How to improve compliance with Breast Cancer Hormonal Therapy?
Joan had been taking a pill to reduce her risk for a recurrence of her Breast Cancer for the last 3 years. She had gotten through the initial phase of side effects with some difficulty, but the hot flashes had diminished, and she had avoided weight gain with greater attention to her diet and exercise habits. She now called the office with complaints of new onset of nausea and insisted it was her medication, and she wanted to discontinue it. It was unlikely that the nausea was due to her breast cancer pill, but we agreed to discontinue the medication, and let the medicine wash out of her system over several weeks. Her symptoms did not change, and she agreed to go back on the medication. She had failed to tell us that she had pulled a muscle in her back and had been taking anti-inflammatory medication for several months, and had developed gastritis. She went on an acid reducing pill and the nausea subsided. She went on to complete her full course of treatment and remains cancer free.
Most Hormone receptor positive Breast Cancer patients are put on long-term hormonal therapy to decrease their recurrence risk. Updated guidelines recommend 5-10 years of oral medications: Tamoxifen followed by Aromatase Inhibitors (AI), or AIs alone, have been shown to lower the risk of breast cancer recurrence by 40 %. Breast cancer patients have been considered a highly motivated population. However, treatment only works if patients take the prescribed medication, and it is also known that the drop out rate is in the range of 31-73 %.
In my practice, I have not been struck by such a widespread discontinuation rate, but studies have shown consistently that there is a high rate of non-adherence.
What issues drive women to stop taking a curative treatment?
Most commonly, it is due to side effects. These are Hot flashes, joint pains, night sweats, vaginal dryness or discharge, which can be attributed to the medications. Other symptoms can be mis-attributed to therapy, like headaches, diarrhea, or abdominal pain. There can be underlying anxiety about the length of treatment, or depression. Or, patients may not believe that the treatment is actually helping, and stop taking it. Paradoxically, patients with a genetic family history of breast or ovarian cancer have been found to be less compliant, as they may believe that the treatment is not going to work in the end. Financial issues can be a burden with copays. All of these can lead to the patient being less than fully adherent or stopping the medication.
Discontinuation of the prescribed therapy is likely to result in significantly worse outcomes for patients with breast cancer. We need to figure out how to improve adherence rates.
How do we identify who is at risk for stopping treatment, and how do we help them through this?
A new Swedish study published in the Journal of Clinical Oncology identified that rate of discontinuation approached 54 % by year 5. While we might expect that proactive use of symptom reducing medication might improve adherence to therapy, in fact use of symptom reducing medications was associated with a higher rate of discontinuation of therapy. Other predictors of discontinuation were sleep disorders, Gastro Intestinal disorders, younger and older ages, and prior use of hormonal therapy.
Since most women stopped taking the drug after the first year of treatment, we have this window of opportunity to identify patients at higher risk of discontinuing the prescribed medication. And since using additional symptom reducing medications actually predicted for more non-adherences, we need to do something else.
That might include proper education before starting treatment, with adequate anticipation of side effects. Strategies to manage hot flashes should be discussed. They should be encouraged to continue an exercise program, which will help with bone and joint pains and overall quality of life scores. Adequate counseling and psychosocial support will help with anxiety and depression. Management of other medical conditions, like sleep apnea, diabetes and hypertension and Gastrointestinal disorders should prevent exacerbation of symptoms which might be misattributed to the Breast Cancer medication.
As the guidelines are now recommending extension of hormonal intervention, it becomes more important that we reduce the drop out rate.
REF:
Predictors of Discontinuation of Adjuvant Hormone Therapy in Patients With Breast CancerWei He, Fang Fang, Catherine Varnum, Mikael Eriksson, Per Hall, and Kamila Czene
J Clin Oncol 33. © 2015 by American Society of Clinical Oncology
The Oncologist 2015;20;598-604: Partridge et al