high-risk women, lack of understanding of risks and benefits, as well as concerns about side effects. Interventions designed to increase uptake have met with limited success. Clinicians can support women in informed decision-making about SERMs and AIs by effectively communicating breast cancer risk and enhancing knowledge about the risks and benefits of chemoprevention. Promoting uptake and adherence to chemoprevention holds promise for reducing the public health burden of this disease.
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Affiliation(s)
- Laura Reimers
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Khaliq W, Visvanathan K. Breast Cancer Chemoprevention: Current Approachesand Future Directions. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2012. [DOI: 10.1007/s13669-011-0005-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fagerlin A, Dillard AJ, Smith DM, Zikmund-Fisher BJ, Pitsch R, McClure JB, Greene S, Alford SH, Nair V, Hayes DF, Wiese C, Ubel PA. Women's interest in taking tamoxifen and raloxifene for breast cancer prevention: response to a tailored decision aid. Breast Cancer Res Treat 2011; 127:681-8. [PMID: 21442198 PMCID: PMC3742062 DOI: 10.1007/s10549-011-1450-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 03/10/2011] [Indexed: 01/03/2023]
Abstract
Although tamoxifen can prevent primary breast cancer, few women use it as a preventive measure. A second option, raloxifene, has recently been approved. The objective of the study was to determine women's interest in tamoxifen and raloxifene after reading a decision aid (DA) describing the risks and benefits of each medication. Women with 5-year risk of breast cancer ≥ 1.66 from two large health maintenance organizations were randomized to receive a DA versus usual care. After reading an on-line DA that discussed the risks and benefits of tamoxifen and raloxifene, women completed measures of risk perception, decisional conflict, behavioral intentions, and actual behavior related to tamoxifen and raloxifene. 3 months following the intervention, 8.1% of participants had looked for additional information about breast cancer prevention drugs, and 1.8% had talked to their doctor about tamoxifen and/or raloxifene. The majority, 54.7%, had decided to not take either drug, 0.5% had started raloxifene, and none had started tamoxifen. Participants were not particularly worried about taking tamoxifen or raloxifene and did not perceive significant benefits from taking these drugs. Over 50% did not perceive a change in their risk of getting breast cancer if they took tamoxifen or raloxifene. After reading a DA about tamoxifen and raloxifene, few women were interested in taking either breast cancer prevention drug.
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Affiliation(s)
- Angela Fagerlin
- Ann Arbor VA HSR&D Center for Practice Management and Outcomes Research, Ann Arbor, MI, USA.
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36
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Cady B, Chung MA. Preventing invasive breast cancer. Cancer 2011; 117:3064-8. [DOI: 10.1002/cncr.25764] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 10/07/2010] [Accepted: 10/07/2010] [Indexed: 11/10/2022]
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Ravdin PM. The lack, need, and opportunities for decision-making and informational tools to educate primary-care physicians and women about breast cancer chemoprevention. Cancer Prev Res (Phila) 2010; 3:686-8. [PMID: 20522798 DOI: 10.1158/1940-6207.capr-10-0100] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This perspective on Vogel et al. (beginning on page 696 in this issue of the journal) examines tamoxifen and raloxifene prescription patterns and why these agents are little used for breast cancer prevention despite their effectiveness in definitive trials, Food and Drug Administration approval, and American Society of Clinical Oncology Guidelines Committee endorsement for this purpose. The complexity of weighing the positive and negative aspects of the drugs and estimating net benefit is discussed, as is the need for informational resources such as interactive Internet-based tools to allow better individualized decisions about the options for chemoprevention.
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Affiliation(s)
- Peter M Ravdin
- University of Texas Health Sciences Center at San Antonio, 78229, USA.
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Hamilton RJ, Kahwati LC, Kinsinger LS. Knowledge and use of finasteride for the prevention of prostate cancer. Cancer Epidemiol Biomarkers Prev 2010; 19:2164-71. [PMID: 20699373 DOI: 10.1158/1055-9965.epi-10-0082] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The knowledge about and use of chemopreventive agents for prostate cancer by physicians has not been described. The Prostate Cancer Prevention Trial (PCPT) showed that finasteride was effective in reducing the incidence of prostate cancer. We examined the influence of the PCPT on finasteride prescribing within the Veterans Health Administration (VHA). METHODS We assessed trends on monthly new and total prescriptions for finasteride filled within the VHA from January 2000 to December 2005. Additionally, all VHA urologists and a random sample of VHA primary care physicians (PCP) were surveyed about their use of finasteride. RESULTS The number of men starting finasteride grew over the study period. Publication of the PCPT was not significantly associated with any change in this pattern (P = 0.45). Fifty-seven percent of urologists and 40% of PCPs endorsed prescribing finasteride more frequently in 2006 than 5 years prior. However, among those who reported changing prescribing patterns, fewer than 2% reported being influenced by the PCPT. Sixty-four percent of urologists and 80% of PCPs never prescribe finasteride for prostate cancer chemoprevention; 55% of urologists cited concerns of inducing high-grade tumors, whereas 52% of PCPs did not know it could be used for chemoprevention. CONCLUSIONS The number of men starting finasteride in the VHA increased over time, but the change did not seem to be due to increased use of finasteride for chemoprevention. Publication of the PCPT seemed to have little influence over the study period. IMPACT Physicians may not readily accept the use of chemopreventive agents for prostate cancer.
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Affiliation(s)
- Robert J Hamilton
- Division of Urologic Surgery, Department ofSurgery, Duke University School of Medicine, Durham, North Carolina, USA
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39
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Ropka ME, Keim J, Philbrick JT. Patient decisions about breast cancer chemoprevention: a systematic review and meta-analysis. J Clin Oncol 2010; 28:3090-5. [PMID: 20458026 PMCID: PMC2903338 DOI: 10.1200/jco.2009.27.8077] [Citation(s) in RCA: 165] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Accepted: 03/11/2010] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Women at high risk of breast cancer face the complex decision of whether to take tamoxifen or raloxifene for breast cancer chemoprevention. We investigated what is known about decisions of women regarding chemoprevention. METHODS Using MEDLINE, CINAHL, and PSYCINFO, plus reviewing reference lists of relevant articles, in December 2009 we identified 13 studies that addressed patient decisions about breast cancer chemoprevention, were published in 1995 or later, were peer-reviewed primary clinical studies, and reported rates at which participants showed interest in (hypothetical uptake) or accepted (real uptake) chemoprevention medications. RESULTS Nine studies provided information about hypothetical breast cancer chemoprevention decisions (mean uptake rate, 24.7%) and five provided information about real decisions (mean uptake rate, 14.8%). The range of rates was wide, and each of the hypothetical uptake studies assessed interest differently. A logistic regression model found significant correlation with uptake of decision type (hypothetical versus real, odds ratio [OR] = 1.65; 95% CI, 1.26 to 2.16), educational or decision support intervention (provided v not, OR = 0.21; 95% CI, 0.17 to 0.27), and cohort risk for breast cancer (high-risk v general population, OR = 0.65; 95% CI, 0.56 to 0.75). Perceived vulnerability to breast cancer was consistently correlated with increased uptake, and concern for adverse effects was correlated with reduced uptake. All studies used a correlational/descriptive design, and most studies used convenience sampling strategies. CONCLUSION Breast cancer chemoprevention uptake rates are low and variation is wide. Hypothetical uptake rates are higher than real uptake, and interventions markedly reduce uptake. Research is needed that uses reproducible sampling methods and examines decision support strategies that lead to quality decisions.
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Affiliation(s)
- Mary E Ropka
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA 22908, USA.
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Waters EA, Cronin KA, Graubard BI, Han PK, Freedman AN. Prevalence of tamoxifen use for breast cancer chemoprevention among U.S. women. Cancer Epidemiol Biomarkers Prev 2010; 19:443-6. [PMID: 20142242 DOI: 10.1158/1055-9965.epi-09-0930] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tamoxifen can reduce the risk of developing invasive estrogen receptor-positive breast cancer by 49%, but it is unknown how many women in the United States are taking tamoxifen for primary prevention of breast cancer. METHODS Data from the years 2000 and 2005 National Health Interview Surveys were analyzed to estimate the prevalence of tamoxifen use among U.S. women for primary chemoprevention of breast cancer. RESULTS In 2000, approximately 0.2% of U.S. women ages 40 to 79 years without a personal history of breast cancer took tamoxifen for chemoprevention (95% confidence interval, 0.13-0.31). In 2005, the prevalence was approximately 0.08% (95% confidence interval, 0.03-0.17). CONCLUSION The prevalence of tamoxifen use for primary prevention of breast cancer was very low in the years 2000 and 2005. Possible explanations for the low uptake are explored.
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Affiliation(s)
- Erika A Waters
- Cancer Prevention Fellowship Program, Center for Cancer Training, Health Communication and Informatics Research Branch/Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland, USA.
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Women's decisions regarding tamoxifen for breast cancer prevention: responses to a tailored decision aid. Breast Cancer Res Treat 2010; 119:613-20. [PMID: 19908143 DOI: 10.1007/s10549-009-0618-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 10/22/2009] [Indexed: 10/20/2022]
Abstract
Tamoxifen reduces primary breast cancer incidence, yet causes serious side effects. To date, few women with increased breast cancer risk have elected to use tamoxifen for chemoprevention. The objective of the study was to determine women's knowledge of and attitudes toward tamoxifen following exposure to a tailored decision aid (DA). A total of 632 women with a 5-year risk of breast cancer > or = 1.66% (Mean = 2.56, range = 1.7-17.3) were recruited from two healthcare organizations. Participants viewed an online DA that informed them about their 5-year risk of breast cancer and presented individually tailored content depicting the risks/benefits of tamoxifen prophylaxis. Outcome measures included behavioral intentions (to seek additional information about tamoxifen, to talk to a physician about tamoxifen, and to take tamoxifen); knowledge; and perceived risks and benefits of tamoxifen. After viewing the DA, 29% of participants said they intended to seek more information or talk to their doctor about tamoxifen, and only 6% believed they would take tamoxifen. Knowledge was considerable, with 63% of women answering at least 5 of 6 knowledge questions correctly. Participants were concerned about the risks of tamoxifen, and many believed that the benefits of tamoxifen did not outweigh the risks. This study is the largest to date to test women's preferences for taking tamoxifen and one of the largest to have tested the impact of a tailored DA. After viewing the DA, women demonstrated good understanding of tamoxifen's risks and benefits, but most were not interested in taking tamoxifen for breast cancer chemoprevention.
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Cyrus-David M, King J, Bevers T, Robinson E. Validity assessment of the Breast Cancer Risk Reduction Health Belief scale. Cancer 2009; 115:4907-16. [PMID: 19637346 DOI: 10.1002/cncr.24541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND : Women at increased risk of breast cancer (BC) are not widely accepting of chemopreventive interventions, and ethnic minorities are underrepresented in related trials. Furthermore, there is no validated instrument to assess the health-seeking behavior of these women with respect to these interventions. METHODS : By using constructs from the Health Belief Model, the authors developed and refined, based on pilot data, the Breast Cancer Risk Reduction Health Belief (BCRRHB) scale using a population of 265 women at increased risk of BC who were largely medically underserved, of low socioeconomic status (SES), and ethnic minorities. Construct validity was assessed using principal components analysis with oblique rotation to extract factors, and generate and interpret summary scales. Internal consistency was determined using Cronbach alpha coefficients. RESULTS : Test-retest reliability for the pilot and final data was calculated to be r = 0.85. Principal components analysis yielded 16 components that explained 64% of the total variance, with communalities ranging from 0.50-0.75. Cronbach alpha coefficients for the extracted factors ranged from 0.45-0.77. CONCLUSIONS : Evidence suggests that the BCRRHB yields reliable and valid data that allows for the identification of barriers and enhancing factors associated with use of breast cancer chemoprevention in the study population. These findings allow for tailoring treatment plans and intervention strategies to the individual. Future research is needed to validate the scale for use in other female populations. Cancer 2009. (c) 2009 American Cancer Society.
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Affiliation(s)
- Mfon Cyrus-David
- Department of Medicine, The University of Texas Medical School, Houston, Texas, USA.
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Layeequr Rahman R, Crawford S. Chemoprevention Indication Score: A user-friendly tool for prevention of breast cancer – Pilot analysis. Breast 2009; 18:289-93. [DOI: 10.1016/j.breast.2009.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 06/27/2009] [Accepted: 08/06/2009] [Indexed: 01/15/2023] Open
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Sparano JA, Hortobagyi GN, Gralow JR, Perez EA, Comis RL. Recommendations for research priorities in breast cancer by the Coalition of Cancer Cooperative Groups Scientific Leadership Council: systemic therapy and therapeutic individualization. Breast Cancer Res Treat 2009; 119:511-27. [PMID: 19526354 DOI: 10.1007/s10549-009-0433-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 05/28/2009] [Indexed: 01/23/2023]
Abstract
Over 9,000 women with breast cancer are enrolled annually on clinical trials sponsored by the National Cancer Institute (NCI), accounting for about one-third of all patients enrolled on NCI-sponsored trials. Thousands are also enrolled on pharmaceutical-sponsored studies. Although breast cancer mortality rates have recently declined for the first time in part due to systemic therapeutic advances, coordinated efforts will be necessary to maintain this trend. The Coalition of Cancer Cooperative Groups convened the Scientific Leadership Council in breast cancer (BC), an expert panel, to identify priorities for future research and current trials with greatest practice-changing potential. Panelists formed a consensus on research priorities for chemoprevention, development and application of molecular markers for predicting therapeutic benefit and toxicity, intermediate markers predictive of therapeutic effect, pathogenesis-based therapeutic approaches, utilization of adaptive designs requiring fewer patients to achieve objectives, special and minority populations, and effects of BC and treatment on patients and families. Panelists identified 13 ongoing studies as High Priority and identified gaps in the current trial portfolio. We propose priorities for current and future clinical breast cancer research evaluating systemic therapies that may serve to improve the efficiency of clinical trials, identify individuals most likely to derive therapeutic benefit, and prioritize therapeutic strategies.
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Waters EA, Weinstein ND, Colditz GA, Emmons K. Explanations for side effect aversion in preventive medical treatment decisions. Health Psychol 2009; 28:201-9. [PMID: 19290712 DOI: 10.1037/a0013608] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Many laypeople demonstrate excessive sensitivity to negative side effects of medical treatments, which may lead them to refuse beneficial therapies. This Internet-based experiment investigated three possible explanations for such "side effect aversion." One was derived from mental accounting, one examined the mere presence of a side effect, and one focused on computational difficulties. DESIGN Participants (N = 5,379) were presented with a hypothetical cancer preventive treatment situation that was or was not accompanied by one or two small side effects. The side effects were either beneficial or harmful. In all conditions, the net absolute risk reduction associated with the treatment was 15%. MAIN OUTCOME MEASURES Participants indicated their willingness to accept treatment and their perceptions of the treatment's effects on their overall cancer risk. RESULTS Data were consistent only with the "mere presence" explanation of side effect aversion, the idea that side effects act as a strong negative cue that directly affects treatment appraisal. The number of negative side effects did not influence treatment willingness. CONCLUSION Side effect aversion is a challenge to informed decision making. Specific mechanisms that produce side effect aversion should be identified.
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Affiliation(s)
- Erika A Waters
- Cancer Prevention Fellowship Program, Office of Preventive Oncology, National Cancer Institute, Bethesda, MD 20892-7365, USA.
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Lo SS, Pritchard KI, Robinson P, Albain KS. Endocrine Therapy with Selective Estrogen Receptor Modulators (SERMs) and Aromatase Inhibitors in the Prevention and Adjuvant Therapy Settings. Cancer Treat Res 2009; 147:1-29. [PMID: 21461825 DOI: 10.1007/978-0-387-09463-2_7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Shelly S Lo
- Division of Hematology/Oncology, Department of Medicine, Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL, USA,
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Rondanina G, Puntoni M, Severi G, Varricchio C, Zunino A, Feroce I, Bonanni B, Decensi A. Psychological and clinical factors implicated in decision making about a trial of low-dose tamoxifen in hormone replacement therapy users. J Clin Oncol 2008; 26:1537-43. [PMID: 18349406 DOI: 10.1200/jco.2007.13.6739] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess the sociodemographic, health-related, and psychological factors that influence the decision of women on hormone replacement therapy (HRT) to participate in a phase III trial of low-dose tamoxifen. PATIENTS AND METHODS Clinical and psychological factors were assessed in 265 women who accepted and 192 women who refused to participate in a proposed trial. Health-related and sociodemographic factors included age, Gail risk, body mass index, education, current HRT use, regular mammographic screening, smoking habit, physical activity, alcohol use, concern about adverse effects, and physician recommendation. Psychological factors included breast cancer-related worry, absolute and comparative cancer risk perception, anxiety, and depression. RESULTS The most frequent reasons for entry were willingness to participate in a research program (60%), the need/desire to receive frequent medical care (58%), and the desire to contribute to medical knowledge (44%); whereas reasons for refusal included fear of medication abuse (33%), concern about adverse effects (31%), and physician advice against enrollment (24%). In a logistic model, after adjusting for current HRT use, the trial participation was directly associated with satisfaction with clearly explained study objectives (odds ratio [OR] = 9.33; 95% CI, 4.04 to 21.55) and inversely associated with high breast cancer worry (OR = 0.15; 95% CI, 0.03 to 0.77) and age > or = 60 years (OR = 0.40; 95% CI, 0.22 to 0.73). CONCLUSION Participation in a chemoprevention trial among HRT users is associated with a younger age, no breast cancer worry, and satisfaction with health care providers, suggesting a condition of psychological well-being as a promoting factor and emphasizing the importance of thorough counseling at study presentation.
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Lin NU, Winer EP. Optimizing endocrine therapy for estrogen receptor-positive breast cancer: treating the right patients for the right length of time. J Clin Oncol 2008; 26:1919-21. [PMID: 18332468 DOI: 10.1200/jco.2007.14.7744] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Goldenberg VK, Seewaldt VL, Scott V, Bean GR, Broadwater G, Fabian C, Kimler B, Zalles C, Lipkus IM. Atypia in random periareolar fine-needle aspiration affects the decision of women at high risk to take tamoxifen for breast cancer chemoprevention. Cancer Epidemiol Biomarkers Prev 2007; 16:1032-4. [PMID: 17507634 DOI: 10.1158/1055-9965.epi-06-0910] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Random periareolar fine-needle aspiration (RPFNA) is a research procedure designed to (a) evaluate short-term breast cancer risk in women at high risk for developing breast cancer, and (b) track response to chemoprevention. Of import, cellular atypia in breast RPFNA is prospectively associated with a 5.6-fold increase in breast cancer risk in women at high risk. Among 99 women attending a clinic for high-risk breast cancer, we explored the effects of RPFNA cytology results on decision making pertaining to the use of tamoxifen for breast cancer chemoprevention. No patient with nonproliferative or hyperplastic cytology subsequently elected to take tamoxifen. Only 7% of subjects with borderline atypia elected to take tamoxifen. In contrast, 50% with atypia elected to take tamoxifen. These results suggest that the provision of a biomarker of short-term risk can affect the motivation to take tamoxifen for chemoprevention. This conclusion is informative given that tamoxifen, due to its side effects, is often underused by women at high risk of developing breast cancer. Further research is needed to determine the mechanisms through which RPFNA results affect the decision to use tamoxifen, or any other breast cancer chemopreventive agent.
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MESH Headings
- Adult
- Anticarcinogenic Agents/therapeutic use
- Biopsy, Fine-Needle/methods
- Breast/cytology
- Breast/pathology
- Breast Neoplasms/diagnosis
- Breast Neoplasms/pathology
- Breast Neoplasms/prevention & control
- Carcinoma, Ductal, Breast/diagnosis
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/prevention & control
- Carcinoma, Lobular/diagnosis
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/prevention & control
- Cohort Studies
- Decision Making
- Female
- Humans
- Middle Aged
- Nipples
- Risk Factors
- Selective Estrogen Receptor Modulators/therapeutic use
- Tamoxifen/therapeutic use
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