Supportive interventions improve endocrine therapy adherence for breast cancer survivors
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For many breast cancer survivors, adjuvant endocrine therapy can substantially reduce the risk for recurrence.
Despite this fact, approximately 40% of patients discontinue these treatments early, and one third take them less often than indicated, according to past research.
“Treatment adherence, particularly adherence to medication that needs to be taken by the patient on their own at home, is one of the largest challenges — if not the largest challenge — in all of medicine,” Joanna Arch, PhD, professor in the department of psychology and neuroscience at the University of Colorado Boulder and member in cancer prevention and control at the University of Colorado Cancer Center, said in an interview with Healio. “Across all medications, adherence hovers at around 50%, with some better and some worse, depending on the regimen. So, this is not a problem that is unique to breast cancer.”
To better characterize this problem and its potential solutions, Arch and colleagues conducted a meta-analysis of intervention and policy changes to improve adherence to adjuvant endocrine therapies. Arch spoke with Healio about the study, which is published in Journal of Clinical Oncology.
Healio: Why is it important to improve adherence to adjuvant endocrine therapies?
Arch: What is striking about these medications is that they are very powerful, and women stand to gain a tremendous amount by taking them as prescribed. These medications reduce the risk for breast cancer recurrence by up to 50%. Women who take these medications live longer because recurrences are often metastatic. These truly are life-extending medications.
Healio: Why do so few women adhere to adjuvant endocrine therapy?
Arch: The most important reason is that these medications often come with myriad side effects that can affect a woman’s daily quality of life. The side effects depend on the individual and the type of antihormonal medication they are taking. However, they might include pronounced joint and muscle pain, sleep disruptions, issues with sexual functioning, mood disruption, depression and fatigue. These effects can make a woman feel older and more tired than she was prior to starting the medication.
The second reason is that for most women, these medications are not free. Cancer in the United States comes with tremendous financial toxicity for many people. Even with insurance, patients often have a copay for these medications, and they must be taken every day for 5 to 10 years. Without insurance, the cost is even higher.
The third reason is that women forget, just like anyone else. Taking a medication every day for 5 to 10 years is a lot to remember. Many women are just getting back into the swing of working full-time or caring for children or family members after cancer treatment. This treatment comes at a very busy time for many women.
The last reason is that we’ve heard from women that many of them simply don’t want to be reminded of cancer on a daily basis. This medication, for many women, signifies breast cancer. They want to be done with the treatment they’ve already undergone, and they don’t want to still be on cancer treatment for the next decade. It’s very understandable.
Healio: What are the potential effects of nonadherence to these medications?
Arch: Poor medication persistence — which means quitting early — and poor adherence, which means not taking it daily — are associated with substantial mortality costs. Lack of persistence and adherence are associated with up to a 49% increase in all-cause mortality.
Most people who don’t adhere aren’t necessarily going to die from that decision, because some forms of breast cancer have higher recurrence rates than others. However, it does increase future risks.
Adherence is particularly poor among our most economically vulnerable breast cancer survivors — those with low incomes. We know they have lower adherence rates than many higher-income women. We’re talking about a problem that potentially puts all breast cancer survivors at risk, but that risk differs by vulnerability status.
Healio: How did you go about conducting your study?
Arch: The National Cancer Institute and other funding bodies around the world have invested more research dollars into medication adherence problems in cancer over the last 5 to 10 years. This isn’t only because the data are out that this is a problem for antihormonal treatments, but also because an increasing number of primary targeted anticancer therapies are taken orally.
If you have a medication that’s infused, the doctor or nurse knows whether or not you showed up for your appointment. If you have a medication that you’re taking at home, nobody knows if you’ve taken it or not. There’s been a lot of interest in this area around the world, not just for antihormonal treatments, but for all oral anticancer treatments.
NCI funded us to conduct a clinical trial of a new intervention in this space. We also knew that there were no up-to-date reviews or meta-analyses in this burgeoning research area. So, we decided to conduct an up-to-date, systematic review and meta-analysis of all behavioral interventions and policy-level interventions to support breast cancer survivors in adhering to adjuvant endocrine therapy. We reviewed data on 375,951 women across 33 unique studies in the systematic review and slightly less than that — about 367,000 across 25 studies — in the meta-analysis. To our knowledge, ours was the first meta-analysis in this space to show statistically significant effects of these interventions that support breast cancer survivors in adhering to antihormonal medication.
Healio: What did your study find?
Arch: We found that, collectively, the policy-level, behavioral, psychological and medication reminder interventions across studies are exerting a positive effect on adherence. However, we found that that effect was relatively modest, which means we have a lot more work to do. Many existing interventions to support medication adherence in breast cancer survivors are promising, but now we need to make them even more powerful.
We also found that interventions that simply educate women about side effects and give them tips on how to handle them did not work, for the most part. It’s not enough to simply say, “There are numerous side effects that many women experience with these medications — this is what they are,” and offer some tips. It doesn’t seem sufficient to boost adherence.
What consistently does boost adherence is making medications more affordable, often through oral parity laws, which require that oral anticancer medications be reimbursed at the same rate as infused anticancer medications. It is ultimately these types of interventions that consistently worked to improve adherence.
Additionally, we found that adherence was boosted through interventions that increased women’s positive associations with the medication. Other promising interventions increased the sense that the medications were important, or reminded women to take them, or provided much more active help in managing side effects. These types of interventions connected women with physical therapist or other providers who could prescribe medications to counter side effects. Those types of interventions had promise, and many of them showed a positive effect. That’s very exciting.
Healio: What do you hope will be the long-term implications of your study?
Arch: I would love for cancer care clinics to offer specific supportive interventions for breast cancer survivors prescribed antihormonal therapies, and to not assume that because a prescription was written, it is being taken as prescribed.
I would also love to see insurance companies covering these supportive adherence interventions, because most of them are not very resource intensive. They aren’t very expensive, but they can make a big difference.
Lastly, I would love to see more research dollars invested in further improving these interventions and making them even more powerful.
Reference:
For more information:
Joanna Arch, PhD, can be reached at University of Colorado Boulder, Muenzinger Psychology, 345 UCB, Boulder, CO 80309-0345; email: joanna.arch@colorado.edu.
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