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Rattsev I, Stearns V, Blackford AL, Hertz DL, Smith KL, Rae JM, Taylor CO. Incorporation of emergent symptoms and genetic covariates improves prediction of aromatase inhibitor therapy discontinuation. JAMIA Open 2024; 7:ooae006. [PMID: 38250582 PMCID: PMC10799747 DOI: 10.1093/jamiaopen/ooae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/09/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024] Open
Abstract
Objectives Early discontinuation is common among breast cancer patients taking aromatase inhibitors (AIs). Although several predictors have been identified, it is unclear how to simultaneously consider multiple risk factors for an individual. We sought to develop a tool for prediction of AI discontinuation and to explore how predictive value of risk factors changes with time. Materials and Methods Survival machine learning was used to predict time-to-discontinuation of AIs in 181 women who enrolled in a prospective cohort. Models were evaluated via time-dependent area under the curve (AUC), c-index, and integrated Brier score. Feature importance was analysis was conducted via Shapley Additive Explanations (SHAP) and time-dependence of their predictive value was analyzed by time-dependent AUC. Personalized survival curves were constructed for risk communication. Results The best-performing model incorporated genetic risk factors and changes in patient-reported outcomes, achieving mean time-dependent AUC of 0.66, and AUC of 0.72 and 0.67 at 6- and 12-month cutoffs, respectively. The most significant features included variants in ESR1 and emergent symptoms. Predictive value of genetic risk factors was highest in the first year of treatment. Decrease in physical function was the strongest independent predictor at follow-up. Discussion and Conclusion Incorporation of genomic and 3-month follow-up data improved the ability of the models to identify the individuals at risk of AI discontinuation. Genetic risk factors were particularly important for predicting early discontinuers. This study provides insight into the complex nature of AI discontinuation and highlights the importance of incorporating genetic risk factors and emergent symptoms into prediction models.
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Affiliation(s)
- Ilia Rattsev
- Institute for Computational Medicine, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, 21218, United States
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, 21218, United States
| | - Vered Stearns
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, United States
| | - Amanda L Blackford
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, United States
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, 48109, United States
| | - Karen L Smith
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, United States
| | - James M Rae
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, United States
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI, 48109, United States
| | - Casey Overby Taylor
- Institute for Computational Medicine, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, 21218, United States
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, 21218, United States
- Department of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, United States
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Bhuptani PH, López G, Peterson R, Orchowski LM. Associations Among Online Social Reactions to Disclosure of Sexual Victimization, Coping and Social Isolation. JOURNAL OF CHILD SEXUAL ABUSE 2024; 33:146-168. [PMID: 38339999 PMCID: PMC11034772 DOI: 10.1080/10538712.2024.2314287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
Social reactions to the disclosure of sexual victimization are critical to post-assault recovery. The popular social media hashtag "#MeToo" resulted in numerous survivors of sexual victimization disclosing their experience online. Whereas previous research has examined the association between social reactions to in-person disclosure of sexual victimization and factors commonly associated with adjustment among survivors - such as coping and social support - research is needed to examine correlates of social reactions to online disclosure of sexual victimization. Accordingly, the current study investigated the relationship between online social reactions to the disclosure of sexual victimization via #MeToo and engagement in various coping strategies (problem-focused coping, emotion-focused coping) and social isolation among a sample of 195 adults with a history of sexual victimization. Results indicated that the provision of online resources was associated with lower use of problem-focused and emotion-focused coping strategies. Receipt of online emotional and informational support was associated with increased use of emotion-focused coping strategies. Further, receipt of online social reactions that turned against the survivor and receipt of online social reactions that "made fun of you, insulted you, or said something to hurt you" were associated with higher levels of social isolation. Lastly, online unsupportive acknowledgment and "sharing your tweet with other people" were associated with lower levels of social isolation. Results highlight how online social reactions to disclosure of sexual victimization via #MeToo intersect with coping and social support among survivors of sexual victimization and help to give context to the experience of online disclosure of sexual victimization.
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Yang S, Park SW, Bae SJ, Ahn SG, Jeong J, Park K. Investigation of Factors Affecting Adherence to Adjuvant Hormone Therapy in Early-Stage Breast Cancer Patients: A Comprehensive Systematic Review. J Breast Cancer 2023; 26:309-333. [PMID: 37272247 PMCID: PMC10475712 DOI: 10.4048/jbc.2023.26.e22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/05/2023] [Accepted: 04/16/2023] [Indexed: 06/06/2023] Open
Abstract
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.
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Affiliation(s)
- Seongwoo Yang
- HERINGS, The Institute of Advanced Clinical & Biomedical Research, Seoul, Korea
| | - Seong Won Park
- HERINGS, The Institute of Advanced Clinical & Biomedical Research, Seoul, Korea
| | - Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine/Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine/Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine/Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyounghoon Park
- HERINGS, The Institute of Advanced Clinical & Biomedical Research, Seoul, Korea.
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Smith SG, Green SMC, Ellison R, Foy R, Graham CD, Mason E, French DP, Hall LH, Wilkes H, McNaught E, Raine E, Walwyn R, Howdon D, Clark J, Rousseau N, Buxton J, Moore SJL, Parbutt C, Velikova G, Farrin A, Collinson M. 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. BMJ Open 2023; 13:e069971. [PMID: 36737093 PMCID: PMC9900066 DOI: 10.1136/bmjopen-2022-069971] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Samuel G Smith
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Sophie M C Green
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Rachel Ellison
- Complex Interventions Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Robbie Foy
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Ellen Mason
- Complex Interventions Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David P French
- School of Psychological Sciences, Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Louise H Hall
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Hollie Wilkes
- Complex Interventions Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Emma McNaught
- Complex Interventions Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Erin Raine
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Rebecca Walwyn
- Complex Interventions Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Daniel Howdon
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Jane Clark
- Department of Clinical and Health Psychology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nikki Rousseau
- Surgical, Diagnostic and Devices Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jacqueline Buxton
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Sally J L Moore
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Catherine Parbutt
- Medicines Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Galina Velikova
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Amanda Farrin
- Complex Interventions Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Michelle Collinson
- Complex Interventions Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Kuhn EP, Pirruccello J, Boothe JT, Li Z, Tosteson TD, Stahl JE, Schwartz GN, Chamberlin MD. Preventing metastatic recurrence in low-risk ER/PR + breast cancer patients-a retrospective clinical study exploring the evolving challenge of persistence with adjuvant endocrine therapy. Breast Cancer Res Treat 2023; 198:31-41. [PMID: 36592233 PMCID: PMC9883310 DOI: 10.1007/s10549-022-06849-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/30/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE In the genomic era, more women with low-risk breast cancer will forego chemotherapy and rely on adjuvant endocrine therapy (AET) to prevent metastatic recurrence. However, some of these patients will unfortunately relapse. We sought to understand this outcome. Preliminary work suggested that early discontinuation of AET, also known as non-persistence, may play an important role. A retrospective analysis exploring factors related to our breast cancer patients' non-persistence with AET was performed. METHODS Women who underwent Oncotype-DX® testing between 2011 and 2014 with minimum 5 years follow-up were included. 'Low risk' was defined as Oncotype score < 26. Outcomes of recurrence and persistence were determined by chart review. Patient, tumor and treatment factors were collected, and persistent versus non-persistent groups compared using multivariable ANOVA and Fisher Chi square exact test. RESULTS We identified six cases of distant recurrence among low-risk patients with a median follow-up of 7.7 years. Among them, five of six patients (83%) were non-persistent with AET. The non-persistence rate in our cohort regardless of recurrence was 57/228 (25%). Non-persistent patients reported more severe side effects compared with persistent patients (p = 0.002) and were more likely to be offered a switch in endocrine therapy, rather than symptom-relief (p = 0.006). In contrast, persistent patients were 10.3 times more likely to have been offered symptom-alleviating medications compared with non-persistent patients (p < 0.001). A subset analysis revealed that patients who persisted with therapy had a higher Oncotype-DX® score than patients who discontinued early (p = 0.028). CONCLUSION Metastatic recurrence in low-risk breast cancer patients may be primarily due to non-persistence with endocrine therapy. Further work is needed to optimize care for patients who struggle with side effects. To our knowledge, these are the first published data suggesting that Oncotype-DX® score may influence persistence with AET.
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Affiliation(s)
- Elaine P Kuhn
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | - Jonathan Pirruccello
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - James T Boothe
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Zhongze Li
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Biomedical Data Sciences, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Tor D Tosteson
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Biomedical Data Sciences, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - James E Stahl
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Gary N Schwartz
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Mary D Chamberlin
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Verma N, Blackford AL, Thorner E, Lehman J, Snyder C, Stearns V, Smith KL. Factors associated with worsening sexual function during adjuvant endocrine therapy in a prospective clinic-based cohort of women with early-stage breast cancer. Breast Cancer Res Treat 2022; 196:535-547. [PMID: 36197536 PMCID: PMC10084786 DOI: 10.1007/s10549-022-06750-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/17/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Sexual function problems are common but under-reported among women receiving adjuvant endocrine therapy for breast cancer. Worsening scores on patient-reported outcomes (PROs) may identify those at risk for sexual function problems during treatment. We performed a secondary analysis of prospectively collected PROs in women receiving adjuvant endocrine therapy to identify factors associated with worsening sexual function. METHODS Women with stage 0-III breast cancer initiating adjuvant endocrine therapy participating in a prospective cohort completed PROs at baseline, 3, 6, 12, 24, 36, 48, and 60 months. Sexual function was evaluated by the MOS-SP measure. Other measures included PROMIS pain interference, fatigue, depression, anxiety, physical function, and sleep disturbance and the Endocrine Symptom Subscale of the FACT-ES. We evaluated associations between score worsening of at least the minimal important difference (MID) in PROMIS T-scores (4 points) and FACT-ES scores (5 points) with score worsening of at least the MID in MOS-SP scores (8 points) using logistic regression. RESULTS Among 300 participants, 45.7% experienced ≥ 8-point worsening of MOS-SP score at any time point compared to baseline. Worsening endocrine symptoms (OR 1.34, 95% CI 1.22-1.49, p < 0.001), worsening physical function (OR 1.09, 95% CI 1.00-1.18, p = 0.06), and prior mastectomy (OR 1.45, 95% CI 0.94-2.23, p = 0.09) were associated with MOS-SP score worsening by at least the MID. CONCLUSION Worsening endocrine symptoms and physical function identified on PROs are associated with worsening sexual function during adjuvant endocrine therapy. Routine assessment of these domains with PROs may identify women at risk for sexual function problems. TRIAL REGISTRATION NUMBER NCT01937052; Date of Registration: 09/09/2013.
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Affiliation(s)
- Neha Verma
- Johns Hopkins Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amanda L Blackford
- Division of Biostatistics and Bioinformatics, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Elissa Thorner
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Lehman
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claire Snyder
- Johns Hopkins Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vered Stearns
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Lisa Smith
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Medical Oncology, Johns Hopkins Sidney Kimmel Cancer Center at Sibley Memorial Hospital, First Floor, Building B, 5255 Loughboro Road, NW, Washington, DC, 20016, USA.
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Botelho LOD, Sañudo A, Facina G, Wagner GA. Adesão à Terapia Hormonal Adjuvante com Tamoxifeno e Anastrozol utilizando ARMS-12 e MMAS-4. REVISTA BRASILEIRA DE CANCEROLOGIA 2022. [DOI: 10.32635/2176-9745.rbc.2022v68n2.1960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Introdução: Entre os canceres de mama, aproximadamente 75% das mulheres são receptores hormonais positivos, sendo estas mais propensas a responderem a hormonioterapia com anastrozol e tamoxifeno. Apesar de eficazes, apresentam taxas significativas de não adesão. Objetivo: Avaliar a adesão a terapia hormonal adjuvante com tamoxifeno e anastrozol em pacientes atendidos nos Ambulatórios da Mastologia e de Quimioterapia do Hospital São Paulo entre os anos de 2019 e 2020. Método: Estudo transversal com 102 mulheres, realizado entre os meses de setembro de 2019 e marco de 2020. A adesão a terapia hormonal adjuvante foi avaliada utilizando-se as escalas Morisky Medication Adherence Scale (MMAS-4) e Adherence to Refills and Medications Scale of 12 items (ARMS-12). Resultados: A média de idade foi de 61,5 anos (59,3-63,6). Entre as pacientes, 27,7% faziam uso de tamoxifeno e 72,3% de anastrozol. Relataram desconforto em relação ao uso do medicamento 84,4%, sendo as ondas de calor (42,2%) e as dores articulares (55,9%) os mais frequentes. A escala de ARMS>12 foi pontuada por 79,2%; cerca de 90% das mulheres pontuaram a MMAS-4 até dois pontos, porém não houve diferença significativa entre os tipos de hormônios utilizados para escalas de adesão (p=0,815 e p=0,489). Conclusão: A adesão a hormonioterapia observada foi relativamente baixa, independentemente da endocrinoterapia, podendo essas pacientes estarem em risco de inadequação quanto a resposta clínica.
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Smith KL, Verma N, Blackford AL, Lehman J, Westbrook K, Lim D, Fetting J, Wolff AC, Jelovac D, Miller RS, Connolly R, Armstrong DK, Nunes R, Visvanathan K, Riley C, Papathakis K, Zafman N, Sheng JY, Snyder C, Stearns V. Association of treatment-emergent symptoms identified by patient-reported outcomes with adjuvant endocrine therapy discontinuation. NPJ Breast Cancer 2022; 8:53. [PMID: 35449210 PMCID: PMC9023490 DOI: 10.1038/s41523-022-00414-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 03/14/2022] [Indexed: 11/08/2022] Open
Abstract
Many patients discontinue endocrine therapy for breast cancer due to intolerance. Identification of patients at risk for discontinuation is challenging. The minimal important difference (MID) is the smallest change in a score on a patient-reported outcome (PRO) that is clinically significant. We evaluated the association between treatment-emergent symptoms detected by worsening PRO scores in units equal to the MID with discontinuation. We enrolled females with stage 0-III breast cancer initiating endocrine therapy in a prospective cohort. Participants completed PROs at baseline, 3, 6, 12, 24, 36, 48, and 60 months. Measures included PROMIS pain interference, fatigue, depression, anxiety, physical function, and sleep disturbance; Endocrine Subscale of the FACT-ES; and MOS-Sexual Problems (MOS-SP). We evaluated associations between continuous PRO scores in units corresponding to MIDs (PROMIS: 4-points; FACT-ES: 5-points; MOS-SP: 8-points) with time to endocrine therapy discontinuation using Cox proportional hazards models. Among 321 participants, 140 (43.6%) initiated tamoxifen and 181 (56.4%) initiated aromatase inhibitor (AI). The cumulative probability of discontinuation was 23% (95% CI 18-27%) at 48 months. For every 5- and 4-point worsening in endocrine symptoms and sleep disturbance respectively, participants were 13 and 14% more likely to discontinue endocrine therapy respectively (endocrine symptoms HR 1.13, 95% CI 1.02-1.25, p = 0.02; sleep disturbance HR 1.14, 95% CI 1.01-1.29, p = 0.03). AI treatment was associated with greater likelihood of discontinuation than tamoxifen. Treatment-emergent endocrine symptoms and sleep disturbance are associated with endocrine therapy discontinuation. Monitoring for worsening scores meeting or exceeding the MID on PROs may identify patients at risk for discontinuation.
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Affiliation(s)
- Karen Lisa Smith
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Neha Verma
- Johns Hopkins Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amanda L Blackford
- Division of Biostatistics and Bioinformatics, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Jennifer Lehman
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly Westbrook
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - David Lim
- Division of Biostatistics and Bioinformatics, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - John Fetting
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Antonio C Wolff
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniela Jelovac
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S Miller
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- CancerLinQ, American Society of Clinical Oncology, Alexandria, VA, USA
| | - Roisin Connolly
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Cancer Research @UCC, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Deborah K Armstrong
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raquel Nunes
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kala Visvanathan
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Cancer Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carol Riley
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katie Papathakis
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nelli Zafman
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Y Sheng
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claire Snyder
- Johns Hopkins Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vered Stearns
- Johns Hopkins Women's Malignancies Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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9
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Smith SG, Ellison R, Hall L, Clark J, Hartley S, Mason E, Metherell J, Olivier C, Napp V, Naik J, Buckley S, Hirst C, Hartup S, Neal RD, Velikova G, Farrin A, Collinson M, Graham CD. Acceptance and Commitment Therapy to support medication decision-making and quality of life in women with breast cancer: protocol for a pilot randomised controlled trial. Pilot Feasibility Stud 2022; 8:33. [PMID: 35135619 PMCID: PMC8822728 DOI: 10.1186/s40814-022-00985-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 01/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adherence to adjuvant endocrine therapy is affected by medication side-effects and associated distress. Previous interventions focused on educating women to enhance adherence have proved minimally effective. We co-designed an Acceptance and Commitment Therapy (ACT) intervention to enhance medication decision-making and quality of life by targeting a broader range of factors, including side-effect management and psychological flexibility. This study aims to establish key trial parameters, assess the acceptability of the intervention and the extent to which it can be delivered with fidelity, and to demonstrate "proof of principle" regarding its efficacy on primary and process outcomes. METHODS The ACTION intervention includes an individual 1:1 ACT session followed by three group sessions involving 8-10 women and two practitioner psychologists. Participants are also provided with access to a website containing evidence-based methods for self-managing side-effects. The ACT sessions were adapted during the COVID-19 pandemic to be remotely delivered via video conferencing software. To evaluate the feasibility and acceptability of this intervention, a multi-site, exploratory, two-arm, individually randomised external pilot trial with a nested qualitative study will be undertaken. Eighty women with early stage breast cancer prescribed adjuvant endocrine therapy will be randomised (1:1) to receive treatment as usual or treatment as usual plus the ACTION intervention. The planned future primary outcome is medication adherence assessed by the ASK-12 measure. Progression to a phase III RCT will be based on criteria related to recruitment and follow-up rates, acceptability to patients, competency and fidelity of delivery, and proof of principle for change in medication adherence. DISCUSSION This external pilot trial will be used to ascertain the feasibility of undertaking a future phase III RCT to definitively evaluate an ACT-based intervention to support medication taking behaviour and quality of life in women with early stage breast cancer on adjuvant endocrine therapy. TRIAL REGISTRATION ISRCTN: 12027752. Registered 24 December 2020, https://doi.org/10.1186/ISRCTN12027752.
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Affiliation(s)
- Samuel G Smith
- Leeds Institute of Health Science, University of Leeds, Leeds, LS2 9JT, UK.
| | - Rachel Ellison
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Louise Hall
- Leeds Institute of Health Science, University of Leeds, Leeds, LS2 9JT, UK
| | - Jane Clark
- Department of Clinical and Health Psychology, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Suzanne Hartley
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Ellen Mason
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Jamie Metherell
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Catherine Olivier
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Vicky Napp
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Jay Naik
- Department of Oncology, Harrogate & District Foundation Trust, Park Road, Lancaster, HG2 7SX, UK
| | - Sarah Buckley
- Department of Clinical Research, Mid Yorkshire Hospitals NHS Trust, Aberford Road, Wakefield, WF1 4AL, UK
| | - Charlotte Hirst
- Department of Clinical Research, Mid Yorkshire Hospitals NHS Trust, Aberford Road, Wakefield, WF1 4AL, UK
| | - Sue Hartup
- St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Richard D Neal
- Leeds Institute of Health Science, University of Leeds, Leeds, LS2 9JT, UK
| | - Galina Velikova
- St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Michelle Collinson
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
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10
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Smith SG, Sestak I, Morris MA, Harvie M, Howell A, Forbes J, Cuzick J. The impact of body mass index on breast cancer incidence among women at increased risk: an observational study from the International Breast Intervention Studies. Breast Cancer Res Treat 2021; 188:215-223. [PMID: 33656637 PMCID: PMC8233270 DOI: 10.1007/s10549-021-06141-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND We investigated the association between body mass index (BMI) and breast cancer risk in women at increased risk of breast cancer receiving tamoxifen or anastrozole compared with placebo using data from the International Breast Cancer Intervention Studies [IBIS-I (tamoxifen) and IBIS-II (anastrozole)]. METHODS Baseline BMI was calculated from nurse assessed height and weight measurements for premenopausal (n = 3138) and postmenopausal (n = 3731) women in IBIS-I and postmenopausal women in IBIS-II (n = 3787). The primary endpoint was any breast cancer event (invasive and ductal carcinoma in situ). We used Cox proportional hazards regression to calculate hazard ratios (HRs) for risk after adjustment for covariates. RESULTS There were 582 (IBIS-I) and 248 (IBIS-II) breast cancer events [median follow-up = 16.2 years (IQR 14.4-17.7) and 10.9 years (IQR 8.8-13.0), respectively]. In adjusted analysis, women with a higher BMI had an increased breast cancer risk in both IBIS-I [HR = 1.06 per 5 kg/m2 (0.99-1.15), p = 0.114] and in IBIS-II [HR per 5 kg/m2 = 1.21 (1.09-1.35), p < 0.001]. In IBIS-I, the association between BMI and breast cancer risk was positive in postmenopausal women [adjusted HR per 5 kg/m2 = 1.14 (1.03-1.26), p = 0.01] but not premenopausal women [adjusted HR per 5 kg/m2 = 0.97 (0.86-1.09), p = 0.628]. There was no interaction between BMI and treatment group for breast cancer risk in either IBIS-I (p = 0.62) or IBIS-II (p = 0.55). CONCLUSIONS Higher BMI is associated with greater breast cancer risk in postmenopausal women at increased risk of the disease, but no effect was observed in premenopausal women. The lack of interaction between BMI and treatment group on breast cancer risk suggests women are likely to experience benefit from preventive therapy regardless of their BMI. Trial registration Both trials were registered [IBIS-I: ISRCTN91879928 on 24/02/2006, retrospectively registered ( http://www.isrctn.com/ISRCTN91879928 ); IBIS-II: ISRCTN31488319 on 07/01/2005, retrospectively registered ( http://www.isrctn.com/ISRCTN31488319 )].
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Affiliation(s)
- Samuel G Smith
- Leeds Institute of Health Science, University of Leeds, Clarendon Way, Leeds, LS2 9NL, UK.
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK.
| | - Ivana Sestak
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Michelle A Morris
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, UK
| | - Michelle Harvie
- Prevent Breast Cancer Unit, Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Anthony Howell
- Prevent Breast Cancer Unit, Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Institute of Cancer Sciences, University of Manchester, Manchester, UK
| | | | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
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11
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Macis D, Aristarco V, Johansson H, Guerrieri-Gonzaga A, Raimondi S, Lazzeroni M, Sestak I, Cuzick J, DeCensi A, Bonanni B, Gandini S. A Novel Automated Immunoassay Platform to Evaluate the Association of Adiponectin and Leptin Levels with Breast Cancer Risk. Cancers (Basel) 2021; 13:cancers13133303. [PMID: 34209441 PMCID: PMC8268385 DOI: 10.3390/cancers13133303] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/11/2021] [Accepted: 06/29/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary Adiponectin and leptin are adipokines secreted by the adipose tissue that have been associated with several chronic diseases including cancer. We compared two methods for their measurement and investigated their association with breast cancer. We measured adiponectin and leptin with the automated ELLA platform and a manual commercially available enzyme-linked immunosorbent assay (ELISA) kit on serum samples of women enrolled in two international breast cancer prevention trials. We found a good concordance between the two methods and our results support the association of low adiponectin levels with breast cancer, irrespective of the method used. The take-home message is that ELLA is a very robust platform that represents a step forward for the future use of adipokines, along with other biomarkers, in clinical cancer risk assessment and prevention. Its use should be taken into account whenever biomarkers should be measured in a large cohort of patients for clinical validation or cancer association studies. Abstract Adiponectin and leptin are adipokines secreted by the adipose tissue that are associated with several chronic diseases including cancer. We aimed to compare the immunoassay platform ELLA with an enzyme-linked immunosorbent assay (ELISA) kit and to assess whether the results of the association analyses with breast cancer risk were dependent on the assay used. We measured adiponectin and leptin with ELLA and ELISA on baseline serum samples of 116 Italian postmenopausal women enrolled in two international breast cancer prevention trials. Results were compared with Deming, Passing–Bablok regression and Bland–Altman plots. Disease-free survival was analyzed with the Cox model. There was a good correlation between the methods for adiponectin and leptin (r > 0.96). We found an increased breast cancer risk for very low adiponectin levels (HR for ELLA = 3.75; 95% CI: 1.37;10.25, p = 0.01), whereas no significant association was found for leptin levels. The disease-free survival curves were almost identical for values obtained with the two methods, for both biomarkers. The ELLA platform showed a good concordance with ELISA for adiponectin and leptin measurements. Our results support the association of very low adiponectin levels with postmenopausal breast cancer risk, irrespective of the method used. The ELLA platform is a time-saving system with high reproducibility, therefore we recommend its use for biomarker assessment.
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Affiliation(s)
- Debora Macis
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.A.); (H.J.); (A.G.-G.); (M.L.); (B.B.)
- Correspondence:
| | - Valentina Aristarco
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.A.); (H.J.); (A.G.-G.); (M.L.); (B.B.)
| | - Harriet Johansson
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.A.); (H.J.); (A.G.-G.); (M.L.); (B.B.)
| | - Aliana Guerrieri-Gonzaga
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.A.); (H.J.); (A.G.-G.); (M.L.); (B.B.)
| | - Sara Raimondi
- Molecular and Pharmaco-Epidemiology Unit, Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (S.R.); (S.G.)
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.A.); (H.J.); (A.G.-G.); (M.L.); (B.B.)
| | - Ivana Sestak
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M-6BQ, UK; (I.S.); (J.C.); (A.D.)
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M-6BQ, UK; (I.S.); (J.C.); (A.D.)
| | - Andrea DeCensi
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M-6BQ, UK; (I.S.); (J.C.); (A.D.)
- Division of Medical Oncology, Ente Ospedaliero Ospedali Galliera, 16128 Genoa, Italy
| | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.A.); (H.J.); (A.G.-G.); (M.L.); (B.B.)
| | - Sara Gandini
- Molecular and Pharmaco-Epidemiology Unit, Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (S.R.); (S.G.)
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12
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Jahan N, Jones C, Rahman RL. Endocrine prevention of breast cancer. Mol Cell Endocrinol 2021; 530:111284. [PMID: 33882282 DOI: 10.1016/j.mce.2021.111284] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 01/01/2023]
Abstract
Breast cancer (BC) is the most common non-cutaneous malignancy among women worldwide and is a significant cause of morbidity, mortality, and national health care expenditure. Unfortunately, with few exceptions like alcohol consumption, obesity, and physical activity, most BC risk factors are unmodifiable. Antiestrogen endocrine therapy, commonly known as BC chemoprevention, is an effective method of BC prevention. In multiple randomized trials, two selective estrogen receptor modulators - tamoxifen and raloxifene, and two aromatase inhibitors - exemestane and anastrozole have reduced BC incidence by 50%-65% in high-risk women. An estimated 15% of the US women between 35 and 79 years of age may qualify as high risk for BC, yet a small percentage of these women will ever have a formal BC risk assessment or a discussion of endocrine prevention options. The etiology of underutilization of endocrine prevention of BC is multifactorial - infrequent use of BC risk assessment tools in the primary care settings, insufficient knowledge of BC risk assessment tools and antiestrogen agents among primary care providers, concerns of side effects, inadequate time for counseling during primary care visit, and lack of predictive biomarkers may play significant roles. Many small studies incorporating risk assessment tools and decision-making aids showed minimal success in enhancing endocrine prevention. One critical factor for underutilization of endocrine prevention is low uptake of endocrine prevention by high-risk women even when appropriately recommended. Furthermore, adherence to BC endocrine prevention is unsatisfactorily low. Despite the current infrequent usage, endocrine prevention has the potential to reduce the public health burden of BC significantly. Innovative approaches like finding new agents, alternative dosing and schedule of currently available agents, transdermal medication delivery, increased public and professional awareness, and policymakers' commitments may bring the desired changes.
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Affiliation(s)
- Nusrat Jahan
- Division of Hematology-Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA.
| | - Catherine Jones
- Division of Hematology-Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA
| | - Rakhshanda Layeequr Rahman
- Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA
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Long-Term Evaluation of Women Referred to a Breast Cancer Family History Clinic (Manchester UK 1987-2020). Cancers (Basel) 2020; 12:cancers12123697. [PMID: 33317064 PMCID: PMC7763143 DOI: 10.3390/cancers12123697] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/02/2020] [Accepted: 12/05/2020] [Indexed: 12/20/2022] Open
Abstract
Simple Summary This study reports the management of women at high risk for breast cancer over a 33 years period. The aim was to summarize the numbers seen and to report the results of our studies on gene testing, the outcomes of screening and the success of preventive methods including lifestyle change, chemoprevention and risk-reducing mastectomy. We also discuss how the clinical Family History Service may be improved in the future. Abstract Clinics for women concerned about their family history of breast cancer are widely established. A Family History Clinic was set-up in Manchester, UK, in 1987 in a Breast Unit serving a population of 1.8 million. In this review, we report the outcome of risk assessment, screening and prevention strategies in the clinic and propose future approaches. Between 1987–2020, 14,311 women were referred, of whom 6.4% were from known gene families, 38.2% were at high risk (≥30% lifetime risk), 37.7% at moderate risk (17–29%), and 17.7% at an average/population risk who were discharged. A total of 4168 (29.1%) women were eligible for genetic testing and 736 carried pathogenic variants, predominantly in BRCA1 and BRCA2 but also other genes (5.1% of direct referrals). All women at high or moderate risk were offered annual mammographic screening between ages 30 and 40 years old: 646 cancers were detected in women at high and moderate risk (5.5%) with a detection rate of 5 per 1000 screens. Incident breast cancers were largely of good prognosis and resulted in a predicted survival advantage. All high/moderate-risk women were offered lifestyle prevention advice and 14–27% entered various lifestyle studies. From 1992–2003, women were offered entry into IBIS-I (tamoxifen) and IBIS-II (anastrozole) trials (12.5% of invitees joined). The NICE guidelines ratified the use of tamoxifen and raloxifene (2013) and subsequently anastrozole (2017) for prevention; 10.8% women took up the offer of such treatment between 2013–2020. Since 1994, 7164 eligible women at ≥25% lifetime risk of breast cancer were offered a discussion of risk-reducing breast surgery and 451 (6.2%) had surgery. New approaches in all aspects of the service are needed to build on these results.
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Hwang ES, Solin L. De-Escalation of Locoregional Therapy in Low-Risk Disease for DCIS and Early-Stage Invasive Cancer. J Clin Oncol 2020; 38:2230-2239. [PMID: 32442066 DOI: 10.1200/jco.19.02888] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- E Shelley Hwang
- Duke Cancer Institute and Duke University Health System, Durham, NC
| | - Lawrence Solin
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.,Deceased
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15
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Thorneloe RJ, Hall LH, Walter FM, Side L, Lloyd KE, Smith SG. Knowledge of Potential Harms and Benefits of Tamoxifen among Women Considering Breast Cancer Preventive Therapy. Cancer Prev Res (Phila) 2020; 13:411-422. [PMID: 31988145 PMCID: PMC7611305 DOI: 10.1158/1940-6207.capr-19-0424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/19/2019] [Accepted: 01/21/2020] [Indexed: 12/28/2022]
Abstract
Tamoxifen reduces breast cancer incidence in women at increased risk, but may cause side effects. We examined women's knowledge of tamoxifen's potential harms and benefits, and the extent to which knowledge reflects subjective judgments of awareness and decision quality. After a hospital appointment, 408 (55.7%) women at increased risk of breast cancer completed a survey assessing objective knowledge about the potential benefit (risk reduction) and harms (endometrial cancer, thromboembolic events, and menopausal side effects) of tamoxifen, and subjective tamoxifen knowledge and decisional quality. Two hundred fifty-eight (63.2%) completed a 3-month follow-up survey. Sixteen percent (15.7%) of participants recognized the potential benefit and three major harms of using tamoxifen. These women were more likely to have degree-level education [vs. below degree level; OR, 2.24; 95% confidence interval (CI), 1.11-4.55] and good numeracy (vs. poor numeracy; OR, 5.91; 95% CI, 1.33-26.19). Tamoxifen uptake was higher in women who recognized all harms and benefits (vs. not recognizing; OR, 2.47; 95% CI, 0.94-6.54). Sixty-six percent (65.8%) of tamoxifen users were unaware of its potential benefit and harms. Most (87.1%) women reported feeling informed about tamoxifen, and subjective decisional quality was high [Mean (SD), 17.03 (1.87), out of 18]. Knowledge regarding the potential harms and benefit of tamoxifen is low in women considering prevention therapy, and they may need additional support to make informed decisions about tamoxifen preventive therapy.
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Affiliation(s)
| | - Louise Hazel Hall
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Fiona Mary Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Lucy Side
- Wessex Clinical Genetics Service, University Hospitals Southampton, Southampton, United Kingdom
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Visvanathan K, Fabian CJ, Bantug E, Brewster AM, Davidson NE, DeCensi A, Floyd JD, Garber JE, Hofstatter EW, Khan SA, Katapodi MC, Pruthi S, Raab R, Runowicz CD, Somerfield MR. Use of Endocrine Therapy for Breast Cancer Risk Reduction: ASCO Clinical Practice Guideline Update. J Clin Oncol 2019; 37:3152-3165. [DOI: 10.1200/jco.19.01472] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To update the ASCO guideline on pharmacologic interventions for breast cancer risk reduction and provide guidance on clinical issues that arise when deciding to use endocrine therapy for breast cancer risk reduction. METHODS An Expert Panel conducted targeted systematic literature reviews to identify new studies. RESULTS A randomized clinical trial that evaluated the use of anastrozole for reduction of estrogen receptor–positive breast cancers in postmenopausal women at increased risk of developing breast cancer provided the predominant basis for the update. UPDATED RECOMMENDATIONS In postmenopausal women at increased risk, the choice of endocrine therapy now includes anastrozole (1 mg/day) in addition to exemestane (25 mg/day), raloxifene (60 mg/day), or tamoxifen (20 mg/day). The decision regarding choice of endocrine therapy should take into consideration age, baseline comorbidities, and adverse effect profiles. Clinicians should not prescribe anastrozole, exemestane, or raloxifene for breast cancer risk reduction to premenopausal women. Tamoxifen 20 mg/day for 5 years is still considered standard of care for risk reduction in premenopausal women who are at least 35 years old and have completed childbearing. Data on low-dose tamoxifen as an alternative to the standard dose for both pre- and postmenopausal women with intraepithelial neoplasia are discussed in the Clinical Considerations section of this article. Additional information is available at www.asco.org/breast-cancer-guidelines .
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Affiliation(s)
- Kala Visvanathan
- Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | | | | | - Andrea DeCensi
- National Hospital E.O. Ospedali Galliera S.C. Oncologia Medica, Genoa, Italy; and Queen Mary University of London, United Kingdom
| | | | | | | | - Seema A. Khan
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | - Rachal Raab
- Cancer Care of Western North Carolina, Asheville, NC
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Solin LJ. Management of Ductal Carcinoma In Situ (DCIS) of the Breast: Present Approaches and Future Directions. Curr Oncol Rep 2019; 21:33. [PMID: 30834994 DOI: 10.1007/s11912-019-0777-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Ductal carcinoma in situ (DCIS; intraductal carcinoma) of the breast is commonly found in an asymptomatic woman on routine screening mammography. The purpose of this review is to describe current approaches to the management of DCIS as well as areas for future investigation. RECENT FINDINGS Randomized trials have demonstrated that adding radiation treatment after breast conservation surgery (lumpectomy; surgical excision) reduces the rate of ipsilateral local recurrence by about half, and that adding hormonal therapy reduces the rate of all breast cancer events (ipsilateral plus contralateral). Early clinical studies attempted to stratify the risk of recurrence using conventional clinical and pathologic features. More recent clinical studies have attempted to define prospectively patients with lower risk DCIS for whom omission of radiation treatment after lumpectomy is a reasonable option. Molecular profiling is a newer approach to define risk stratification for DCIS. Combining molecular profiling with clinical and pathologic features appears to be more accurate in defining and stratifying the risk of recurrence after lumpectomy. After lumpectomy for DCIS, risk stratification using clinical and pathologic characteristics, and more recently molecular profiling, can help guide clinical decision-making for the use of radiation treatment and hormonal therapy. Ongoing studies are evaluating the possibility of de-escalating therapy, and in some studies, even using core biopsy alone, without surgical excision.
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Affiliation(s)
- Lawrence J Solin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Thorneloe RJ, Horne R, Side L, Wolf MS, Smith SG. Beliefs About Medication and Uptake of Preventive Therapy in Women at Increased Risk of Breast Cancer: Results From a Multicenter Prospective Study. Clin Breast Cancer 2019; 19:e116-e126. [PMID: 30518498 PMCID: PMC6395889 DOI: 10.1016/j.clbc.2018.10.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/12/2018] [Accepted: 10/24/2018] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Uptake of preventive therapies for breast cancer is low. We examined whether women at increased risk of breast cancer can be categorized into groups with similar medication beliefs, and whether belief group membership was prospectively associated with uptake of preventive therapy. PATIENTS AND METHODS Women (n = 732) attending an appointment to discuss breast cancer risk were approached; 408 (55.7%) completed the Beliefs About Medicines and the Perceived Sensitivity to Medicines questionnaires. Uptake of tamoxifen at 3 months was reported in 258 (63.2%). The optimal number of belief groups were identified using latent profile analysis. RESULTS Uptake of tamoxifen was 14.7% (38/258). One in 5 women (19.4%; 78/402) reported a strong need for tamoxifen. The model fit statistics supported a 2-group model. Both groups held weak beliefs about their need for tamoxifen for current and future health. Group 2 (38%; 154/406 of the sample) reported stronger concerns about tamoxifen and medicines in general, and stronger perceived sensitivity to the negative effects of medicines compared with group 1 (62%; 252/406). Women with low necessity and lower concerns (group 1) were more likely to initiate tamoxifen (18.3%; 33/180) than those with low necessity and higher concerns (group 2) (6.4%; 5/78). After adjusting for demographic and clinical factors, the odds ratio was 3.37 (95% confidence interval, 1.08-10.51; P = .036). CONCLUSION Uptake of breast cancer preventive therapy was low. A subgroup of women reported low need for preventive therapy and strong medication concerns. These women were less likely to initiate tamoxifen. Medication beliefs are targets for supporting informed decision-making.
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Affiliation(s)
| | - Rob Horne
- Centre for Behavioural Medicine, School of Pharmacy, University College London, London, United Kingdom
| | - Lucy Side
- Wessex Clinical Genetics Service, University Hospitals Southampton, Southampton, United Kingdom
| | - Michael Scott Wolf
- Division of General Internal Medicine and Geriatrics, Northwestern University, Evanston, IL
| | - Samuel George Smith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.
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19
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Hackett J, Thorneloe R, Side L, Wolf M, Horne R, Cuzick J, Smith SG. Uptake of breast cancer preventive therapy in the UK: results from a multicentre prospective survey and qualitative interviews. Breast Cancer Res Treat 2018; 170:633-640. [PMID: 29687178 PMCID: PMC6022517 DOI: 10.1007/s10549-018-4775-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 03/30/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Uptake of preventive therapy for women at increased breast cancer risk in England is unknown following the introduction of UK clinical guidelines in 2013. Preventive therapy could create socioeconomic inequalities in cancer incidence if it is more readily accepted by particular socio-demographic groups. In this multicentre study, we investigated uptake of tamoxifen and evaluated socio-demographic and clinical factors associated with initiation. We explored women's experiences of treatment decision-making using qualitative interview data. METHODS Between September 2015 and December 2016, women (n = 732) attending an appointment at one of 20 centres in England to discuss breast cancer risk were approached to complete a survey containing socio-demographic details and nulliparity. Of the baseline survey respondents (n = 408/732, 55.7% response rate), self-reported uptake of tamoxifen at 3-month follow-up was reported in 258 (63.2%). Sixteen women participated in semi-structured interviews. RESULTS One in seven (38/258 = 14.7%) women initiated tamoxifen. Women who had children were more likely to report use of tamoxifen than those without children (OR = 5.26; 95%CI: 1.13-24.49, p = 0.035). Interview data suggested that women weigh up risks and benefits of tamoxifen within the context of familial commitments, with exposure to significant other's beliefs and experiences of cancer and medication a basis for their decision. CONCLUSIONS Uptake of tamoxifen is low in clinical practice. There were no socio-demographic differences in uptake, suggesting that the introduction of breast cancer preventive therapy is unlikely to create socioeconomic inequalities in cancer incidence. Women's decision-making was influenced by familial priorities, particularly having children.
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Affiliation(s)
- Julia Hackett
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
| | - Rachael Thorneloe
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
| | - Lucy Side
- Wessex Clinical Genetics Service, University Hospitals Southampton, Southampton, UK
- UCL Institute for Women's Health, London, UK
| | - Michael Wolf
- Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, USA
| | - Rob Horne
- Centre for Behavioural Medicine, School of Pharmacy, University College London, London, UK
| | - Jack Cuzick
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Samuel G Smith
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK.
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK.
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