Adherence to Long-term Adjuvant Hormonal Therapy for Breast Cancer

Carolyn Gotay; Julia Dunn


Expert Rev Pharmacoeconomics Outcomes Res. 2011;11(6):709-715. 

In This Article

Interventions to Increase Adherence

A number of reviews have identified potential avenues for interventions to improve adherence, including educational, behavioral, pharmacological and multidimensional approaches. Specific suggestions include greater involvement of oncology nurses,[33,34] counseling and education by healthcare providers, particularly physicians,[13,14,35] including ongoing assessment and attention to psychosocial factors and side effects,[33] and improving accessibility to healthcare and the dosing plan.[13,14]

Although not specific to tamoxifen or AIs, interventions to increase adherence for a variety of self-administered medications may be relevant. For example, education, psychological home support and training in pill taking increased the proportion of hematologic cancer patients achieving acceptable drug levels of allopurinal from 17 to 44–48%.[36] Although not in cancer patients, in a randomized trial in elderly men with at least four chronic medications, Lee et al. found impressive results for their intervention.[37] After 6 months of a program including medication education, pharmacist follow-up and special medication, the men were randomly assigned to receive either additional pharmacist monitoring or standard care; men who received standard care had compliance levels of 69%, compared with 96% in the pharmacist condition. This study suggests a potentially important role for the pharmacist in encouraging adherence to breast adjuvant treatments.

Other specific suggestions are that oncologists and/or primary care providers should ask patients whether the regimen is causing distress or side effects, and on a regular and ongoing basis. Discussing the importance of adherence may be beneficial, as it may prompt those with poor adherence to improve, and encourage those who are already adherent to continue.[13] Physicians may wish to recommend daily pill boxes or tricks (placing an individual pill on the bedside table) to increase adherence in those who find remembering to take their medication difficult. If possible, ongoing consultations with a pharmacist may prove beneficial, as well as providing patients with access to information about support groups and related resources they may not have been aware of or used. Perhaps most important is treating any side effects, mental or physical, that may be significantly interfering with the patient's quality of life, whether by pharmacological or nonpharmacological means. Interventions specific to various side effects have been developed and tested, and in a future paper, we will review interventions developed for hot flashes, the most common side effect of both tamoxifen and AIs.

Whether or not such interventions will increase adherence is not known. We could find only one study that specifically addressed increasing adherence to adjuvant hormonal treatment in breast cancer. Ell and colleagues randomly assigned 487 low-income, mostly Hispanic women to receive either written materials developed to enhance adherence, or written materials plus the services of a patient navigator who provided telephone or in-person counseling for up to 1 year.[38] There was no difference between the intervention conditions on the primary outcome variables, and while adherence to breast cancer adjuvant chemotherapy and radiation therapy was high in both groups (88% and higher), adherence to hormonal therapy was not striking, with only 59% adherent at 1 year. Still, the impact of patient navigators (perhaps trained cancer survivors) to provide personalized support specific to adherence might be further examined in future research. Other approaches, such as patient support groups, and online communities and blogs, remain to be explored. Virtually every paper listed in Table 1 & Table 2 concluded with the suggestion that effective interventions to enhance adherence were needed. This area of research is an urgent priority.


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