A Systematic Review and Meta-Analysis of Interventions to Promote Adjuvant Endocrine Therapy Adherence Among Breast Cancer Survivors

Guideline for the Management Pathway and Quality Control of Breast Cancer Prevention and Treatment in China's Counties

Breast cancer is one of the most common malignant tumors among women in China, with approximately 306,000 new cases reported in 2016. Notably, around 33% (100,400) of these cases occurred in rural areas. County-level hospitals, encompassing counties and county-level cities, serve as the primary diagnostic units for the majority of rural breast cancer patients. These hospitals are integral to cancer prevention, screening, maintenance treatment, rehabilitation, follow-up, and referral processes. However, economic and geographical constraints result in county-level hospitals being relatively deficient in medical equipment, health human resources, and drug accessibility. Consequently, there is a critical need for breast cancer prevention and management guidelines that are tailored to the specific conditions of China's counties. In response to this need, and within the policy framework of hierarchical diagnosis and treatment, a Chinese expert group has developed the Guideline for the Management Pathway and Quality Control of Breast Cancer Prevention and Treatment in China's Counties (2023 Edition). This guideline aims to expand the availability of quality medical resources, ensure better distribution of these resources across regions, and enhance the capacity for breast cancer prevention and treatment. Ultimately, the goal is to improve the prognosis and quality of life for breast cancer patients in China's counties. This guideline includes clear and concise path diagrams that are easy to implement in clinical practice, serving as a valuable reference for clinicians in county-level hospitals.

Acceptability of acceptance and commitment therapy for medication-decision-making and quality of life in women with breast cancer: A qualitative process evaluation

OBJECTIVES

Adjuvant endocrine therapy (AET) reduces breast cancer recurrence, but side effects and distress impact adherence. We co-designed an Acceptance and Commitment Therapy (ACT) intervention to support medication decision-making and quality of life in women prescribed AET (ACTION). In a qualitative process evaluation nested in the pilot trial, we aimed to elicit participant experiences of receipt and therapists experience of delivery of ACTION to enhance our understanding of acceptability.

DESIGN

Remote semi-structured interviews were conducted with women with breast cancer who received ACTION (n = 20) and trial therapists (n = 3).

METHODS

Interviews were guided by the Theoretical Framework of Acceptability (TFA). Rapid Assessment Procedure (RAP) sheets were completed after each interview to map responses onto TFA constructs, and sections of interviews were selectively transcribed. Individual RAP sheets were collated to identify key findings.

RESULTS

ACTION was generally liked, in particular, the group format (affective attitude). Participants and therapists felt ACTION was low effort, but therapists acknowledged the burden associated with trial procedures (burden). Participants generally felt able to engage with ACTION, and therapists felt they were able to deliver it (self-efficacy). The perceived effectiveness of ACTION on well-being was good, but was mixed for impact on treatment adherence (perceived effectiveness). Participants and therapists understood the aims of ACTION (coherence), and ACTION generally aligned with therapists' values (ethicality). Therapists questioned who would be most appropriate to deliver ACTION (opportunity costs).

CONCLUSION

ACTION was acceptable to women with breast cancer and trial therapists. Rapid qualitative analysis can facilitate efficient process evaluations in time- and resource-limited contexts.

Outcomes based on risk-adapted adjuvant therapy in postmenopausal women with early breast cancer: a nationwide, prospective cohort study by the Danish Breast Cancer Group

BACKGROUND

Clinical prediction models are increasingly used to guide treatment in patients with early breast cancer. The Danish Breast Cancer Group (DBCG) has developed a prognostic standard mortality rate index (PSI) for prediction of excess mortality based on 5 years of endocrine therapy. In this study, we aimed to evaluate the clinical utility of the PSI.

METHODS

In this nationwide, prospective cohort study, we included postmenopausal Danish women aged 50 years or older with invasive oestrogen receptor-positive and HER2-negative resected breast cancer registered in the DBCG clinical database (close to all Danish women newly diagnosed with invasive breast cancer are registered in the national database). All participants were assigned a PSI category. Patients in the PSI 1 category were recommended 5 years of endocrine therapy; patients in PSI 2, 3, or 4 category were recommended endocrine therapy plus adjuvant chemotherapy according to Danish national guidelines. The primary endpoint was standard mortality ratio. Univariable and multivariable analyses for standard mortality ratio, overall survival, and recurrence-free survival were performed applying Kaplan-Meier, cumulative incidence, Poisson regression, and Fine-Gray subdistribution hazards model.

FINDINGS

25 027 women diagnosed with breast cancer between Aug 1, 2013, and Dec 31, 2018, and registered with the DBCG clinical database were identified. 8921 of those registered were eligible, assigned a PSI category (6704 [75%] PSI 1, 1300 [15%] PSI 2, 745 [8%] PSI 3, and 172 [2%] PSI 4), and included in the study. 8514 [96%] of 8830 women initiated endocrine therapy and 91 had an unknown therapy status. Adherence at 4·5 years was 67·8% (66·6-69·0) in the PSI 1 group and 72·3% (70·5-74·3) in the PSI 2-4 groups. Crude standard mortality ratio was 0·89 (95% CI 0·85-0·95) with PSI 1, 1·71 (95% CI 1·47-1·97) with PSI 2, and 2·39 (95% CI 1·99-2·88) with PSI 3-4. Compared with patients who completed adjuvant therapy with PSI 1, relative risk (RR) for excess mortality was 1·33 (95% CI 1·01-1·76) for patients with PSI 2 whereas patients with PSI 3-4 retained an excess mortality (RR 2·31, 95% CI 1·74-3·05) even with completed therapy.

INTERPRETATION

These data validate the clinical use of the PSI tool for risk adapted treatment allocation. In patients with PSI 1, the omission of chemotherapy was not associated with excess mortality overall and a distinct better outcome was seen in patients with completed endocrine therapy versus those who had not completed. With completed adjuvant therapy, excess mortality was low for patients with PSI 2, whereas patients with PSI 3-4 had high excess mortality, potentially warranting intensified treatment and requiring further investigation.

FUNDING

None.

Survival analysis and establishment of prognostic nomograms for primary breast signet ring cell carcinoma

Primary breast signet ring cell carcinoma (BSRCC) is an extremely rare malignancy with poor prognosis. Few consensus exists regarding the prognostic factors and treatment modalities. This study aimed to develop a nomogram model to predict survival probability and guide clinical treatment for BSRCC patients. Clinicopathological data of BSRCC patients were retrieved from SEER database. Univariate and multivariate Cox regression analyses were performed to screen and identify prognostic factors. Kaplan-Meier method was used to describe the survival curve for each prognostic factor. Additionally, these factors were incorporated to construct nomograms for predicting overall survival (OS) and disease-specific survival (DSS) of BSRCC patients. The nomograms were internally validated using receiver operating characteristic (ROC) curves, calibration curves and decision curve analysis (DCA). A total of 362 eligible BSRCC patients were included in this study. Multivariate Cox analysis demonstrated that age at diagnosis, T stage, N stage, and surgery were identified as independent prognostic factors for OS, while grade, T stage, N stage, ER status, and surgery were independent DSS-related factors. Our study elucidated that surgery is the effective treatment for BSRCC, while postoperative radiotherapy does not confer additional benefit to patients. Nomograms were established to predict OS and DSS probability by incorporating independent prognostic factors among BSRCC patients. The nomograms were subsequently validated using ROC curves, calibration curves, and DCA to display the robust prognostic capability. Robust nomograms for OS and DSS of BSRCC patients were established, facilitating precise personalized risk assessment and appropriate treatment regimens in clinical practice.

The association of distress and depression screening measures and other electronic health record information with adjuvant endocrine therapy persistence

PURPOSE

Few risk factors for early adjuvant endocrine discontinuation have been identified, but clinical trials suggest pre-AET symptom burden might be important. We sought to assess this in an academic practice.

METHODS

We examined baseline and up to five years of follow-up information for postmenopausal women with stage I-III hormone-receptor positive breast cancer 2014-2019 receiving oncologist prescriptions for AET. The Distress Thermometer (DT) and its problem list, the Patient Health Questionnaire 2/9 (PHQ 2/9), cancer extent of disease and treatments, comorbidities, sociodemographics, and pharmacy prescription fill dates were abstracted from the cancer registry and electronic health record (EHR). The association of these variables with early AET prescription fill discontinuation (prior to 5 years) was examined using survival analysis and Bayesian machine learning, with censoring for recurrence, death, or provider change.

RESULTS

Among the cohort of 961 women (mean 68.8 years, SD 2.88), 91.6% were white, 74.6% had Stage I disease, and 45.0% a pre-AET DT showing high distress (> 3). The median follow-up time was 820 (25, 75% 448,1282) days, and 29.6% discontinued early. Neither the DT score nor the PHQ 2/9 was associated with nonadherence, although three physical problems were modestly associated. Over 25% of women who stopped filling prescriptions did not have their prescriptions discontinued in the EHR.

CONCLUSIONS

Several commonly available baseline EHR variables were not associated with early discontinuation, although some symptoms may have modest effects. Many women who discontinued still had EHR prescriptions, suggesting that physicians could use prescription fill information to intervene earlier.

Perspectives of Women with Breast Cancer and Healthcare Providers Participating in an Adherence-Enhancing Program for Adjuvant Endocrine Therapy: A Qualitative Study

BACKGROUND

Adjuvant endocrine therapy (AET) is prescribed for 5-10 years to women with hormone-sensitive breast cancer to prevent recurrence. However, a significant proportion of women do not adhere to AET. We developed SOIE, a one-year program designed to enhance the AET experience and adherence. SOIE was pilot-tested in a mixed-methods randomized controlled trial. This report presents the experience of women and healthcare providers (HCPs) with SOIE.

METHODS

A descriptive qualitative study using semi-structured interviews and thematic analysis was conducted with 20 women and 7 HCPs who participated in the program.

RESULTS

Most women and HCPs reported high satisfaction with the program. Women felt it addressed their need for information and strategies to manage side effects. They felt supported and developed a more positive attitude toward AET, which contributed to their intention to pursue AET. They perceived that the program helped them navigate the AET experience and reduced their stress or fear regarding AET. HCPs corroborated these benefits.

CONCLUSIONS

Findings suggest that SOIE can enhance the experience and motivation to pursue the AET treatment by meeting important needs for information, side-effects management, and psycho-emotional support. Programs like SOIE can have benefits beyond adherence by improving patients' well-being during this crucial long-term treatment.

Assessing multidimensional fidelity in a pilot optimization trial: A process evaluation of four intervention components supporting medication adherence in women with breast cancer

Adherence to adjuvant endocrine therapy in women with breast cancer is low. We conducted a 24-1 fractional factorial pilot optimization trial to test four intervention components supporting medication adherence [text messages, information leaflet, acceptance and commitment therapy (ACT), self-management website], in the preparation phase of the multiphase optimization strategy. Guided by the National Institute of Health Behavior Change Consortium fidelity framework, we investigated fidelity of design, training, delivery, receipt, and enactment of four intervention components. Women prescribed adjuvant endocrine therapy (n = 52) were randomized to one of eight experimental conditions comprised of combinations of the four intervention components (ISRCTN: 10487576). We assessed fidelity using self-report data (4 months post-randomization), trial data, ACT session observations, behavior change technique (BCT) coding, and interviews with participants (n = 20) and therapists (n = 6). Design: Each intervention component targeted unique behavior change techniques with some overlap. Training: All 10 therapists passed the competency assessment. Delivery: All leaflets (27/27) and website (26/26) details were sent, and ACT procedural fidelity was high (85.1%-94.3%). A median of 32.5/41 (range 11-41) text messages were delivered, but a system error prevented some messages being sent to 22 of 28 participants. Receipt: Most participants [63.0% (ACT, leaflet) to 71.4% (text messages)] read all or at least some of the intervention components they were randomized to receive. Enactment was reported most positively for ACT. All intervention components demonstrated adequate fidelity. We have provided an exemplar for assessing fidelity using the National Institute of Health Behavior Change Consortium framework in the preparation phase of multiphase optimization strategy.

Optimizing the Use of Personal Values to Promote Medication Adherence: A Randomized Controlled Trial Comparing Affective and Behavioral Responses to Theory-Driven Domain Congruent Versus Incongruent Values Approaches

BACKGROUND

Self-affirmation theory (SAT) and acceptance and commitment therapy (ACT) embody competing approaches to leveraging personal values to motivate behavior change but are rarely compared in the domain of health behavior. This study compares these theory-driven values-based interventions for promoting medication adherence.

PURPOSE

To compare affective and behavioral responses to competing values-based medication adherence interventions.

METHODS

In this three-armed randomized trial, participants with cancer (n = 95) or diabetes (n = 97) recruited online using Prolific and prescribed daily oral medication for that disease completed a one-session online writing intervention leveraging (1) a domain incongruent (DI) value, where the value was not connected to medication adherence; (2) a domain congruent (DC) value, where the value was connected to adherence; or (3) a control condition, focused on medication adherence procedures.

RESULTS

There were no main effects of conditions on reported medication adherence at the 1-month follow-up. During the intervention, positive affect was higher in the values conditions than control (p < .001), and trended higher in DI versus DC (p = .054). Negative affect did not vary between the values and control groups (p = .093) but was lower in DI versus DC (p = .006). Improvements in positive affect over the course of the intervention were associated with increased adherence behavior for individuals who started with low levels of positive affect (p = .003). Disease type did not moderate findings.

CONCLUSIONS

Consistent with SAT, focusing on DI values led to more positive and less negative affect than connecting values directly to behavior in a threatening domain such as chronic illness. For some participants, increases in positive affect predicted greater adherence.

Supporting endocrine therapy adherence in women with breast cancer: findings from the ROSETA pilot fractional factorial randomized trial

BACKGROUND

Adherence to adjuvant endocrine therapy (AET) in women with breast cancer is poor. Multicomponent intervention packages are needed to address adherence barriers. Optimizing these packages prior to definitive evaluation can increase their effectiveness, affordability, scalability, and efficiency.

PURPOSE

To pilot procedures for an optimization-randomized controlled trial (O-RCT) of the 'Refining and Optimizing Strategies to support Endocrine Therapy Adherence' (ROSETA) intervention.

METHODS

This was a multisite individually randomized external pilot trial using a 24-1 fractional factorial design (ISRCTN10487576). Breast cancer survivors prescribed AET were recruited from 5 hospitals and randomized to one of 8 conditions, each comprising a combination of 4 intervention components set to "on" or "off" (SMS messages, information leaflet, guided self-help, and self-management website). We set criteria to inform the decision to progress to an O-RCT for consent rate, component adherence, and availability of outcome measures, with predefined cutoffs for "green" (proceed), "amber" (minor changes), and "red" (major changes).

RESULTS

Among 141 eligible patients, 54 (38.3%) consented (green range). At least 50.0% of participants adhered to the minimum threshold set for each intervention component (green range). Data for one of the 3 medication adherence measures were available (amber range). Most (86.8%) participants were satisfied with their trial experience. Exploratory analysis indicated some evidence of a negative main effect of the information leaflet on medication adherence (adjusted mean difference = 0.088, 95% CI, 0.018, 0.158).

CONCLUSIONS

Progression to a fully powered O-RCT of the ROSETA intervention package is feasible, but review of medication adherence measures is required.

[The effect of acetylamide synthetic peptide HLDF-6 on cell differentiation in breast cancer]

The development of drugs with the ability to increase differentiation and reduce tumor malignancy is one of the promising directions in the treatment of breast cancer (BC). As such, Human Leukemia Differentiation Factor (HLDF), a protein consisting of 54 amino acids and contributing to an increase in the degree of differentiation of invasive ductal breast carcinoma cells, can be used. The key disadvantage of the full-size HLDF is its rapid biodegradation. In this connection, the acetylamide form of the peptide (HLDF-6) was synthesized to protect against hydrolysis.

OBJECTIVE

To evaluate the effect of HLDF-6 on cell differentiation in various molecular biological subtypes of breast cancer.

MATERIAL AND METHODS

The relative content of tumor cells of various degrees of differentiation in biopsies of 33 women with breast cancer when exposed to HLDF-6 tumor was evaluated.

RESULTS

HLDF-6 significantly increases the relative content of differentiated cells in the luminal B HER2-negative subtype of breast cancer, without significantly affecting the cells of patients with luminal A and basal-like subtypes.

CONCLUSION

The study revealed the prospects of using HLDF-6 as part of differentiating therapy in patients with luminal B HER2-negative subtype of breast cancer.

Complex intervention including pain science education and patient-led goal setting-based self-management strategies for management of aromatase inhibitor-induced musculoskeletal symptoms: a single-arm feasibility and pilot study

PURPOSE

Up to 74% of breast cancer survivors (BCS) treated with aromatase inhibitor (AI) experience AI-induced musculoskeletal symptoms (AIMSS). AIMSS is the predominant cause of poor adherence to AI therapy, yet no definitive treatment exists. The primary research objectives of this study were (1) to develop a novel BCS-specific complex intervention to alleviate AIMSS, and to assess its feasibility. The secondary research objective was (2) to assess the preliminary efficacy of this intervention.

METHODS

A single-arm, longitudinal pilot study was conducted involving 15 BCS with AIMSS. The complex intervention, which included pain science education, patient-led goal setting, and self-management strategies, was administered over 3 months. Feasibility was assessed by measuring overall participation, treatment completion rates, and satisfaction after 3 months of intervention. Additionally, the preliminary efficacy of the intervention was evaluated using a mixed model repeated measures analysis, with the change in pain intensity (brief pain inventory [BPI] worst pain/stiffness intensity) at 3 months as the primary endpoint.

RESULTS

The feasibility assessment showed promising results, with a 70.7% participation rate, an 83.3% intervention completion rate, and a satisfaction score of 8.2 ± 1.5. The intervention significantly reduced BPI worst pain/stiffness intensity by 2.78 points after 3 months (95% CI, - 4.5 to - 0.87, p < 0.01). Secondary outcomes demonstrated significant improvements in disability, quality of life, and pain catastrophizing (p < 0.05).

CONCLUSION

The novel complex intervention appears valuable for management AIMSS in BCS. Future large-scale studies, including randomized controlled trials, are warranted.

TRIAL REGISTRATION

The study was registered in the Clinical Trials Registry of the University Hospital Medical Information Network (UMIN-CTR: UMIN 000049035) in October 2022.

IMPLICATIONS FOR CANCER SURVIVORS

The novel BCS-specific complex intervention program holds the potential to aid in managing AIMSS, improving adherence to AI therapy, and enhancing their quality of life.

Symptom Monitoring App Use Associated With Medication Adherence Among Woman Survivors of Breast Cancer on Adjuvant Endocrine Therapy

PURPOSE

Oral adjuvant endocrine therapy (AET) reduces the risk of cancer recurrence and death for women with hormone receptor-positive (HR+) breast cancer. Because of adverse symptoms and socioecologic barriers, AET adherence rates are low. We conducted post hoc analyses of a randomized trial of a remote symptom and adherence monitoring app to evaluate characteristics associated with higher app use, satisfaction, and how app use was associated with AET adherence.

METHODS

Patients prescribed AET were randomly assigned to receive one of three intervention conditions: app, app + feedback, or enhanced usual care. Baseline and 6-month follow-up surveys, app use, and pillbox-monitored AET adherence data for app and app + feedback participants were used. Logistic regression evaluated the association between sociodemographic/clinical characteristics and app utilization and satisfaction, and how app use was associated with AET adherence (>80%).

RESULTS

Overall, 163 women with early-stage HR+ breast cancer were included; 35.0% had high app use (≥75% of weeks enrolled). No sociodemographic characteristics were associated with app use. Satisfaction with the app was higher among those who were younger (88.9% for age 31-49 years v 54.9% for age 65+ years, P < .001), identified as White (76.8% v 60.1% for Black, P = .045), had lower health literacy (85.4% v 68.2% with higher health literacy, P = .017), or were nonurban residents (85.7% v 68.6% for urban, P = .021). Most participants (90.3%) with high app use were AET-adherent compared with 66.8% for those with lower app use (P < .001).

CONCLUSION

Use of a remote monitoring app was similar across sociodemographic characteristics, and more frequent app use was associated with a higher likelihood of 6-month AET adherence. Encouraging women to monitor medication adherence and communicate adverse symptoms could improve AET adherence.

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.

Development and psychometric evaluation of the adjuvant endocrine therapy beliefs scale for breast cancer survivors

PURPOSE

Adjuvant endocrine therapy has a vital role in reducing breast cancer mortality. The beliefs in adjuvant endocrine therapy is a very important factor in the medication adherence of breast cancer survivors. Therefore, it is necessary to develop a standardized scale for assessment of adjuvant endocrine therapy. The purpose of this study was to identify the attributes of adjuvant endocrine therapy beliefs, and to evaluate adjuvant endocrine therapy beliefs scale psychometric properties.

METHODS

A hybrid model was applied to identify the concept of adjuvant endocrine therapy beliefs and measurement question were developed by the scale development process. Statistical analysis using validity analysis and Rasch analysis based on item response theory were performed. A total of 228 breast cancer survivors in South Korea participated in the study.

RESULTS

The finally developed adjuvant endocrine therapy beliefs scale consisted of 22 items. The items extracted by 4 factors explained 59.72% of the total variance. The model fit showed an acceptable level. The adjuvant endocrine therapy beliefs scale was excellent in convergent and discriminant validity with reliability.

CONCLUSION

This scale is expected to be practical and useful in identifying adjuvant endocrine therapy beliefs and developing intervention strategies to promote adjuvant endocrine therapy adherence. In addition, continuous education and support should be accompanied so that breast cancer survivors can maintain positive beliefs in adjuvant endocrine therapy adherence.

Active symptom monitoring for premenopausal women with breast cancer initiating adjuvant endocrine therapy: Protocol for the SWOG S2010 randomized controlled efficacy trial

BACKGROUND

Premenopausal women with early stage, high risk hormone receptor positive breast cancer are at risk of early discontinuation of adjuvant endocrine therapy (ET), primarily because of toxicity, which can increase the risk of disease recurrence and death. We hypothesize that identification of bothersome symptoms between clinic visits, and automated notification of clinicians about symptoms, will result in improved persistence with ET.

METHODS

Pre- and perimenopausal women planning to receive adjuvant treatment with tamoxifen or an aromatase inhibitor plus ovarian function suppression or ablation for treatment of breast cancer are eligible. A total of 540 participants will be enrolled and randomized 1:1 to patient education with or without Active Symptom Monitoring (ASM). The ASM intervention includes 6 symptom questions (hot flashes, sadness, anxiety, insomnia, vaginal dryness, joint pain) that will be completed via text, email, or telephone weekly for 24 weeks, then every 4 weeks for 48 weeks. All participants will complete a battery of questionnaires every 12 weeks to examine symptoms, beliefs about medicine, self-efficacy, and ET adherence. Optional blood draws will be collected at baseline and after 12, 48, and 72 weeks of therapy to examine estradiol and ET concentrations. The primary endpoint is time to nonpersistence with initially prescribed ET within the first 72 weeks, evaluated using Kaplan-Meier plots and multivariable Cox regression.

CONCLUSION

We expect early identification and management of ET-related toxicities to improve persistence with breast cancer therapy, breast cancer outcomes, and quality of life for premenopausal women at high risk of breast cancer recurrence.

CLINICALTRIALS

govNCT05568472.

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.

Acceptability of Four Intervention Components Supporting Medication Adherence in Women with Breast Cancer: a Process Evaluation of a Fractional Factorial Pilot Optimization Trial

Adjuvant endocrine therapy (AET) reduces mortality in early-stage breast cancer, but adherence is low. We developed a multicomponent intervention to support AET adherence comprising: text messages, information leaflet, acceptance and commitment therapy (ACT), and side-effect website. Guided by the multiphase optimization strategy, the intervention components were tested in the ROSETA pilot optimization trial. Our mixed-methods process evaluation investigated component acceptability. The pilot optimization trial used a 24-1 fractional factorial design. Fifty-two women prescribed AET were randomized to one of eight experimental conditions, containing unique component combinations. An acceptability questionnaire was administered 4 months post-randomization, and semi-structured interviews with 20 participants further explored acceptability. Assessments were guided by four constructs of the theoretical framework of acceptability: affective attitude, burden, perceived effectiveness, and coherence. Quantitative and qualitative findings were triangulated to identify agreements/disagreements. There were high overall acceptability scores (median = 14-15/20, range = 11-20). There was agreement between the qualitative and quantitative findings when triangulated. Most participants "liked" or "strongly liked" all components and reported they required low effort to engage in. Between 50% (leaflet) and 65% (SMS) "agreed" or "strongly agreed," it was clear how each component would help adherence. Perceived effectiveness was mixed, with 35.0% (text messages) to 55.6% (ACT) of participants "agreeing" or "strongly agreeing" that each component would improve their adherence. Interview data provided suggestions for improvements. The four components were acceptable to women with breast cancer and will be refined. Mixed-methods and triangulation were useful methodological approaches and could be applied in other optimization trial process evaluations.

Sticking to the script: Breast cancer patients' decision making regarding oral endocrine therapy

OBJECTIVES

We sought to understand why some women with early-stage breast cancer decide to forgo or discontinue endocrine therapy (ET), and to identify factors that might lead to greater acceptance of, and long-term adherence to, this treatment.

METHODS

We conducted in-depth interviews with N = 53 stage I-III HR+ women who were either non-initiators of ET, initiators who discontinued or initiators who continued with variable daily patterns of adherence. An inductive content analysis was performed to explore the decision-making process of women prescribed ET.

RESULTS

Qualitative analyses revealed 55 themes that drove complex decision making. The initiators generally trusted their physicians and did little research before starting the medication. Non-initiators were more suspicious of the medical system, believing that ET presented more risks than benefits. Most discontinuers stopped ET because of side effects. Both non-initiators and discontinuers indicated that push-back from their physicians could have changed their decision. Stories and social support were important in decision making.

CONCLUSIONS

Although ET can significantly reduce the risk of breast cancer recurrence, substantial barriers prevent many women from initiating or continuing it.

PRACTICE IMPLICATIONS

Physicians have powerful influence over patients' decisions to initiate ET and can be important levers for motivating patients to persist.

Social Characteristics and Adherence to Adjuvant Endocrine Therapy in Premenopausal Women With Breast Cancer

PURPOSESocial characteristics, including cohabitation/marital status and socioeconomic position (SEP)-education level, employment status, and income-influence breast cancer prognosis. We investigated the impact of these social characteristics on adherence to adjuvant endocrine therapy (AET) from treatment initiation to 5 years after diagnosis.METHODSWe assembled a nationwide, population-based cohort of premenopausal women diagnosed in Denmark with stage I-III, estrogen receptor-positive breast cancer during 2002-2011. We ascertained prediagnostic social characteristics from national registries. AET adherence was based on information from the Danish Breast Cancer Group and operationalized as (1) adherence trajectories (from group-based trajectory modeling) and (2) early discontinuation. We computed odds ratios (ORs) and associated 95% CI to estimate the association of cohabitation and SEP with AET adherence using multinomial and logistic regression models adjusted according to directed acyclic graphs.RESULTSAmong 4,353 patients, we identified three adherence trajectories-high adherence (57%), slow decline (36%), and rapid decline (6.9%). Compared with cohabiting women, those living alone had higher ORs of slow (1.26 [95% CI, 1.08 to 1.46]) or rapid decline (1.66 [95% CI, 1.27 to 2.18]) versus high adherence. The corresponding ORs for women not working versus employed women were 1.22 (95% CI, 1.02 to 1.45) and 1.76 (95% CI, 1.30 to 2.38). For early discontinuation (17%), the ORs were 1.48 (95% CI, 1.23 to 1.78) for living alone and 1.44 (95% CI, 1.17 to 1.78) for women not working.CONCLUSIONAdherence to AET was lower among women living alone or unemployed than cohabiting or employed women, respectively. These women may benefit from support programs to enhance AET adherence.

[Adherence to endocrine therapy: A major issue in breast cancer management]

Endocrine therapy plays a crucial role in the treatment of women with hormone receptor-positive breast cancer. However, non-adherence remains a frequent issue known to negatively impact survival. Based on a comprehensive literature review, this article explores the terminologies employed to describe adherence and methods used for its assessment, the adherence data reported with adjuvant endocrine therapy with targeted therapies, the determinants of adherence or non-adherence, and finally, tested solutions to address it. The results show that a better understanding of the causes of non-adherence would help to better identify patients at risk, and to develop personalized intervention programs capable of improving adherence to adjuvant endocrine therapy. In light of the literature, interventions are likely to require a multimodal approach and integration into our future healthcare pathways.

Screening and Testing for Homologous Recombination Repair Deficiency (HRD) in Breast Cancer: an Overview of the Current Global Landscape

PURPOSE OF REVIEW

Homologous recombination repair deficiency (HRD) increases breast cancer susceptibility and influences both prophylactic and active management of breast cancer. This review evaluates HRD testing and the therapeutic implications of HRD in a global context.

RECENT FINDINGS

Ongoing research efforts have highlighted the importance of HRD beyond BRCA1/2 as a potential therapeutic target in breast cancer. However, despite the improved affordability of next-generation sequencing (NGS) and the discovery of PARP inhibitors, economic and geographical barriers in access to HRD testing and breast cancer screening do not allow all patients to benefit from the personalized treatment approach they provide. Advancements in HRD testing modalities and targeted therapeutics enable tailored breast cancer management. However, inequalities in access to testing and optimized treatments are contributing to widening health disparities globally.

Associations between HIV infection status, psychosocial factors, and adjuvant endocrine therapy adherence among South African women with early-stage breast cancer

Purpose

We aimed to evaluate for associations between HIV status, psychosocial factors, and adjuvant endocrine therapy (AET) adherence in South African (SA) women with estrogen receptor positive (ER+) breast cancer (BC).

Methods

We enrolled South African women with early-stage ER + BC in remission and prescribed tamoxifen or an aromatase inhibitor to the prospective observational study. We performed AET pill counts at enrollment, 12 weeks, and 24 weeks, and calculated adherence ratios of pills consumed between visits to days between visits. Women completed questionnaires on social support, attitude towards medication, health literacy, self-efficacy, mental health, and AET toxicity. We collected household wealth data. We used hierarchical linear (HLM) and structural equation modelling (SEM) to compare adherence ratios between women with and without HIV while adjusting for psychosocial factors.

Results

We collected adherence data from 239 women, 63 (26.4%) with co-morbid HIV. Comparing women with and without HIV, median AET adherence ratio was 0.88 vs 0.89, respectively (HLM p = 0.31). In our SEM model for the full cohort, mental health, healthcare savvy, and side effect burden latent variables were not significantly associated with adherence. In the subgroup of women living with HIV, lower SES quintile (β 0.04, SE 0.02, p = 0.08) and poorer mental health (β -0.02, SE 0.01, p = 0.10) showed trends toward association with adherence.

Conclusions

HIV status is not predictive of AET adherence among SA women with ER + BC, though decreasing SES status and increasing mental health symptoms are marginally associated with adherence in women with BC and HIV.

Breast cancer survivors' opinion on personalizing endocrine therapy and developing informative tools

Understanding breast cancer survivors' perspectives is critical to personalizing endocrine therapy (ET) in the adjuvant setting. A nationwide survey among breast cancer survivors was proposed in France, in collaboration with patient advocacy organizations, to assess their perspectives on personalizing ET and developing dedicated informative tools. This survey explored patients' preferences regarding ET intake schedule, formulation, presentation (color, taste, shape, size, design, and packaging), combination with agents targeting ET-related adverse events, and a mobile application to support them during ET. Of the 1103 individuals who started the survey, 939 (85.1%) were eligible for enrollment and completed the survey. The majority of the participants considered that a personalized ET should take into consideration the intake schedule (n = 974, 90.7%) and swallowable tablet formulation (n = 606, 64.5%), without a preference for ET presentation (n = 619; 65.9%). The majority of the participants expressed a willingness to participate in a potential clinical trial evaluating the combination of ET with agents targeting ET-related adverse events at the start of ET (n = 752, 80.1%) or in the case of major ET-related adverse events (n = 778, 82.8%). The primary considerations were to have an uncompromised ET efficacy and a guaranteed reduction of adverse events. Last, a dedicated mobile application was considered helpful by 665 participants (70.8%). Informative tools should focus on the recommendations for dealing with adverse events (n = 593, 63.2%), the impact on the patient's daily life (n = 515, 54.9%), benefits (n = 504, 53.7%), and adverse events (n = 494, 52.6%) of ET. This survey paves the way for multimodal strategies that can include a personalized ET (e.g., ET in combination with agents targeting ET-related adverse events) and dedicated mobile applications to ultimately improve adherence.

Dataset for a randomised factorial experiment to optimise an information leaflet for women with breast cancer

Background

Adherence to adjuvant endocrine therapy (AET) is low in women with breast cancer, which increases the risk of recurrence and mortality. A consistently reported barrier to adherence is low perceived necessity of AET and high concerns. Existing interventions to support medication beliefs have mixed effectiveness and rarely target medication beliefs specifically. We developed an information leaflet with five candidate components aiming to increase necessity beliefs about AET and reduce concerns; (1) diagrams explaining how AET works; (2) icon arrays displaying the benefits of AET; (3) information about the prevalence of side-effects; (4) answers to common concerns and (5) quotes and pictures from breast cancer survivors. Guided by the multiphase optimisation strategy (MOST), we aimed to optimise the content of the information leaflet. We planned for the dataset to be open access to provide an exemplar for other investigators to use.

Methods

The content of the leaflet was optimised in a fully powered online 2 5 factorial experiment. Each candidate component of the leaflet was operationalised as a factor with two levels; on vs off or enhanced vs basic. Healthy women (n=1604) completed the beliefs about medicines questionnaire and were randomised to view one of 32 versions of the information leaflet. The 32 versions comprised unique combinations of the factor levels corresponding to the five candidate intervention components. Time spent on the information leaflet page of the survey was recorded. After viewing the information leaflet, participants completed the beliefs about medicines questionnaire again, a true/false questionnaire assessing their objective knowledge of AET, a subjective rating of their knowledge of AET, and a questionnaire evaluating their satisfaction with the information they received.

Importance of this dataset

The factorial dataset provides the opportunity for other investigators interested in using the MOST framework to learn about complex factorial designs, using a real dataset.

Pilot randomized controlled trial of a program to enhance experience and adherence with adjuvant endocrine therapy among women with non-metastatic breast cancer: 12-month quantitative results

PURPOSE

Adjuvant endocrine therapy (AET) reduces recurrence risk after hormone receptor-positive breast cancer, but non-adherence is common. We pilot-tested SOIE, a program to enhance AET experience and adherence, to assess its acceptability, feasibility, and effects on psychosocial precursors of AET adherence.

METHODS

We conducted a 12-month pilot randomized controlled trial among women who had a first AET prescription. Intervention group received SOIE while control group received usual care. Psychosocial factors from the Theory of Planned Behavior (TPB) (intention - primary outcome -, attitude, subjective norm, behavioral control), additional constructs (AET knowledge, social support, coping planning), impact of AET services received, and adherence were measured by questionnaires at baseline, 3-month, and 12-month endpoints. Group patterns were compared using repeated measures analyses with generalized estimating equations.

RESULTS

A total of 106 women were randomized (participation = 54.9%; intervention n = 52; control n = 54; retention = 93.8%). Among SOIE women, ≥ 90% received the program components and were satisfied. Both groups scored high on adherence intentions and group patterns over time were not statistically different. In the intervention group, AET knowledge and coping planning with side effects increased (group-by-time p-value = .002 and .016), a higher proportion reported that AET services received helped them take their AET (p < .05) and have a consistent daily intake (p = .01).

CONCLUSION

SOIE is feasible and acceptable for survivors with an AET. SOIE did not significantly impact adherence intentions but was beneficial for other program outcomes and daily intake.

IMPLICATIONS FOR CANCER SURVIVORS

SOIE may represent an encouraging avenue to enhance supportive care and empower survivors with managing AET.

A pilot randomised controlled trial of acceptance and commitment therapy for medication decision-making and quality of life in women with breast cancer: The ACTION trial

OBJECTIVE

Non-adherence to adjuvant endocrine therapy (AET) in women with breast cancer is common and associated with medication side-effects and distress. We co-designed an Acceptance and Commitment Therapy intervention (ACTION) to enhance medication decision-making and quality of life (QoL). We undertook a pilot trial of ACTION to inform the feasibility of a phase III trial, and to examine intervention acceptability.

METHODS

This was a multi-site, exploratory, two-arm, individually randomised external pilot trial. Women with early breast cancer prescribed AET were randomised (1:1) to receive usual care (UC) or UC + ACTION. The ACTION intervention comprised a remotely delivered one-to-one ACT session followed by three group sessions delivered by clinical psychologists, alongside a website containing ideas for the self-management of side effects.

RESULTS

Of the 480 women screened for eligibility, 260 (54.2%) were approached and 79 (30.4%) randomised. 71 (89.9%) women provided data at 3-month and 70 (88.6%) at 6-month 40 women were randomised to receive UC + ACTION and 32 (80.0%) completed the intervention. Most (75.0%) accessed the website at least once. ACTION was acceptable to participants (Borkovec & Nau Scale: mean = 7.8 [SD = 2.7] out of 10). Signals of effectiveness in favour of the UC + ACTION arm were observed for medication adherence (Adherence Starts with Knowledge questionnaire-12), QoL (work and social adjustment scale), health-related QoL (functional assessment of cancer therapy[FACT] general and FACT-ES-19/23), distress (generalised anxiety disorder -7, patient health questionnaire-9) and psychological flexibility (valuing questionnaire).

CONCLUSIONS

The ACTION intervention was acceptable to patients. There were promising signals for effectiveness on primary and secondary outcomes. A phase III randomised controlled trial is feasible.

TRIAL REGISTRATION

ISRCTN12027752.

Adherence to adjuvant endocrine therapy for breast cancer: a qualitative exploration of attribution of symptoms among post-menopausal women

PURPOSE

Oral adjuvant endocrine therapy (AET) is an effective treatment for hormone receptor positive breast cancer to decrease recurrence and mortality, but adherence is poor. This study explored post-menopausal women's experiences with AET, with a particular focus on adherence to AET as well as distress and symptoms experienced prior to and during AET treatment.

METHODS

Participants were recruited from a hospital registry, stratified by adherence to/discontinuation of AET. Telephone interviews followed a semi-structured interview guide and were recorded and transcribed verbatim. Transcripts were systematically coded using team-based coding, with analysis of themes using a grounded theory approach.

RESULTS

Thirty-three participants were interviewed; ages ranged from 57 to 86 years. Participants included 10 discontinued patients and 23 patients who completed their AET course or were adherent to AET at the time of interviewing. Both adherent and discontinued patients reported symptoms throughout their AET treatment course, and both attributed symptoms to factors other than AET (e.g., older age and pre-existing comorbidities). However, discontinued patients were more likely to attribute symptoms to AET and to describe difficulty managing their symptoms, with some directly citing symptoms as the reason for discontinuing AET therapy. Conversely, adherent patients were more likely to describe the necessity of taking AET, despite symptoms.

CONCLUSIONS

AET adherence was associated with beliefs about AET, symptom attribution, and symptom management. Routine symptom monitoring during AET and addressing both symptoms and patients' understanding of their symptoms may promote adherence to AET.

Developing questions to assess and measure patients' perceived survival benefit from adjuvant endocrine therapy in breast cancer: a mixed methods pilot study

This mixed method study developed multiple question types to understand and measure women's perceived benefit from adjuvant endocrine therapy. We hypothesis that patients do not understand this benefit and sought to develop the questions needed to test this hypothesis and obtain initial patient estimates. From 8/2022 to 3/2023, qualitative interviews focused on assessing and modifying 9 initial varied question types asking about the overall survival (OS) benefit from adjuvant endocrine therapy. Subsequent focus groups modified and selected the optimal questions. Patients' self-assessment of their OS benefit was compared to their individualized PREDICT model results. Fifty-three patients completed the survey; 42% Hispanic, 30% rural, and 47% with income < $39,999 per year. Patients reported adequate health care literacy (61.5%) and average confidence about treatment and medication decisions 49.4 (95% CI 24.4-59.5). From the original 9 questions, 3 modified questions were ultimately found to capture patients' perception of this OS benefit, focusing on graphical and prose styles. Patients estimated an OS benefit of 42% compared to 4.4% calculated from the PREDICT model (p < 0.001). In this group with considerable representation from ethnic minority, rural and low-income patients, qualitative data showed that more than one modality of question type was needed to clearly capture patients' understanding of treatment benefit. Women with breast cancer significantly overestimated their 10-year OS benefit from adjuvant endocrine therapy compared to the PREDICT model.

Effect of telehealth interventions on adherence to endocrine therapy among patients with breast cancer: a systematic review and meta-analysis

PURPOSE

To evaluate the effect of telehealth interventions on adherence to endocrine therapy among patients with breast cancer.

METHODS

A systematic search of five English databases (PubMed, Web of Science, Embase, the American Psychological Association PsycNet, and the Cochrane Library) and four Chinese databases (Chinese National Knowledge Infrastructure, SinoMed, WanFang Data, and WeiPu Data) was performed from inception to March 31, 2023. Two investigators independently screened the available studies for eligibility and extracted relevant data. Quality assessment was conducted using the Cochrane Risk of Bias Tool. The effect size was computed based on the risk ratio for dichotomous data and standardized mean difference for continuous data using Review Manager 5.4.

RESULTS

A total of 1,780 participants from eight randomized controlled trials were included. These studies involved treatment with aromatase inhibitors only (n = 3) or aromatase inhibitors plus tamoxifen (n = 5). Telehealth interventions involved web-based interventions, telephone-based interventions, interventions via mobile applications, and interventions based on technology. In three studies, subjective measures were used, while objective measures were utilized in another three. Two studies incorporated a combination of both subjective and objective measures. The duration of the interventions varied among studies, ranging from a week to 36 months. The follow-up duration ranged from 4 weeks to 36 months. The quality of included studies was moderate to high. The meta-analysis of the five studies reporting dichotomous data showed that telehealth interventions had a significant effect on adherence to endocrine therapy (RR = 0.86, 95% CI = 0.76-0.97). Moreover, four studies reported continuous data. The meta-analysis demonstrated that telehealth interventions significantly improved adherence to endocrine therapy at 1 month (SMD = 0.50, 95% CI = 0.10-0.90), 3 months (SMD = 0.58, 95% CI = 0.17-0.99), and 6 months (SMD = 0.27, 95% CI = 0.08-0.47) of follow-up.

CONCLUSION

Telehealth interventions may facilitate adherence to endocrine therapy among patients with breast cancer. Further research should adopt a theory-based design and explore the longer-term effects.