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

Medication nonadherence - definition, measurement, prevalence, and causes: reflecting on the past 20 years and looking forwards

In 2003, Sabate's World Health Organisation report defined medication nonadherence as a phenomenon where individuals' behaviour does not correspond to prescribed treatment recommendations from their healthcare provider. This concept of nonadherence evolved beyond a categorisation of patients as adherent or nonadherent. Rather, nonadherence varies within the same individual and treatment over time, and between treatments and individuals. The type and patterns of nonadherence are key determinants of outcome with individuals with the same percentage nonadherence having different outcomes depending on their pattern of nonadherence. Often the poorest clinical outcomes occur in individuals who do not initiate medication or discontinue early, but much of the nonadherence literature remains focused on implementation. This paper provides a nuanced discussion of nonadherence which has been enabled in part by the growing availability of technologies such as electronic nonadherence monitors, new biomarkers for adherence and greater access to 'big data' (e.g., on prescription refills). These allow granular assessment of nonadherence that can be linked with biophysical markers captured using technologies such as wearables. More validated self-report measures have also become available to profile nonadherence in research and practice. Together, in-depth data on dosing and clinical measures provide an opportunity to explore complex interactions between medications, therapeutic effects and clinical outcomes. This variation in measurement and definition means that there is a more fine-grained understanding of the prevalence of nonadherence and a greater recognition of the prevalence of nonadherence, with growing evidence suggesting that approximately a fifth of patients do not initiate treatment, of those initiating treatment approximately 30%-50% of patients do not implement their treatment as prescribed and that, over long follow-up periods in some conditions 80%-100% of patients discontinue. There is potential too to better understand causes of nonadherence. New behavioural models synthesise determinants of nonadherence previously considered separately. Frameworks like the COM-B (considering individual capability, opportunity, and motivation factors) and MACO (focusing on Medication Adherence Contexts and Outcomes) emphasize the multifaceted nature of nonadherence determinants. Greater focus on dynamic processes with interplay between individual, social, and environmental influences is needed. Addressing these complexities could lead to more effective and personalised support for patients.

Management of vasomotor symptoms in cancer patients

Many cancer treatments can lead to reduced levels of sex hormones, which in turn may cause vasomotor symptoms (VMS) such as hot flashes. These symptoms are associated with impaired quality of life, as well as suboptimal tolerability of and adherence to cancer treatment. Hormone therapy, performed by increasing estradiol or testosterone levels, is the gold standard for treatment of VMS. However, this approach is generally contraindicated in patients with hormone-sensitive cancers. Nonhormone agents with low to moderate efficacy in controlling VMS are available, but their use may be limited by side effects and tolerability. In this narrative review, the approach to VMS in cancer patients will be discussed. The evidence for various treatment options, including novel agents such as fezolinetant that target the hypothalamic thermoregulatory pathway, will be evaluated. Finally, special considerations in different patient populations based on cancer types (eg, breast, prostate) and age groups (eg, older adults) will be explored.

Patient-Nurse Communication in an Oncology Hospital Setting: A Qualitative Study

BACKGROUND

Communication is an important aspect in making patients competent to define, process, and manage their disease condition as well as to intercept and satisfy psychosocial needs. Communication between patient and nurse is central to the learning and orientating process since the nurse has the greatest frequency and continuity of relationship with patients and their families. This study aims to investigate the quality of communication between patient and nurse and the factors that promote or hinder effective communication from the oncology patient's perspective within an inpatient hospital setting.

METHODS

A descriptive qualitative study was conducted with one-to-one semi-structured interviews analyzed using the Framework Analysis methodology. The population consisted of oncologic patients admitted to the Medical Oncology Units of the Regina Elena National Cancer Institute in Rome. Data were analyzed using Ritchie and Spencer's Framework Analysis.

RESULTS

The sample comprised 20 patients, with an average age of 61.35, admitted to the Medical Oncology Units of the Regina Elena National Cancer Institute in Rome. Three themes emerged: positive communication as an element of care, factors fostering communication, and factors hindering communication.

CONCLUSIONS

The sample interviewed deems the quality of communication satisfactory. Familiar communication style, direct language, and caring are factors fostering communication. In contrast, lack of communication between medical and nursing staff, shortage of staff, and lack of time are considered communication barriers. Advanced communication competencies in nurses are crucial for effectively addressing the emotional and psychosocial needs of cancer patients, fostering a more empathetic and supportive care environment.

Effects of Adjuvant Endocrine Therapy-Specific Perceptions on Response to a Behavioral Intervention for Adjuvant Endocrine Therapy Adherence in Patients With Breast Cancer

PURPOSE

Adjuvant endocrine therapy (AET) is a life-saving medication for patients with hormone-sensitive breast cancer, yet many struggle with adherence, warranting behavioral intervention. In our recent trial, participation in a group cognitive behavioral intervention (STRIDE) for symptom management and adherence was associated with improvements in symptom distress, coping, quality of life, and mood. We now explore whether baseline patient- and medication-specific factors-which may be modifiable by clinician-led discussions-moderated the effect of STRIDE on adherence rates.

METHODS

From October 2019 to June 2021, 100 patients with early-stage breast cancer reporting AET-related distress were enrolled and randomly assigned to STRIDE or a medication monitoring (MM) control group. All patients stored their AET in electronic pill bottles to track objective adherence. Patients also self-reported their adherence on the Medication Adherence Report Scale-5 and their perceptions of AET on the Cancer Therapy Satisfaction Questionnaire at baseline. We conducted hierarchical linear modeling to test moderators of intervention effects on objective adherence rates. We report the time × group × moderator effects.

RESULTS

Among patients reporting greater perceived difficulties with AET adherence at baseline, STRIDE participants had higher adherence rates over time compared with MM (b = -13.80; SE = 4.56; P < .01). Patients with greater expectations of therapeutic benefit from AET also had improved adherence rates if they were assigned to STRIDE, versus MM (b = 0.25; SE = 0.10; P = .01). Patients who perceived taking AET as convenient and had been taking their AET for less time had higher adherence rates in STRIDE, versus MM.

CONCLUSION

The current study identified patient- and medication-specific factors that may augment AET adherence interventions and may be modifiable through clinician-led discussions, such as perceptions of adherence problems, therapeutic efficacy, and convenience of AET.

Impact of Patient Personality on Adherence to Oral Anticancer Medications: An Opportunity?

Adherence to prescribed oral anticancer therapy is an important determinant of patient outcomes, including progression-free and overall survival. While many factors (eg, medication side effects and out-of-pocket costs, problems with insurance authorization, and timely medication refills) can affect adherence, one that is relatively unexplored is the impact of a patient's attitude and personality. Patient personality influences medication adherence and persistence in nonmalignant chronic conditions such as cardiovascular disease and diabetes. In breast cancer and chronic myeloid leukemia, studies suggest that personality also affects adherence to oral chemotherapy which can be targeted to improve adherence. In this viewpoint, we highlight the opportunity of incorporating patient personality as interventions to oral cancer therapy adherence and discuss current barriers to implementation.

Natural compounds-based nanomedicines for cancer treatment: Future directions and challenges

Several efforts have been extensively accomplished for the amelioration of the cancer treatments using different types of new drugs and less invasives therapies in comparison with the traditional therapeutic modalities, which are widely associated with numerous drawbacks, such as drug resistance, non-selectivity and high costs, restraining their clinical response. The application of natural compounds for the prevention and treatment of different cancer cells has attracted significant attention from the pharmaceuticals and scientific communities over the past decades. Although the use of nanotechnology in cancer therapy is still in the preliminary stages, the application of nanotherapeutics has demonstrated to decrease the various limitations related to the use of natural compounds, such as physical/chemical instability, poor aqueous solubility, and low bioavailability. Despite the nanotechnology has emerged as a promise to improve the bioavailability of the natural compounds, there are still limited clinical trials performed for their application with various challenges required for the pre-clinical and clinical trials, such as production at an industrial level, assurance of nanotherapeutics long-term stability, physiological barriers and safety and regulatory issues. This review highlights the most recent advances in the nanocarriers for natural compounds secreted from plants, bacteria, fungi, and marine organisms, as well as their role on cell signaling pathways for anticancer treatments. Additionally, the clinical status and the main challenges regarding the natural compounds loaded in nanocarriers for clinical applications were also discussed.

Sex disparity of DAPT noncompliance in patients with left main stem PCI with DES

This retrospective study aims to explore the sex disparity in dual antiplatelet therapy (DAPT) noncompliance among left main stem percutaneous coronary intervention (PCI) patients with drug-eluting stent (DES) and identify predictors associated with non-adherence. Data were collected from the medical records of 1585 patients, including 1104 males and 481 females, who underwent left main stem PCI with DES. Baseline characteristics, angiographic features, and DAPT compliance rates at 1 month and 12 months were analyzed. Univariate logistic regression was used to identify predictors of DAPT noncompliance. The overall DAPT noncompliance rate at 1 month was 8.5%, increasing to 15.5% at 12 months. Females exhibited slightly higher noncompliance rates than males at both 1 month (15.6% vs 14.5%) and 12 months (28.1% vs 19.0%), although the difference was not statistically significant. Smoking status showed a modest impact on non-adherence, with current smokers exhibiting a lower noncompliance rate (14.9% at 1 month). Prior coronary artery disease history was associated with increased noncompliance at 12 months (18.9%). Angiographic characteristics, including lesion location and Syntax score, had no consistent association with DAPT noncompliance. This study highlights sex disparity in DAPT noncompliance among patients undergoing left main stem PCI with DES. Comorbidities, socioeconomic status, smoking status, and prior coronary artery disease history were identified as predictors of non-adherence.

No pain, no gain revisited: the impact of positive and negative psychotherapy experiences on treatment outcome

Objective

Psychotherapy may have many benefits for patients with mental health problems, but patients may also have negative experiences related to the therapy. Not much is known about these negative psychotherapy experiences and their impact on treatment outcome. The aim of this study was to examine the association between positive and negative psychotherapy experiences and treatment outcome.

Methods

A total of 130 patients participated in the study. They received treatment as usual and were assessed for positive and negative psychotherapy experiences at mid-treatment and post-treatment using the Positive and Negative Experiences of Psychotherapy Questionnaire (PNEP). Treatment outcome was measured by the Outcome Questionnaire - 45 (OQ-45). Multiple linear regression was used to analyze the data.

Results

All patients reported positive psychotherapy experiences at mid-treatment. At least one negative experience was reported by 69% of participants. After correction for baseline severity (i.e., OQ-45 at baseline) and relevant demographic variables, positive psychotherapy experiences at mid-treatment emerged as a predictor for treatment outcome. In contrast, negative psychotherapy experiences did not predict treatment outcome. However, reporting more negative experiences was associated with reporting fewer positive experiences at mid- and end of treatment.

Conclusion

Both positive and negative psychotherapy experiences commonly occur. Although in this study negative psychotherapy experiences did not predict treatment outcome in terms of symptom reduction, the findings do suggest that negative experiences may influence the way in which patients evaluate their treatment. Although positive experiences outweigh negative experiences, patients should be informed that negative experiences may also occur.

The impact of symptom clusters on endocrine therapy adherence in patients with breast cancer

BACKGROUND

When taken as prescribed, endocrine therapy is effective in reducing risk of recurrence and mortality in the treatment of patients with breast cancer. However, treatment side effects can act as a barrier to medication adherence. Existing research has not identified any specific side effects as consistent predictors of nonadherence. Our aim was to explore the influence of symptom clusters on self-reported adherence in patients with breast cancer.

METHODS

A cross-sectional online survey was conducted, including patients with breast cancer currently or previously prescribed endocrine therapy (N = 1051). This included measures of self-reported endocrine therapy adherence and common symptoms among this population (insomnia, depression, anxiety, fatigue, musculoskeletal, and vasomotor symptoms).

RESULTS

Unintentional nonadherence was higher than intentional nonadherence (50.8 % vs 31.01 %). The most troublesome symptom was insomnia (73.83 % displayed probable insomnia disorder). K-means cluster analysis identified 2 symptom clusters: overall High symptoms, and overall Low symptoms. Participants in the Low symptoms cluster were significantly more likely to be classed as adherent based on unintentional and intentional items.

CONCLUSIONS

Nonadherence was high in the current sample, and significantly more likely in participants reporting overall severe symptoms. Clinicians should be aware of the scale of common side effects and facilitate open conversation about potential barriers to adherence. Follow-up care should include assessment of common symptoms and signpost patients to appropriate support or treatment when required. Future research should explore potential for a central symptom to act as a target for intervention, to relieve overall side effect burden and facilitate better medication adherence.

Information and communication priorities of patients and healthcare professionals in shared decision making regarding adjuvant systemic breast cancer treatment: A survey study

PURPOSE

To assess information and communication priorities of patients and healthcare professionals in Shared Decision Making about adjuvant systemic treatment of primary breast cancer and identify key decision-relevant information accordingly.

METHODS

Patients (N = 122) and professionals working with breast cancer patients (N = 118), of whom 38 were nurse practitioners and 32 nurses, were recruited using convenience sampling, and surveyed about information/communication aspects key to decision-making, using ranking assignments. We further posed a simple open question, questions about receiving population-based statistics versus personalized statistics concerning treatment outcomes, and their attitude and experience concerning Shared Decision Making. Data were analyzed using descriptive analysis and a qualitative analysis.

RESULTS

Both patients and professionals prioritized information about treatment outcomes (i.e., survival, recurrence) as key decision-relevant information for patients. Patients prioritized information about relatively severe treatment side-effects and late effects (e.g., blood clot, stroke), whilst professionals prioritized information about effects that occur relatively often (e.g., hair loss, fatigue). Patients specifically wanted to know if the benefit of treatment is worth the negative impact. Both groups prioritized personalized statistics over population-based statistics.

CONCLUSIONS

Some differences between patients and professionals were found in information and communication priorities, specifically related to the different side-effects. It seems worthwhile to precisely address these side-effects in Shared Decision Making concerning adjuvant systemic treatment. Furthermore, it seems important to deliberate together on the question if expected benefit of treatment is worth the potential negative impact for the individual patient.

Identifying determinants of adherence to adjuvant endocrine therapy following breast cancer: A systematic review of reviews

BACKGROUND

In oestrogen-receptor positive breast cancer, daily oral adjuvant endocrine therapy (ET) for at least 5 years significantly reduces risks of recurrence and breast cancer-specific mortality. However, many women are poorly adherent to ET. Development of effective adherence support requires comprehensive understanding of influences on adherence. We undertook an umbrella review to identify determinants of ET adherence.

METHODS

We searched PubMed, Embase, CINAHL, PsycINFO, Cochrane and PROSPERO (inception to 08/2022) to identify systematic reviews on factors influencing ET adherence. Abstracted determinants were mapped to the World Health Organization's dimensions of adherence. Reviews were quality appraised and overlap assessed.

RESULTS

Of 5732 citations screened, 17 reviews were eligible (9 quantitative primary studies; 4 qualitative primary studies; 4 qualitative or quantitative studies) including 215 primary papers. All five WHO dimensions influenced ET non-adherence: The most consistently identified non-adherence determinants were patient-related factors (e.g. lower perceived ET necessity, more treatment concerns, perceptions of ET 'cons' vs. 'pros'). Healthcare system/healthcare professional-related factors (e.g. perceived lower quality health professional interaction/relationship) were also important and, to a somewhat lesser extent, socio-economic factors (e.g. lower levels of social/economic/material support). Evidence was more mixed for medication-related and condition-related factors, but several may be relevant (e.g. experiencing side-effects, cost). Potentially modifiable factors are more influential than non-modifiable/fixed factors (e.g. patient characteristics).

CONCLUSIONS

The evidence-base on ET adherence determinants is extensive. Future empirical studies should focus on less well-researched areas and settings. The determinants themselves are numerous and complex in indicating that adherence support should be multifaceted, addressing multiple determinants.

Comparative efficacy and safety of extended adjuvant endocrine therapy for hormone receptor-positive early breast cancer: a Bayesian network meta-analysis

PURPOSE

Optimal extended adjuvant endocrine therapy (ET) duration and strategy for hormone receptor-positive (HR +) early breast cancer remain unclear. In this network meta-analysis (NMA), the efficacy and safety of all available extended adjuvant ETs were compared and ranked.

METHODS

PubMed, Embase, and Cochrane Library and abstracts presented at ASCO, SABCS, and ESMO were searched on March 5, 2022. Fourteen randomized controlled trials (RCTs) comprising eight extended adjuvant ETs for HR + breast cancer and 38,070 patients were analyzed. Main outcomes were disease-free survival (DFS), overall survival (OS), grade ≥ 3 adverse events (AEs), and contralateral breast cancer (CBC). Direct and indirect comparisons were integrated via Bayesian NMA. Hierarchical cluster analysis was performed to jointly rank efficacy and safety outcomes.

RESULTS

Compared with that of 5 year ET, extended 10 year aromatase inhibitor (AI) treatment provided the greatest DFS benefit (HR = 0.45, 95%CrI 0.23-0.83), whereas no strategy differed significantly in terms of the other main outcomes. Extended 10 year AI treatment was the preferred strategy for DFS improvement and CBC prevention (surface under the cumulative ranking curve: 93.51% and 91.29% probability, respectively). All strategies had comparable safeties (grade ≥ 3 AEs). Compared with that of 5 year ET, 10 year extended AI significantly increased arthralgia (OR = 1.65, 95%CrI 1.02-2.93) and osteoporosis (OR = 3.33, 95%CrI 1.19-9.68).

CONCLUSION

Extended 10 year AI therapy may be optimal for HR + early breast cancer given its relatively high efficacy and safety.

Resistance to Resilience: Understanding Post-surgical Hormone Therapy in Breast Cancer Care

Breast cancer is one of the most common types of cancer affecting women worldwide. Over the years, breast cancer has become a major public health concern, and its incidence is rising globally. The treatment of breast cancer does not stop with surgical intervention, but adjuvant therapies are administered to improve patient outcomes post-surgery based on the type of breast cancer diagnosed. This review focuses on the value of hormone therapy (HT) in improving the prognosis of breast cancer patients and why adhering to adjuvant treatment post-surgery is difficult for patients. HT aims to reduce the chances of breast cancer recurrence after surgical treatment. Even though HT is life-saving, patients tend to not adhere to the therapy due to various factors such as side effects, age-related issues, and socioeconomic status. Most patients stop adhering to the therapy as the duration can be as long as 5-10 years, and the quality of life is greatly impacted due to the side effects of the treatment. This review examines the possible factors leading to non-adherence to HT and tries to propose possible interventions that might improve patient compliance with the treatment. This article not only focuses on the impact of side effects of HT on patients' quality of life but also tries to understand the problems faced by breast cancer patients in adhering to HT.

Medication Adherence in Patients with Hematologic Malignancies Who Are Hematopoietic Stem Cell Transplantation Survivors: A Qualitative Study

Medication adherence is critical for optimal health outcomes in patients with hematologic malignancies who have undergone allogeneic hematopoietic stem cell transplants (HSCT). However, this population struggles with medication nonadherence. Research that comprehensively describes the complex patient- and medication-related factors which impact medication adherence in this population is lacking. Hence, we used semistructured qualitative interviews to explore the diverse and complex factors contributing to medication adherence in HSCT recipients. We conducted 30 in-depth interviews with patients who were more than 180 days post-allogeneic HSCT at the Dana-Farber Cancer Institute. The interviews explored the physical, social, psychological, and sociodemographic factors that facilitate or discourage adherence to the post-transplantation medication regimen. Interviews were audio-recorded, transcribed, and coded using NVivo software. Two themes emerged that characterized the barriers patients face with their medication regimen. Patients reported factors outside of their control, such as managing multiple pharmacies, health insurance difficulties, and dosage timing, as significant barriers to medication adherence. Patients also reported barriers within their control, such as familial responsibilities. Important facilitators for medication adherence included caregiver and clinician support, previous experience managing a medication regimen, and tools that aid pill organization and timing. Furthermore, patients reported that although medication side effects and quantity of pills did not directly impact medication adherence, it increased their psychological distress. Facilitators and barriers to medication adherence can be physical, psychological, organizational, and social. There are many aspects of medication regimens that significantly increase patient distress. Hence, supportive interventions to improve medication adherence in patients undergoing HSCT may need to incorporate strategies to manage medication side effects and skills to improve psychological well-being and social support.

Importance of endocrine treatment adherence and persistence in breast cancer survivorship: a systematic review

PURPOSE

Adjuvant endocrine treatment is essential for treating luminal subtypes of breast cancer, which constitute 75% of all breast malignancies. However, the detrimental side effects of treatment make it difficult for many patients to complete the guideline-required treatment. Such non-adherence may jeopardize the lifesaving ability of anti-estrogen therapy. In this systematic review, we aimed to assess the consequences of non-adherence and non-persistence from available studies meeting strict statistical and clinical criteria.

METHODS

A systematic literature search was performed using several databases, yielding identification of 2,026 studies. After strict selection, 14 studies were eligible for systematic review. The review included studies that examined endocrine treatment non-adherence (patients not taking treatment as prescribed) or non-persistence (patients stopping treatment prematurely), in terms of the effects on event-free survival or overall survival among women with non-metastatic breast cancer.

RESULTS

We identified 10 studies measuring the effects of endocrine treatment non-adherence and non-persistence on event-free survival. Of these studies, seven showed significantly poorer survival for the non-adherent or non-persistent patient groups, with hazard ratios (HRs) ranging from 1.39 (95% CI, 1.07 to 1.53) to 2.44 (95% CI, 1.89 to 3.14). We identified nine studies measuring the effects of endocrine treatment non-adherence and non-persistence on overall survival. Of these studies, seven demonstrated significantly reduced overall survival in the groups with non-adherence and non-persistence, with HRs ranging from 1.26 (95% CI, 1.11 to 1.43) to 2.18 (95% CI, 1.99 to 2.39).

CONCLUSION

The present systematic review demonstrates that non-adherence and non-persistence to endocrine treatment negatively affect event-free and overall survival. Improved follow-up, with focus on adherence and persistence, is vital for improving health outcomes among patients with non-metastatic breast cancer.

An herbal drug combination identified by knowledge graph alleviates the clinical symptoms of plasma cell mastitis patients: A nonrandomized controlled trial

Background

Plasma cell mastitis (PCM) is a nonbacterial breast inflammation with severe and intense clinical manifestation, yet treatment methods for PCM are still rather limited. Although the mechanism of PCM remains unclear, mounting evidence suggests that the dysregulation of immune system is closely associated with the pathogenesis of PCM. Drug combinations or combination therapy could exert improved efficacy and reduced toxicity by hitting multiple discrete cellular targets.

Methods

We have developed a knowledge graph architecture toward immunotherapy and systematic immunity that consists of herbal drug-target interactions with a novel scoring system to select drug combinations based on target-hitting rates and phenotype relativeness. To this end, we employed this knowledge graph to identify an herbal drug combination for PCM and we subsequently evaluated the efficacy of the herbal drug combination in clinical trial.

Results

Our clinical data suggests that the herbal drug combination could significantly reduce the serum level of various inflammatory cytokines, downregulate serum IgA and IgG level, reduce the recurrence rate, and reverse the clinical symptoms of PCM patients with improvements in general health status.

Conclusions

In summary, we reported that an herbal drug combination identified by knowledge graph can alleviate the clinical symptoms of PCM patients. We demonstrated that the herbal drug combination holds great promise as an effective remedy for PCM, acting through the regulation of immunoinflammatory pathways and improvement of systematic immune level. In particular, the herbal drug combination could significantly reduce the recurrence rate of PCM, a major obstacle to PCM treatment. Our data suggests that the herbal drug combination is expected to feature prominently in future PCM treatment.

Funding

C. Liu's lab was supported by grants from the Public Health Science and Technology Project of Shenyang (grant: 22-321-32-18); Y. Yang's laboratory was supported by the National Natural Science Foundation of China (grant: 81874301), the Fundamental Research Funds for Central University (grant: DUT22YG122), and the Key Research project of 'be Recruited and be in Command' in Liaoning Province (2021JH1/10400050).

Clinical trial number

NCT05530226.

Refining and optimising a behavioural intervention to support endocrine therapy adherence (ROSETA) in UK women with breast cancer: protocol for a pilot fractional factorial trial

INTRODUCTION

Women with breast cancer who do not adhere to adjuvant endocrine therapy (AET) have increased risks of mortality and recurrence. There are multiple barriers to AET adherence, including medication side-effects, beliefs about medication, memory and psychological distress. We developed four intervention components, each targeting a different barrier. This pilot trial is part of the preparation phase of the Multiphase Optimisation Strategy, and aims to establish key trial parameters, establish intervention component adherence, establish availability and feasibility of outcome and process data, estimate variability in planned outcome measures and estimate cost of developing and delivering each intervention component.

METHODS AND ANALYSIS

The four intervention components are as follows: short message service text reminders (target: memory); a written information leaflet (target: medication beliefs); a guided self-help Acceptance and Commitment Therapy programme (target: psychological flexibility to reduce distress) and a self-management website (target: side-effect management). To evaluate the feasibility of recruitment, acceptability of the intervention components and the availability of outcome data, we will conduct a multisite, exploratory pilot trial using a 24-1 fractional factorial design, with a nested process evaluation. We will randomise 80 women with early-stage breast cancer who have been prescribed AET to one of eight experimental conditions. This will determine the combination of intervention components they receive, ranging from zero to four, with all conditions receiving usual care. Key outcomes of interest include medication adherence and quality of life. Progression to the optimisation phase will be based on predefined criteria for consent rates, patient adherence to intervention components and availability of medication adherence data.

ETHICS AND DISSEMINATION

The study was reviewed by the Wales Research Authority Research Ethics Committee 3 (21/WA/0322). Written informed consent will be obtained from all patients before randomisation. The results of this trial will be disseminated in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ISRTCN10487576.