Study investigators note their meta-analysis may be the first to demonstrate the importance of interventions to support adherence to adjuvant endocrine therapy for breast cancer.
Health care providers may stand to benefit from the findings of a new systematic review and meta-analysis that show suboptimal adherence rates to adjuvant endocrine therapy (AET) for breast cancer, which highlights the need for tailored, evidence-based interventions that consider medication costs and the psychosocial effects of the cancer.
Findings were published recently in Journal of Clinical Oncology, with the key objective of uncovering effective interventions for promoting AET adherence among female patients living with breast cancer. The database search from October 2021 to November 2022 encompassed Medline, PsycINFO, and Embase; animal studies were excluded. Patients were considered adherent if they had an adherence rate of 80% of more—confirmed through prescription records, electronic monitoring, or self-report—and subgroup analyses covered study design, publication date, interventions that included interaction with cancer care providers/research teams, and policy interventions. Thirty-three studies were identified for the systematic review (15 randomized controlled trials [RCTs] and 18 non-RCTs), and 25 included in the meta-analysis.
“AETs are typically prescribed for 5-10 years; however, up to 40% of patients discontinue the medication early and 30% of patients take the medication less frequently than directed,” the study authors wrote. “Poor medication persistence and adherence have substantial mortality costs: AET nonadherence is associated with a 49% increase in all-cause mortality.”
Overall, data on the adherence rates of 375,951 survivors of breast cancer who had been prescribed AET were included in this analysis, and for the 25 studies covered by the meta-analysis, 367,873 survivors. Most of the studies (n = 21) covered patients taking any AET; 10, aromatase inhibitors (AIs); and 2, tamoxifen. Within the meta-analysis, 14 studies were about patients on any AET, 9 on AIs, and 2 on tamoxifen.
Fifteen studies examined early intervention in the course of AET treatment (at prescription initiation or within 1.5 years of adjuvant treatment start); 4, AET initiation; 15 studies, 0 to 5 years of treatment; and 1, tamoxifen treatment over 4 to 5 years among women who could then continue with letrozole. Two studies lacked data on length of AET.
The interventions investigated in this systematic review and meta-analysis most often targeted several adherence barriers simultaneously. They included education on medication necessity and importance and adverse effects of treatment; reminders through letters, text, mobile phone apps, calls, and smart pill caps; attempts to reduce negative attitudes toward AET; and reducing medication costs with oral parity legislation and generic medication substitution.
Within the meta-analysis, there were statistically significant effects in the intervention vs the control groups (odds ratio [OR], 1.412; 95% CI, 1.183-1.682; P = .0001); however, the non-RCT studies (k = 13; I2 = 97.1%) had greater heterogeneity vs the RCTs (k = 12; I2 = 34.9%). Also, for the studies that evaluated patient and oncology/research communication (bidirectional; OR, 1.574; 95% CI, 0.990-2.500) compared with 1-way communication (unidirectional; OR, 1.105; 95% CI, 0.8102-1.507; P = .214), there was no statistically significant difference in effect sizes.
A final subgroup analysis had the investigators evaluating difference between health system policy changes and nonpolicy interventions, and the former had greater heterogeneity (I2 = 99.4% vs 54.3%).
“Given that suboptimal AET adherence is common and is associated with breast cancer recurrence and mortality, there is a vital need for effective interventions to promote adherence,” the study authors emphasized, adding that research is increasingly recognizing this need, “with 18 new studies published since our previous meta-analysis in 2019.”
Along with their recommendation to better tailor interventions to target patient costs and the psychosocial effects of treatment to increase their efficacy, they note that a wide variety of interventions can be effective. Therefore, they also provided 5 recommended guidelines:
Reference
Bright EE, Finkelstein LB, Nealis MS, et al. A systematic review and meta-analysis of interventions to promote adjuvant endocrine therapy adherence among breast cancer survivors. J Clin Oncol. 2023;41(28):4548-4561. doi:10.1200/JCO.23.00697
Tackling Health Inequality: The Power of Education and Experience
April 30th 2024To help celebrate and recognize National Minority Health Month, we are bringing you a special month-long podcast series with our Strategic Alliance Partner, UPMC Health Plan. Welcome to our final episode of this limited series and our conversation with Janine Jelks-Seale, MSPPM, director of health equity at UPMC Health Plan.
Listen
USPSTF Lowers Age for Biennial Mammograms to 40, Citing Early Detection Benefit
April 30th 2024The USPSTF lowered the recommended starting age for mammograms from 50 to 40 years, citing moderate benefits for early detection in this age group. Disparities persist, especially for Black women, highlighting the need for improved access to health care and social support.
Read More
Examining Low-Value Cancer Care Trends Amidst the COVID-19 Pandemic
April 25th 2024On this episode of Managed Care Cast, we're talking with the authors of a study published in the April 2024 issue of The American Journal of Managed Care® about their findings on the rates of low-value cancer care services throughout the COVID-19 pandemic.
Listen
Medicaid, Medicare Policy Changes Could Lead to More Than 25,000 Additional Deaths, Study Says
April 30th 2024Researchers also estimated that more than 700,000 Americans with diabetes could lose insurance coverage if these proposed retractions are put into place, with some new policies already in effect.
Read More