Informing women with breast cancer about endocrine therapy: effects on knowledge and adherence

Pre-operative expectations in patients with endometriosis - a qualitative interview study

BACKGROUND

Expectations determine treatment outcomes in several medical conditions. The significance of expectations for treatment outcomes in patients with endometriosis remains unknown. Endometriosis is a painful and debilitating disease that negatively affects quality of life. Up to 30% of surgically treated patients report persistent post-operative complaints and pain disability without sufficient medical explanation, indicating the impact of non-medical factors on treatment outcomes.

AIM

The present qualitative study aimed to describe and understand pre-operative patient expectations, facilitators of and barriers to positive treatment outcomes.

METHOD

As part of a large mixed-method cohort study, a subsample of N = 33 patients with endometriosis were interviewed before laparoscopy. Structured content analysis was performed.

RESULTS

Positive expectations included significant improvement or absence of complaints, receiving a diagnosis, and subsequently improved health-related quality of life. However, patients also reported negative expectations such as invalidation of their experience, persistence of complaints, or post-operative side effects. Patients perceived positive expectations as facilitators for positive treatment outcomes. Further facilitators included enhanced patient and treatment information, gynaecologists specialized in endometriosis, and greater awareness of endometriosis. Perceived barriers to good post-operative quality of life included post-operative pain and scarring, insufficient rest, avoidance behaviour, and stress.

CONCLUSION

Positive and negative expectations coexisted. Positive expectations suggest that participants place much hope in laparoscopy. However, these positive expectations may exceed probable treatment outcomes for some patients. Negative expectations were also expressed and constituted a risk for nocebo effects. Further identified facilitators and barriers show that patients are very clear about what is helpful or not for their health-related quality of life after laparoscopy. Patient and treatment information may be enhanced to prevent unrealistic treatment expectations and nocebo effects.

Addressing cancer survivors' information needs and satisfaction: a systematic review of potential intervention components for survivors with a rare cancer type

OBJECTIVE

Providing current, evidence-based information to cancer survivors is critical for informed decision making. People diagnosed with a rare cancer report higher unmet information needs compared to common cancer survivors. However, interventions providing informational support for rare cancers are limited. Therefore, the aims of this systematic review were to identify and synthesise interventions decreasing survivors' information needs and/or improving satisfaction with information, and to explore potential components to be included in an intervention for rare cancer survivors.

METHODS

Searches were conducted in PubMed, CINAHL, Embase, PsycINFO and the Cochrane Library. Studies reporting an intervention targeting information needs and/or patient satisfaction with information in survivors of any cancer type were included. Data were extracted, a quality assessment performed and findings were synthesised.

RESULTS

A total of 7012 studies were identified and 34 were included in the review. Five studies targeted patients with a rare cancer type; the remaining studies included common cancer survivors. Interventions varied in relation to the mode of information provision, timing of intervention delivery, and the intervention provider. The most promising interventions included face-to-face communication and written material and were delivered by a nurse. All rare cancer studies were designed around a web-based program, but none of them improved outcomes.

CONCLUSIONS

Interventions targeting information needs and/or patient satisfaction with information in rare cancer survivors are lacking. Future studies should focus on this underserved group, and successful aspects of interventions for common cancer survivors should be considered for inclusion when designing an intervention for rare cancer survivors.

"Interventions to increase adherence to oral therapies in breast cancer patients: A systematic review based on the behavior change technique taxonomy"

OBJECTIVE

High rates of non-adherence to oral medications in breast cancer (BC) patients have been reported. Here we provide an up-to-date systematic review of the interventions aimed at increasing adherence to oral medication in BC patients, with a particular focus on the content of the interventions.

METHODS

PubMed, Scopus, Embase and Ovid databases and reference lists of relevant studies were searched through October 2022. Studies which (1) described an intervention aimed at increasing adherence to oral anticancer medication, (2) included (or planned to include) at least one sub-group of BC patients, (3) were written in English, and (4) with full-text available were included. The contents of the interventions were coded using the Behavior Change Technique Taxonomy. Quality assessment was conducted using Downs and Black scale.

RESULTS

Thirty-six studies met the inclusion criteria and involved a total sample of 28,528 BC patients. Interventions were mainly delivered with eHealth devices (n = 21) and most of them used mobile app. Other studies used in-person modalities (e.g., CBT, relaxation technique) or written materials (e.g., psycho-educational booklet). The behavior change techniques most frequently implemented were "problem solving," "social support," "information about health consequences," and "prompts/cues". Quality assessment revealed that the higher risk of bias refers to the selection process.

CONCLUSIONS

The use of reminders, monitoring patients' medication-taking behaviors and giving feedback were the most frequently implemented techniques in those interventions that resulted significant. If these preliminary observations were to be confirmed by future comparative studies, they should be taken into account when developing new interventions.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of receiving a customizable brochure on breast cancer patients' knowledge about their diagnosis and treatment: A randomized clinical trial

BACKGROUND

Patients' lack of knowledge about their own disease may function as a barrier to shared decision-making and well-being. This study aimed to evaluate the impact of written educational materials on breast cancer patients.

METHODS

This multicenter, parallel, unblinded, randomized trial included Latin American women aged ≥18 years with a recent breast cancer diagnosis yet to start systemic therapy. Participants underwent randomization in a 1:1 ratio to receive a customizable or standard educational brochure. The primary objective was accurate identification of molecular subtype. Secondary objectives included identification of clinical stage, treatment options, participation in decision-making, perceived quality of information received, and illness uncertainty. Follow-up occurred at 7-21 and 30-51 days post-randomization.

CLINICALTRIALS

gov identifier: NCT05798312.

RESULTS

One hundred sixty-five breast cancer patients with a median age of 53 years and 61 days from diagnosis were included (customizable: 82; standard: 83). At first available assessment, 52%, 48%, and 30% identified their molecular subtype, disease stage, and guideline-endorsed systemic treatment strategy, respectively. Accurate molecular subtype and stage identification were similar between groups. Per multivariate analysis, customizable brochure recipients were more likely to identify their guideline-recommended treatment modalities (OR: 4.20,p = 0.001). There were no differences between groups in the perceived quality of information received or illness uncertainty. Customizable brochure recipients reported increased participation in decision-making (p = 0.042).

CONCLUSIONS

Over one third of recently diagnosed breast cancer patients are incognizant of their disease characteristics and treatment options. This study demonstrates a need to improve patient education and shows that customizable educational materials increase patients' understanding of recommended systemic therapies according to individual breast cancer characteristics.

Adapting an Evidence-Based Exercise and Education Program for Older Breast Cancer Survivors for the REJOIN Trial

Physical activity (PA) promotes survival and mitigates symptoms in older breast cancer survivors (BCS), especially to reduce joint pain associated with adjuvant hormonal treatment. The purpose is to describe the adaptation process for an evidence-based exercise and education curriculum (i.e., Fit & Strong!) to support older BCS participating in the Using Exercise to Relieve Joint Pain and Improve Aromatase Inhibitor Adherence in Older Breast Cancer Survivors trial. We reviewed all educational materials with scientific/clinical experts to identify necessary content changes. Next, we conducted semistructured phone interviews with BCS to review all educational materials and conducted a real-time pretest for the trial. Overall, BCS found the adapted materials and experience acceptable (mean score of 9.2/10 for satisfaction). Content changes included simplifying exercise instructions, prioritizing content related to the trial goals, and updating photographs. Because of COVID, the pretest was conducted via Zoom. Our multistep adaptation process provided an acceptable intervention to meet the needs of older BCS. Lessons learned will be applied to the forthcoming pilot trial.

Supporting adjuvant endocrine therapy adherence in women with breast cancer: the development of a complex behavioural intervention using Intervention Mapping guided by the Multiphase Optimisation Strategy

BACKGROUND

Adjuvant endocrine therapy (AET) reduces the risk of breast cancer recurrence and mortality. However, up to three-quarters of women with breast cancer do not take AET as prescribed. Existing interventions to support adherence to AET have largely been unsuccessful, and have not focused on the most salient barriers to adherence. This paper describes the process of developing four theory-based intervention components to support adherence to AET. Our aim is to provide an exemplar of intervention development using Intervention Mapping (IM) with guidance from the Multiphase Optimisation Strategy (MOST).

METHODS

Iterative development followed the six-stage IM framework with stakeholder involvement. Stage 1 involved a literature review of barriers to adherence and existing interventions, which informed the intervention objectives outlined in Stage 2. Stage 3 identified relevant theoretical considerations and practical strategies for supporting adherence. Stage 4 used information from Stages 1-3 to develop the intervention components. Stages 1-4 informed a conceptual model for the intervention package. Stages 5 and 6 detailed implementation considerations and evaluation plans for the intervention package, respectively.

RESULTS

The final intervention package comprised four individual intervention components: Short Message Service to encourage habitual behaviours surrounding medication taking; an information leaflet to target unhelpful beliefs about AET; remotely delivered Acceptance and Commitment Therapy-based guided self-help to reduce psychological distress; and a website to support self-management of AET side-effects. Considerations for implementation within the NHS, including cost, timing and mode of delivery were outlined, with explanation as to how using MOST can aid this. We detail our plans for the final stage of IM which involve feasibility testing. This involved planning an external exploratory pilot trial using a 24-1 fractional factorial design, and a process evaluation to assess acceptability and fidelity of intervention components.

CONCLUSIONS

We have described a systematic and logical approach for developing a theoretically informed intervention package to support medication adherence in women with breast cancer using AET. Further research to optimise the intervention package, guided by MOST, has the potential to lead to more effective, efficient and scalable interventions.

Investigation of Intervention Solutions to Enhance Adherence to Oral Anticancer Medicines in Adults: Overview of Reviews

BACKGROUND

Adherence to anticancer medicines is critical for the success of cancer treatments; however, nonadherence remains challenging, and there is limited evidence of interventions to improve adherence to medicines in patients with cancer.

OBJECTIVE

This overview of reviews aimed to identify and summarize available reviews of interventions to improve adherence to oral anticancer medicines in adult cancer survivors.

METHODS

A comprehensive search of 7 electronic databases was conducted by 2 reviewers who independently conducted the study selection, quality assessment using the A Measurement Tool to Assess Systematic Reviews 2, and data extraction. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 checklist was adapted to report the results.

RESULTS

A total of 29 reviews were included in the narrative synthesis. The overall quality of the systematic reviews was low. The 4 main strategies to promote adherence were focused on education, reminders, behavior and monitoring, and multicomponent approaches. Digital technology-based interventions were reported in most reviews (27/29, 93%). A few interventions applied theories (10/29, 34%), design frameworks (2/29, 7%), or engaged stakeholders (1/29, 3%) in the development processes. The effectiveness of interventions was inconsistent between and within reviews. However, interventions using multiple strategies to promote adherence were more likely to be effective than single-strategy interventions (12/29, 41% reviews). Unidirectional communication (7/29, 24% reviews) and technology alone (11/29, 38% reviews) were not sufficient to demonstrate improvement in adherence outcomes. Nurses and pharmacists played a critical role in promoting patient adherence to oral cancer therapies, especially with the support of digital technologies (7/29, 24% reviews).

CONCLUSIONS

Multicomponent interventions are potentially effective in promoting patient adherence to oral anticancer medicines. The seamless integration of digital solutions with direct clinical contacts is likely to be effective in promoting adherence. Future research for developing comprehensive digital adherence interventions should be evidence-based, theory-based, and rigorously evaluated.

Hobson's choice or a horned dilemma: a grounded theory on adherence to adjuvant endocrine therapy verified with breast cancer survivors

PURPOSE

A literature review and meta-synthesis of qualitative research had enabled us to develop a grounded theory explaining the difficulties breast cancer survivors face with the initial decision to accept long-term endocrine therapy, and the everyday challenges of continuing or deciding to stop treatment early. Our objective was to interview a cohort of women in a UK setting to corroborate and complete the grounded theory with the end users' primary involvement.

METHODS

A semi-structured interview schedule was written based on the existing grounded theory. Fourteen women with a history of hormone-positive breast cancer were recruited and interviewed. The audio-recorded interviews were transcribed and analysed against the existing grounded theory.

RESULTS

The findings were compatible with the core theory 'Hobson's choice or a horned dilemma' and its constituent categories previously developed, with additional concepts identified and added to our paradigm models. Importantly, we found that some women who started with a strong sense of commitment to their treatment changed their mind as they experienced the medication side effects over time, impacting on their persistence with long-term endocrine therapy.

CONCLUSION

The findings indicate an opportunity for health providers to intervene and influence women's waning perceptions of the necessity of their treatment, for example upon experiencing the side effects. Interventions could involve the provision of side effect management strategies via accessible resources.

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

Background

Objective

Methods

Results

Conclusions

How Negative Is Negative Information

Daily, we face a plenty of negative information that can profoundly affect our perception and behavior. During devastating events such as the current COVID-19 pandemic, negative messages may hinder reasoning at individual level and social decisions in the society at large. These effects vary across genders in neurotypical populations (being more evident in women) and may be even more pronounced in individuals with neuropsychiatric disorders such as depression. Here, we examine how negative information impacts reasoning on a social perception task in females with breast cancer, a life-threatening disease. Two groups of patients and two groups of matched controls (N_TOTAL = 80; median age, 50 years) accomplished a psychometrically standardized social cognition and reasoning task receiving either the standard instruction solely or additional negative information. Performance substantially dropped in patients and matched controls who received negative information compared to those who did not. Moreover, patients with negative information scored much lower not only compared with controls but also with patients without negative information. We suggest the effects of negative information are mediated by the distributed brain networks involved in affective processing and emotional memory. The findings offer novel insights on the impact of negative information on social perception and decision making during life-threatening events, fostering better understanding of its neurobiological underpinnings.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predicting health-related quality of life in dialysis patients: Factors related to negative outcome expectancies and social support

OBJECTIVES

Dialysis patients report a low health-related quality of life (HRQOL) due to high disease burden and far-reaching consequences of dialysis treatment. This study examined several cognitive-behavioral and social factors, with a focus on negative outcome expectancies, that might be relevant for HRQOL in end-stage kidney disease (ESKD) patients treated with dialysis.

METHODS

Patients treated with hemodialysis or peritoneal dialysis were recruited from Dutch hospitals and dialysis centers. Patients completed self-report questionnaires at baseline (n = 175) and six months follow-up (n = 130). Multiple regression analyses were performed.

RESULTS

Higher scores on factors related to negative outcome expectancies at baseline, especially helplessness and worrying, and less perceived social support were significantly related to worse HRQOL six months later. When controlling for baseline HRQOL, besides sex and comorbidity, helplessness remained significantly predictive of worse HRQOL six months later, indicating that helplessness is associated with changes in HRQOL over time.

CONCLUSIONS

Negative outcome expectancies and social support are relevant markers for HRQOL and/or changes in HRQOL over time.

PRACTICE IMPLICATIONS

Negative outcome expectancies could be prevented or diminished by enhanced treatment information, an improved patient-clinician relationship, and interventions that promote adaptive and realistic expectations. Additionally, increasing supportive social relationships could be a relevant treatment focus.

Interventions to Improve Adherence to Tyrosine Kinase Inhibitors in Chronic Myeloid Leukemia: A Systematic Review

BACKGROUND

Lack of adherence to tyrosine kinase inhibitors (TKIs) is a significant problem resulting in incomplete cytogenetic response and increased mortality in patients with chronic myeloid leukemia (CML). Few studies have been conducted on interventions to improve adherence. The authors conducted a systematic review to explore studies that examined the impact of strategies to improve TKI adherence among individuals with CML.

METHODS

The first 2 authors completed a systematic literature review according to the guidelines in Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Studies (n=2633) conducted between 1980 and 2019 were identified through 3 databases and examined for inclusion/exclusion criteria.

RESULTS

Fourteen studies were identified which met the eligibility criteria. The studies only examined adherence to imatinib, dasatinib, or nilotinib. Ten of the 14 used large data sets (commercial health insurance plans or Surveillance Epidemiology and End Results [SEER] data) for analysis. The majority of the studies used a cohort design. Adherence was defined and measured in a variety of ways with most studies using 80% or higher as adequate adherence. Strategies not focused on health care costs used a multidisciplinary team approach.

CONCLUSION

Development of evidence to improve treatment adherence to TKIs for CML have relied on large data sets rather than prospective trials. Current studies lack patient focused interventions.

Study design and methods for the using exercise to relieve joint pain and improve AI adherence in older breast cancer survivors (REJOIN) trial

BACKGROUND

Aromatase Inhibitors (AIs) are recommended for survival in post-menopausal breast cancer survivors (BCS) with hormone-sensitive disease. AI Adherence is suboptimal, especially in older BCS. Joint pain is a common AI-related symptom that is associated with low AI adherence. The Using Exercise to Relieve Joint Pain in Older Breast Cancer Survivors (REJOIN) Trial will evaluate the efficacy of a self-management intervention (exercise + education) to increase knowledge/self-efficacy for symptom management, reduce joint pain and potentially increase AI adherence in older BCS planning to take AIs.

METHODS

This randomized controlled pilot trial will include sedentary BCS, 65 years and older, diagnosed with stage I-III hormone-sensitive breast cancer, who have completed primary cancer treatment and are planning to initiate AIs. We will adapt an evidence-based physical activity program for older adults that includes bi-weekly, supervised exercise sessions plus 30 min of education. The 16-week intervention program includes: 8-weeks of supervised sessions plus 8-weeks of self-guided home sessions with periodic phone coaching. We will conduct geriatric assessments plus measurements of exercise, joint pain, and AI adherence (baseline, 4, 6 and 12 months).

DISCUSSION

REJOIN is one of the first trials to exclusively target older BCS using a self-management intervention, informed by geriatric assessment and exercise physiology, to improve health outcomes in survivorship. The REJOIN trial could lay the foundation for transdisciplinary research that bridges the gap between clinical and public health perspectives in healthy aging, with the opportunity to translate clinical interventions into non-pharmacological tools for a growing, yet underserved population of older survivors.

TRIAL REGISTRATION

NCT03955627.

Use of Adjuvant Endocrine Therapy Among Post-Menopausal Breast Cancer Patients in Malaysia

CONTEXT

Globally, breast cancer is the most common cancer affecting women, and adjuvant endocrine therapy (AET) is part of its treatment modality, which improves patients' outcome. However, there are concerns on side effects related to its use, which may affect treatment adherence.

PURPOSE

This study was conducted to explore attitude and practice on using AET among breast cancer patients in Malaysia.

PATIENTS AND METHODS

Postmenopausal breast cancer patients on at least 3 months of AET attending the outpatient oncology clinic at a tertiary care hospital were interviewed. Patients underwent in-depth interviews exploring their attitude and practices while on AET using a semi-structured interview guide. The interviews were transcribed verbatim and analyzed using thematic analysis.

RESULTS

There were four main themes for attitude toward the use of AET: 1) benefits of using AET, 2) concerns on taking AET, 3) beliefs on alternative treatment, and 4) beliefs toward the doctor. For practice, six themes were obtained: 1) correct use of AET, 2) appointment adherence, 3) information-seeking behavior, 4) counseling services obtained, 5) experienced side effects of AET, and 6) usage of complementary and alternative medicines.

CONCLUSION

Several themes concerning attitude and practice of breast cancer patients receiving AET were identified, which may be addressed during treatment consultations in clinical practice.

Rural cancer survivors' health information needs post-treatment

OBJECTIVE

This study describes the most common cancer-related health information needs among rural cancer survivors and characteristics associated with reporting more information needs.

METHODS

Rural breast, prostate, and colorectal cancer survivors, two to five years post-diagnosis, identified from an institutional cancer registry, completed a mailed/telephone-administered survey. Respondents were asked about 23 health information needs in eight domains (tests and treatment, side effects and symptoms, health promotion, fertility, interpersonal, occupational, emotional, and insurance). Poisson regression models were used to assess relationships between number of health information needs and demographic and cancer characteristics.

RESULTS

Participants (n = 170) reported an average of four health information needs, with the most common domains being: side effects and symptoms (58 %), health promotion (54 %), and tests and treatment (41 %). Participants who were younger (compared to 5-year increase, rate ratio [RR] = 1.11, 95 % CI = 1.02-1.21), ethnic minority (RR = 1.89, 95 % CI = 1.17-3.06), less educated (RR = 1.49, 95 % CI = 1.00-2.23), and financially stressed (RR = 1.87, 95 % CI = 1.25-2.81) had a greater number of information needs.

CONCLUSIONS

Younger, ethnic minority, less educated, and financially strained rural survivors have the greatest need for informational support.

PRACTICE IMPLICATIONS

The provision of health information for rural cancer survivors should consider type of cancer, treatments received, and sociocultural differences to tailor information provided.

Racial and Geographic Disparities in Endocrine Therapy Adherence Among Younger Breast Cancer Survivors

OBJECTIVES

African American (AA) women with breast cancer (BrCA) have higher mortality than any other race. Differential mortality has been attributed to nonadherence to endocrine therapy (ET). ET can lower the risk of dying by one third; yet 50% to 75% of all women are nonadherent to ET. Despite the wealth of research examining adherence to ET, understanding which groups of women at risk for poor adherence is not well established. The aim of this investigation was to describe ET adherence by race and geographic location among a cohort of younger BrCA survivors.

MATERIALS AND METHODS

Cancer registry records were linked to administrative data from Medicaid and a private insurance plan in South Carolina. Inclusion criteria included: European American (EA) or AA race, 3 years of continuous enrollment in the insurance plan after diagnosis, and BrCA diagnosis between 2002 and 2010. Adherence was measured by computing a medication possession ratio (MPR) based upon refill service dates and the number of pills dispensed. Adjusted least squared means were calculated by racial and geographic group using analysis of covariance methods.

RESULTS

The average MPR for EA women was significantly higher at 96% compared with 92% for AA women (P<0.01). After adjustment for years on hormone therapy, age, and number of pharmacies utilized, rural AA women had an average MPR of 90% compared with 95% for EA women (P<0.01).

CONCLUSIONS

AA women residing in rural areas demonstrate significantly lower adherence compared with their EA counterparts. Interventions are needed to improve adherence that may ameliorate AA mortality disparities.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interventions to Enhance Adherence to Oral Antineoplastic Agents: A Scoping Review

BACKGROUND

As new targeted oral antineoplastic therapies have emerged in recent years, the development of effective strategies that promote optimal adherence to cancer medication regimens has become an important priority.

METHODS

We conducted a scoping literature review to search for English language articles published through July 15, 2019, to identify studies that reported the testing and/or evaluation of interventions to improve adherence to oral antineoplastic agents.

RESULTS

A total of 56 articles were selected for review. Of the studies evaluated, 14 were randomized trials. All interventions except two targeted adult patients. Thirty-three studies enrolled fewer than 100 patients. Most interventions were education- and counseling-based and centered on provision of information about the drug and strategies to manage side effects. Only eight studies used an mHealth tool and/or text messages to target nonadherence. Among studies with a comparison sample, fewer than one-half (44.7%) reported statistically significant improvements in adherence or persistence associated with the intervention; however, some pharmacist-directed programs, particularly those that integrated monitoring or routine follow-up with a provider, did demonstrate efficacy.

CONCLUSION

Although the development of adherence-promoting interventions for oral antineoplastic therapies has increased recently, few have been rigorously tested. The nascent literature suggests those that are pharmacist directed and use regular monitoring show promise, though additional prospective studies are needed. Study methodology, population selection, and potential challenges that may be encountered in the implementation and dissemination phases should be considered when developing new interventions to address nonadherence to oral antineoplastic treatment.

Optimizing expectations about endocrine treatment for breast cancer: Results of the randomized controlled psy-breast trial

Background

Medication side effects are strongly determined by non-pharmacological, nocebo mechanisms, particularly patients’ expectations. Optimizing expectations could minimize side effect burden. This study evaluated whether brief psychological expectation management training (EXPECT) optimizes medication-related expectations in women starting adjuvant endocrine therapy (AET) for breast cancer.

Method

In a multisite randomized controlled design, 197 women were randomized to EXPECT, supportive therapy (SUPPORT), or treatment as usual (TAU). The three-session cognitive-behavioral EXPECT employs psychoeducation, guided imagery, and side effect management training. Outcomes were necessity-concern beliefs about AET, expected side effects, expected coping ability, treatment control expectations, and adherence intention.

Results

Both interventions were well accepted and feasible. Patients’ necessity-concern beliefs were optimized in EXPECT compared to both TAU and SUPPORT, d = .41, p < .001; d = .40, p < .001. Expected coping ability and treatment control expectations were optimized compared to TAU, d = .35, p = .02; d = .42, p < 001, but not to SUPPORT. Adherence intention was optimized compared to SUPPORT, d = .29, p = .02, but not to TAU. Expected side effects did not change significantly.

Conclusion

Expectation management effectively and partly specifically (compared to SUPPORT) modified medication-related expectations in women starting AET. Given the influence of expectations on long-term treatment outcome, psychological interventions like EXPECT might provide potential pathways to reduce side effect burden and improve quality of life during medication intake.

Exploring the perspectives of healthcare professionals in delivering optimal oncology medication education

Background

To optimize patient education, it is important to understand what healthcare professionals perceive to be ideal oncology medication education for patients to receive, and what they feel is their role and the role of others in its delivery. Education provided to patients is an important component of chemotherapy as it has been shown to benefit and positively impact patients who receive it. Educational interventions are often provided by multidisciplinary teams with the goal of improving patient care. However, few studies have explored the roles of healthcare professionals in delivering oncology medication education.

Objective

To explore the perspectives of healthcare professionals working in medical, gynaecological or hematological oncology to identify what they perceive to be optimal oncology medication education for patients.

Methods

Healthcare professionals (physicians, nurses and pharmacists) working in medical, gynaecological or hematological oncology at the Nova Scotia Health Authority, Central Zone were invited to participate in one-on-one, semi-structured interviews which were audio-recorded, transcribed and analyzed using thematic analysis.

Findings

Fifteen interviews, including five physicians, four nurses and six pharmacists were conducted from February to April 2018. Four major themes were identified: Delivery of oncology medication education, Facilitating the patient learning process, Multidisciplinary Approach and Understanding barriers to the healthcare professional in providing education.

Conclusion

The identified themes uncovered novel ideas about how healthcare professionals felt oncology medication education could ideally be delivered to patients, and supported findings in the literature. Although participants discussed barriers to their ability to deliver optimal education, they also identified ways in which they can facilitate patient learning, for example, through the reinforcement of education. Participants recognized the importance of increasing collaboration and communication with the multidisciplinary team. This research will inform the design of any new models for oncology medication education at the Nova Scotia Health Authority, Central Zone and potentially other sites.

Understanding persistent physical symptoms: Conceptual integration of psychological expectation models and predictive processing accounts

Persistent physical symptoms (PPS) are distressing, difficult to treat, and pose a major challenge to health care providers and systems. In this article, we review two disparate bodies of literature on PPS to provide a novel integrative model of this elusive condition. First, we draw on the clinical-psychological literature on the role of expectations to suggest that people with PPS develop dysfunctional expectations about health and disease that become increasingly immune to disconfirmatory information (such as medical reassurance) through cognitive reappraisal. Second, we invoke neuroscientific predictive processing accounts and propose that the psychological process of 'cognitive immunization' against disconfirmatory evidence corresponds, at the neurobiological and computational level, to too much confidence (i.e. precision) afforded to prior predictions. This can lead to an attenuation of disconfirming sensory information so that strong priors override benign bodily signals and make people believe that something serious is wrong with the body. Combining these distinct accounts provides a unifying framework for persistent physical symptoms and shifts the focus away from their causes to the sustaining mechanisms that prevent symptoms from subsiding spontaneously. Based on this integrative model, we derive new avenues for future research and discuss implications for treating people with PPS in clinical practice.

THRIVE study protocol: a randomized controlled trial evaluating a web-based app and tailored messages to improve adherence to adjuvant endocrine therapy among women with breast cancer

Background

Long-term use of adjuvant endocrine therapy (AET) among women with early-stage, hormone receptor-positive breast cancer significantly reduces the risk of hospitalizations, cancer recurrence, and mortality. AET is associated with adverse symptoms that often result in poor adherence. A web-enabled app offers a novel way to communicate and manage symptoms for women on AET. In a region with significant racial disparities in breast cancer outcomes, our study tests the impact of a web-enabled app that collects and transmits patient-reported symptoms to healthcare teams to facilitate timely and responsive symptom management on medication adherence.

Methods

In this randomized controlled trial, we randomize 300 patients initiating AET to one of three arms: 1) an “App” group (n = 100) that receives weekly reminders to use the THRIVE study app; 2) an “App+Feedback” group (n = 100) that receives weekly reminders and tailored feedback based on their use of the app; or 3) a “Usual Care” group (n = 100) that receives usual care only. Participants are stratified by race: 50% White and 50% Black. The duration of the intervention is six months following enrollment, and outcomes are assessed at 12-months. The primary outcome is adherence, which is captured using an electronic monitoring pillbox. Secondary outcomes include symptom burden, quality of life, self-efficacy for managing symptoms, and healthcare costs. We also evaluate the impact of the intervention on racial disparities in adherence. Data are derived from three sources: electronic health record data to capture treatment changes, healthcare utilization, and health outcomes; self-report survey data related to adherence, symptom burden, and quality of life; and an electronic medication monitoring device that captures adherence.

Discussion

A successful web-enabled intervention could be disseminated across systems, conditions, and populations. By evaluating the impact of this intervention on a comprehensive set of measures, including AET adherence, patient outcomes, and costs, our study will provide valuable and actionable results for providers, policy makers, and insurers who strive to achieve the “Triple Aim” – reduce costs while improving health outcomes and the patient care experience.

Trial registration

NCT03592771. Prospectively registered on July 19, 2018.

How to prevent, minimize, or extinguish nocebo effects in pain: a narrative review on mechanisms, predictors, and interventions

Possible factors that contribute to nocebo effects on pain are explored. Strategies that can prevent, minimize, or extinguish nocebo effects in clinical settings are suggested.

Nocebo effects, such as side effects due to negative expectations regarding the pain treatment, are a concern for health care providers and come with significant costs. This narrative review focuses on underlying mechanisms and possible factors that contribute to the susceptibility to the nocebo effect on pain and related outcomes and suggests strategies that can prevent, minimize, or extinguish nocebo effects in clinical settings. Nocebo effects are the result of psychological (eg, conditioning, verbal suggestions, and observational learning) and neurobiological (eg, cholecystokinin and dopamine regulation) mechanisms. Evidence from clinical and experimental studies lead to various recommendations and strategies to alter the nocebo effect in order to optimize pain treatments, such as providing patients with enhanced information, optimizing patient–physician communication and relationships, and offering psychoeducation on coping skills in order to manage patient expectations. The current literature from both clinical and experimental studies provides a better understanding of the nocebo effect and possible factors that modulate its strength on treatment outcomes. This allows for the development of evidence-based strategies aimed at the prevention, minimization, and treatment of the nocebo effect in pain conditions and possible other somatic disorders.

"It is not just any pill"-Women's experiences of endocrine therapy after breast cancer surgery

OBJECTIVE

For patients diagnosed with hormone-receptor-positive breast cancer, endocrine therapy (ET) is usually prescribed to reduce recurrence and mortality rates. Despite the benefits, compliance with treatment varies. The aim of this study was to provide qualitative data about women's experiences with ET after breast cancer surgery.

METHODS

Twenty-five women, treated with Tamoxifen after breast cancer surgery, were interviewed in seven focus groups. Six open-ended questions were used to explore their experiences. The interviews were recorded, transcribed verbatim and analysed using inductive content analysis.

RESULTS

The analysis resulted in three categories that described the women's experiences: the treatment "creates discomfort"; "promotes levels of management"; and "causes feelings of abandonment". Women's experiences of treatment could at first glance be seen as positive, as perceived protection, but after further analysis, a deeper meaning was identified: protection with reservation. When experiencing discomfort, the women tried to manage the situation, although the mode of management sometimes varied. The women reported that they needed support, but when the support did not appear, they felt as though they had been abandoned. Moreover, knowledge about side effects became an obstacle, as it could create fear of more severe symptoms. They also described that their disease was perceived by healthcare professionals as "cancer light".

CONCLUSION

The information needs to be customised specifically to each person.

Assessment of patient information needs: A systematic review of measures

Background

Providing patient information is a central aspect of patient-centered care. Fulfilling personal information needs has positive effects on several health-related outcomes. Measurement instruments help to identify individual information needs in an effective way. The present study gives an overview of existing information needs measures and further evaluates the quality of their psychometric properties and their psychometric studies.

Methods

We conducted a systematic search on psychometric studies of measures that assess information needs in PubMed and Embase. Furthermore, we carried out a secondary search with reference and citation tracking of the included articles. Title, abstracts and full texts were screened by two independent reviewers for eligibility. We extracted data on content of the measures, validation samples and psychometric properties. In addition we rated the methodological quality with the COSMIN checklist and the quality of psychometric properties with the criteria of Terwee and colleagues.

Results

24 studies on 21 measures were included. Most instruments assessed information needs of patients with cancer or cardiac diseases. The majority of the instruments were in English language and from western countries. Most studies included information on internal consistency and content validity. The ratings showed mixed results with clear deficiencies in the methodological quality of most studies.

Discussion

This is the first systematic review that summarized the existing evidence on measures on patient information needs using two instruments for a systematic quality assessment. The results show a need for more psychometric studies on existing measures. In addition, reporting on psychometric studies needs to be improved to be able to evaluate the reliability of the psychometric properties. Furthermore, we were not able to identify any measures on information needs for some frequent chronic diseases. Other methods to elicit information needs (e.g. open-ended interviews, question prompt sheets) could be considered as alternatives if sound measures are missing.

A systematic review of interventions to improve adherence to endocrine therapy

PURPOSE

Adherence to endocrine therapy for hormone positive breast cancer is a significant problem, especially in minority populations. Further, endocrine therapy reduces recurrence and thus mortality. However, little data are available on interventions to improve adherence. The authors conducted a systematic review to examine the impact of interventions, strategies, or approaches aimed to improve endocrine therapy adherence among women with breast cancer. A secondary aim was to determine if interventions had any cultural modifications.

METHODS

Two of the authors examined articles published between 2006 and 2017 from a wide variety of databases using Covidence systematic review platform.

RESULTS

In total, 16 eligible studies met criteria for review including 4 randomized controlled trials, 4 retrospective studies, and 8 with various observational designs. Eligible studies used a broad range of definitions for adherence and measured adherence by self-report, medical records, claims data, and combinations of these. All used 80% medication possession ratio as a standard for adherence. Patient information/education was the most frequent intervention strategy but did not demonstrate a significant effect except in one study. Significant results were noted when education was combined with communication strategies.

CONCLUSIONS

Researchers need a standard definition for adherence and a reliable measure that is feasible to use in a variety of studies. While education may be a necessary component of an intervention, when used alone, it is not a sufficient approach to change behavior.

A systematic review of interventions to improve adherence to endocrine therapy

PURPOSE

Adherence to endocrine therapy for hormone positive breast cancer is a significant problem, especially in minority populations. Further, endocrine therapy reduces recurrence and thus mortality. However, little data are available on interventions to improve adherence. The authors conducted a systematic review to examine the impact of interventions, strategies, or approaches aimed to improve endocrine therapy adherence among women with breast cancer. A secondary aim was to determine if interventions had any cultural modifications.

METHODS

Two of the authors examined articles published between 2006 and 2017 from a wide variety of databases using Covidence systematic review platform.

RESULTS

In total, 16 eligible studies met criteria for review including 4 randomized controlled trials, 4 retrospective studies, and 8 with various observational designs. Eligible studies used a broad range of definitions for adherence and measured adherence by self-report, medical records, claims data, and combinations of these. All used 80% medication possession ratio as a standard for adherence. Patient information/education was the most frequent intervention strategy but did not demonstrate a significant effect except in one study. Significant results were noted when education was combined with communication strategies.

CONCLUSIONS

Researchers need a standard definition for adherence and a reliable measure that is feasible to use in a variety of studies. While education may be a necessary component of an intervention, when used alone, it is not a sufficient approach to change behavior.

Effect of one comprehensive education course to lower anxiety and depression among Chinese breast cancer patients during the postoperative radiotherapy period - one randomized clinical trial

BACKGROUND

We investigated the effectiveness of one education course to lower the severity of anxiety and depression symptoms among breast cancer (BC) patients during radiotherapy (RT).

METHODS

All 290 one-sided BC patients were evenly randomized into intervention or control arm. "Intervention" patient was additionally provided with one three-hour course on psychological stresses and management skills. Changes of anxiety and depression score and their 3-level severity category ('normal', 'borderline' and 'abnormal' scored 0-7, 8-10 and 11-21, respectively) from HADS questionnaire over RT were evaluated by multivariable linear and ordinal logistic regressions.

RESULTS

Response rates were 94 and 100% by "intervention" and "control" arm, respectively. Means of score changes by "intervention" and "control" (n = 145) were + 0.59 (SD = 2.47) and + 0.11 (SD = 2.55) for anxiety and + 0.81 (SD = 2.81) and + 0.45 (SD = 2.77) for depression scores, respectively. 'Abnormal' anxiety and depression patients were 4.1 and 6.9% at baseline and 4.8 and 6.9% at end of RT at 'control' arm; those rates were 6.6 and 7.4%, and 8.8 and 10.3% at 'intervention' arm, respectively. Both changes on anxiety and depression measurements between two arms were all insignificant (p > 0.20).

CONCLUSIONS

One education course did not reduce the score and severity of anxiety and depression symptoms over RT period.

TRIAL REGISTRATION

Chinese Clinical Trial Registry #: ChiCTR-IIR-16008818 at www.chictr.org.cn .

Women's Beliefs on Early Adherence to Adjuvant Endocrine Therapy for Breast Cancer: A Theory-Based Qualitative Study to Guide the Development of Community Pharmacist Interventions

Adjuvant endocrine therapy (AET) taken for a minimum of five years reduces the recurrence and mortality risks among women with hormone-sensitive breast cancer. However, adherence to AET is suboptimal. To guide the development of theory-based interventions to enhance AET adherence, we conducted a study to explore beliefs regarding early adherence to AET. This qualitative study was guided by the Theory of Planned Behavior (TPB). We conducted focus groups and individual interviews among women prescribed AET in the last two years (n = 43). The topic guide explored attitudinal (perceived advantages and disadvantages), normative (perception of approval or disapproval), and control beliefs (barriers and facilitating factors) towards adhering to AET. Thematic analysis was conducted. Most women had a positive attitude towards AET regardless of their medication-taking behavior. The principal perceived advantage was protection against a recurrence while the principal inconvenience was side effects. Almost everyone approved of the woman taking her medication. The women mentioned facilitating factors to encourage medication-taking behaviors and cope with side effects. For adherent women, having trouble establishing a routine was their main barrier to taking medication. For non-adherent women, it was side effects affecting their quality of life. These findings could inform the development of community pharmacy-based adherence interventions.

Deconstructing Decisions to Initiate, Maintain, or Discontinue Adjuvant Endocrine Therapy in Breast Cancer Survivors: A Mixed-Methods Study

PURPOSE/OBJECTIVES

Adjuvant endocrine therapy (AET) has been shown to improve survival in hormone receptor-positive breast cancer survivors, but as many as half do not complete recommended treatment. Management of medication-related side effects and engagement with providers are two potentially modifiable factors, but their associations with adherence are not well understood. The aims were to build on survey results to qualitatively explore survivors' experiences with prescribed AET to (a) describe appraisal and management of AET side effects and (b) deconstruct decisions to initiate, discontinue, or maintain AET.
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RESEARCH APPROACH

The authors used a mixed-methods explanatory sequence research design with a qualitative emphasis.
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SETTING

Survivors were recruited from a clinical cancer registry maintained at the University of Texas Southwestern Medical Center, which includes the Harold C. Simmons Comprehensive Cancer Center (National Cancer Institute-designated), in Dallas.
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PARTICIPANTS

452 survivors completed a survey, and 30 took part in telephone interviews.
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METHODOLOGIC APPROACH

Qualitative methods were used in which the authors recorded and transcribed interviews for analysis and used open coding to reduce data into themes.
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FINDINGS

Among adherent survivors, the themes of tolerance of side effects and perseverance were strong. Nonadherent survivors expressed more difficulty managing side effects and perceived fewer benefits when side effects were bothersome. The most common side effects mentioned by all survivors were menopausal symptoms and joint pain; less common side effects were cognitive decline and cardiac distress. Some sought advice from their oncology team. Nonadherent survivors appeared initially motivated to maintain AET but identified a tolerance limit for side effects after which a provider's recommendation was less influential in their decision to maintain or discontinue AET.
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INTERPRETATION

This study elucidated adherence as a complex continuum of behaviors, appraisals, and decision points. These insights may be particularly useful in counseling survivors taking AET and promoting timely delivery of clinical interventions to enhance adherence.
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IMPLICATIONS FOR NURSING

Nurses should be involved in the planning and implementation of clinical interventions to manage side effects and other barriers to AET adherence.

Facilitating adherence to endocrine therapy in breast cancer: stability and predictive power of treatment expectations in a 2-year prospective study

PURPOSE

To identify modifiable factors predictive of long-term adherence to adjuvant endocrine therapy (AET).

METHODS

As part of a 2-year cohort study in primary care (n = 116), we investigated whether initial treatment expectations predict adherence at 24 months after controlling for demographic, medical, and psychosocial variables. Treatment expectations were measured as necessity-concern beliefs, expected side-effect severity, and expected coping with side effects. Their stability over time and differences of trajectories between the adherent and nonadherent group were examined.

RESULTS

Nonadherence at 24 months was 14.7% (n = 17). Side-effect severity at 3 months [OR 0.25, 95% CI (0.08, 0.81), p = 0.02] and necessity-concern beliefs [OR 2.03, 95% CI (1.11, 3.72), p = 0.02] were the sole predictors of adherence. Necessity-concern beliefs remained stable over 2 years, whereas expected side-effect severity (p = 0.01, η p2  = 0.07) and expected coping with side effects became less optimistic over time (p < 0.001, η p2  = 0.19), the latter particularly among nonadherers (p < 0.01, η p2  = 0.10).

CONCLUSIONS

Patients' initial necessity-concern beliefs about the AET and early severity of side effects affect long-term adherence. Expecting poor management of side effects may also facilitate nonadherence. We suggest that discussing benefits, addressing concerns of AET, and providing side-effect coping strategies could constitute a feasible and promising option to improve adherence in clinical practice.

Why current drug adherence programs fail: addressing psychological risk factors of nonadherence

PURPOSE OF REVIEW

To provide an overview of a selection of largely neglected psychological risk factors for nonadherence, and to offer new approaches to improve medication adherence.

RECENT FINDINGS

Current adherence research and intervention programs focus on a few risk factors for nonadherence, such as complexity of the drug regimen. In addition, other important risk factors of nonadherence are neglected or insufficiently addressed. There is good evidence for the significant role of the quality of the patient-healthcare provider relationship. Other risk factors like the individual history of nonadherence, the lack of acceptance of having a treatable disorder, fear of side-effects, comorbid depression, and cognitive impairment have been broadly neglected in adherence programs, although they offer a powerful key to improve adherence-oriented interventions.

SUMMARY

Current research on determinants of nonadherence has focused on a few risk factors, while neglecting crucial psychological predictors of nonadherence. The personalized consideration of a multiplicity of risk factors offers a new basis for the development and evaluation of interventions to better promote adherence.

Effectiveness of a decision aid for patients with depression: A randomized controlled trial

Background

Shared decision making is an important component of patient‐centred care and decision aids are tools designed to support patients' decision making and help patients with depression to make informed choices.

Objective

The study aim was to assess the effectiveness of a web‐based decision aid for patients with unipolar depression.

Design

Randomized controlled trial.

Setting and participants

Adults diagnosed with a major depressive disorder and recruited in primary care centres were included and randomized to the decision aid (n=68) or usual care (n=79).

Intervention

Patients in the decision aid group reviewed the decision aid accompanied by a researcher.

Outcome measures

Knowledge about treatment options, decisional conflict, treatment intention and preference for participation in decision making. We also developed a pilot measure of concordance between patients' goals and concerns about treatment options and their treatment intention.

Results

Intervention significantly improved knowledge (P<.001) and decisional conflict (P<.001), and no differences were observed in treatment intention, preferences for participation, or concordance. One of the scales developed to measure goals and concerns showed validity issues.

Conclusion

The decision aid “Decision making in depression” is effective improving knowledge of treatment options and reducing decisional conflict of patients with unipolar depression. More research is needed to establish a valid and reliable measure of concordance between patients' goals and concerns regarding pharmacological and psychological treatment, and the choice made.

Supporting adherence to oral anticancer agents: clinical practice and clues to improve care provided by physicians, nurse practitioners, nurses and pharmacists

Background

Healthcare provider (HCP) activities and attitudes towards patients strongly influence medication adherence. The aim of this study was to assess current clinical practices to support patients in adhering to treatment with oral anticancer agents (OACA) and to explore clues to improve the management of medication adherence.

Methods

A cross-sectional, observational study among HCPs in (haemato-)oncology settings in Belgium and the Netherlands was conducted in 2014 using a composite questionnaire. A total of 47 care activities were listed and categorised into eight domains. HCPs were also asked about their perceptions of adherence management on the items: insight into adherence, patients’ communication, capability to influence, knowledge of consequences and insight into causes. Validated questionnaires were used to assess beliefs about medication (BMQ) and shared decision making (SDM-Q-doc).

Results

In total, 208 HCPs (29% male) participated; 107 from 51 Dutch and 101 from 26 Belgian hospitals. Though a wide range of activities were reported, certain domains concerning medication adherence management received less attention. Activities related to patient knowledge and adverse event management were reported most frequently, whereas activities aimed at patient’s self-efficacy and medication adherence during ongoing use were frequently missed. The care provided differed between professions and by country. Belgian physicians reported more activities than Dutch physicians, whereas Dutch nurses and pharmacists reported more activities than Belgian colleagues. The perceptions of medication adherence management were related to the level of care provided by HCPs. SDM and BMQ outcomes were not related to the care provided.

Conclusions

Enhancing the awareness and perceptions of medication adherence management of HCPs is likely to have a positive effect on care quality. Care can be improved by addressing medication adherence more directly e.g., by questioning patients about (expected) barriers and discussing strategies to overcome them, by asking for missed doses and offering (electronic) reminders to support long-term medication adherence. A multidisciplinary approach is recommended in which the role of the pharmacist could be expanded.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3110-2) contains supplementary material, which is available to authorized users.

Nocebo effects in clinical studies: hints for pain therapy

INTRODUCTION

Nocebo-induced algesic responses occurring within clinical contexts present a challenge for health care practitioners working in the field of pain medicine.

OBJECTIVES

Following the recent research on algesic nocebo effects, the scope of this review is to develop ethically acceptable strategies to help avoid, or at least reduce, nocebo responses within clinical settings.

METHODS

We reviewed relevant clinical studies that depict how patient-practitioner interactions may contribute to the reduction of nocebo responses.

RESULTS

A strong algesic nocebo effect may adversely impact a patient's condition by causing decreases in both the efficacy and effectiveness of interventions, as well as by promoting treatment nonadherence and discontinuation. These effects may be triggered through multiple channels and can lead to significant alterations in a patient's perception of pain, consequently producing a weakening of the specific positive effects of pharmacological, psychological, or physical pain-management interventions.

CONCLUSION

To minimize nocebo effects in clinical settings, we identified and discussed five contextual aspects relevant to the treatment of patients with chronic pain: (1) negative patient-clinician communication and interaction during treatment; (2) emotional burden of patients during treatment with analgesic medication; (3) negative information provided via informational leaflets; (4) cued and contextual conditioning nocebo effects; and (5) patient's lack of positive information. Through an understanding of these elements, many preventive and ethically acceptable clinical actions can be taken to improve multidisciplinary pain treatment outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Racial differences in receipt of adjuvant hormonal therapy among Medicaid enrollees in South Carolina diagnosed with breast cancer

Several factors contribute to the pervasive Black-White disparity in breast cancer mortality in the U.S., such as tumor biology, access to care, and treatments received including adjuvant hormonal therapy (AHT), which significantly improves survival for hormone receptor-positive breast cancers (HR+). We analyzed South Carolina Central Cancer Registry-Medicaid linked data to determine if, in an equal access health care system, racial differences in the receipt of AHT exist. We evaluated 494 study-eligible, Black (n = 255) and White women (n = 269) who were under 65 years old and diagnosed with stages I-III, HR+ breast cancers between 2004 and 2007. Bivariate and multivariate analyses were conducted to assess receipt of ≥1 AHT prescriptions at any point in time following (ever-use) or within 12 months of (early-use) breast cancer diagnosis. Seventy-two percent of the participants were ever-users (70 % Black, 74 % White) and 68 % were early-users (65 % Black, 71 % White) of AHT. Neither ever-use (adjusted OR (AOR) = 0.75, 95 % CI 0.48-1.17) nor early-use (AOR = 0.70, 95 % CI 0.46-1.06) of AHT differed by race. However, receipt of other breast cancer-specific treatments was independently associated with ever-use and early-use of AHT [ever-use: receipt of surgery (AOR = 2.15, 95 % CI 1.35-3.44); chemotherapy (AOR = 1.97, 95 % CI 1.22-3.20); radiation (AOR = 2.33, 95 % CI 1.50-3.63); early-use: receipt of surgery (AOR = 2.03, 95 % CI 1.30-3.17); chemotherapy (AOR = 1.90, 95 % CI 1.20-3.03); radiation (AOR = 1.73, 95 % CI 1.14-2.63)]. No racial variations in use of AHT among women with HR+ breast cancers insured by Medicaid in South Carolina were identified, but overall rates of AHT use by these women is low. Strategies to improve overall use of AHT should include targeting breast cancer patients who do not receive adjuvant chemotherapy and/or radiation.

What do women with breast cancer expect from their treatment? Correlates of negative treatment expectations about endocrine therapy

OBJECTIVES

Patients' negative treatment expectations can lead to nocebo-related side effects and non-initiation of treatment. This study aims to identify correlates of treatment expectations in patients with breast cancer before the start of endocrine therapy.

METHODS

Expectations were assessed in a cross-sectional sample of 166 patients with breast cancer after receiving treatment information. Side effect expectations (one item) and treatment necessity-concern balance (Beliefs about Medicines Questionnaire) were assessed. Correlates were analyzed using regression analyses. The structure of treatment expectations was investigated using a network analysis.

RESULTS

About 25% of patients expressed negative expectations. Higher side effect expectations were associated with lower treatment efficacy expectations (ß = -0.20, p = 0.01), higher medication overuse beliefs (ß = 0.17, p = 0.01), and a negative treatment appraisal before study treatment information (ß = -0.17, p = 0.02). A negative necessity-concern balance was associated with lower treatment efficacy expectations (ß = 0.36, p < 0.001), lower adherence intention (ß = 0.21, p < 0.001), and no knowledge of tumor's receptor status (ß = 0.21, p < 0.001); furthermore, it was associated with higher medication harmfulness beliefs (ß = -0.16, p = 0.02), negative treatment pre-appraisal (ß = 0.15, p = 0.01), higher somatosensory amplification (ß = -0.14, p = 0.02), and higher education (ß = -0.12, p = 0.02). The most important network node was the concern that endocrine therapy disrupts life.

CONCLUSION

Negative treatment expectations before treatment start are mainly associated with psychological variables. These results are relevant for patient education in clinical settings. To improve expectations, clinicians might emphasize treatment efficacy and discuss general and specific medication concerns. Improving treatment knowledge could also be beneficial. Copyright © 2016 John Wiley & Sons, Ltd.

Effects of a Cancer Prevention Advertisement on Beliefs and Knowledge about Cancer Prevention

BACKGROUND

Outcome-expectation beliefs and knowledge may ultimately influence behavior for cancer prevention. The aims of this study were to measure changes in knowledge and beliefs about cancer prevention before and after viewing a television advertisement and identify the factors affecting receptivity to its messages.

MATERIALS AND METHODS

A one-group pretest-posttest design was used in this study of 1,000 individuals aged 20 to 65 years who were recruited online in November 2014. The outcome variables included cancer prevention beliefs based on the Health Belief Model (five items) and knowledge about risk factors for cancer (seven items).

RESULTS

Perceived susceptibility, perceived benefits, and self-efficacy increased significantly and their perceived severity and perceived barriers decreased significantly, after participants viewed the television advertisement. Correct responses to questions about risk factors also increased significantly, except for smoking. The main factors affecting changes in the outcome variables were age, interest in cancer prevention, social network, satisfaction with the ad, and pretest scores.

CONCLUSIONS

Television advertisements with positive frameworks can be an efficient channel of improving beliefs and knowledge about cancer prevention in a short period. The continuous development of intervention materials that consider the demographics, needs, and satisfaction of the target group will be necessary for future studies.