50% of early breast cancer patients did not complete their current adjuvant treatment.¹ It's time to talk.
ScrollRETHINKING COMMUNICATION
Let's close the patient knowledge gap
Finding the right time to discuss breast cancer recurrence and the need for adjuvant treatment with your patients can be difficult. The nature and volume of this information can be overwhelming for patients to hear; however it is crucial they continue their journey with as much information as possible about potential outcomes, treatment decisions and side effects. A European survey of 547 post-menopausal women with early breast cancer showed:
of patients were not involved in the decision to start adjuvant treatment2
received information about possible side effects2
received information about the possible long-term effects of treatment2
received information about the risk of their cancer returning2
Miscommunication can have a negative effect on patient outcomes
A recent survey of oncologists, oncology nurses and HR+/HER2- patients showed that:*
56 %
of patients said their nurse never asks about quality of life during follow-up appointments
Despite 92% of nurses believing the topic is addressed7
34 %
of patients said their oncologist never asks about quality of life during follow-up appointments
However, 88% of oncologists believe this topic is addressed7
There is a need to address this patient knowledge gap and improve communication between healthcare professionals and patients, ensuring patients remain informed at every stage of their journey to reduce the risk of their breast cancer returning.
CRUCIAL TOPICS TO COVER
Conversations with your patients
Each appointment with your breast cancer patients should cover, or reiterate, their risk of recurrence and the importance of adhering to their adjuvant treatment.
It has been widely demonstrated that patient–physician communication plays a primary role in adherence to any medical treatment.4
Read on below for important topics of discussion which could benefit your patients:
AGE5
GRADE5
NODAL INVOLVEMENT5
HORMONE RECEPTOR STATUS5
TREATMENT OF THE PRIMARY TUMOUR5
Factors associated with later recurrence**
In a study from Pedersen et al. (2021), recurrences continued to occur up to 32 years after primary diagnosis. Women with high lymph node burden, large tumour size, and oestrogen receptor–positive tumours had increased risk of late recurrence.6 It is apparent that as the number of nodes that are involved increases, so too does the risk of recurrence. However, it ought to be noted that patients with N0 are also at risk of recurrence and this risk persists, continuing to increase, for many years after initial diagnosis or surgery.
The cumulative incidence 10-25 years after diagnosis increased with increasing lymph node involvement at baseline, ranging from 12.7% (95% CI = 11.9% to 13.5%) in patients with T1N0 to 24.6% (95% CI = 20.7% to 28.6%) for patients with T2N4-9 disease.6
CONVERSATION TOPIC
Nonadherence and treatment discontinuation
Low adherence to adjuvant endocrine therapy is linked with higher rates of recurrence and all-cause mortality.8
The following negative clinical effects of low and non-adherence have been demonstrated in most breast cancer studies.9
- Increased risk of distant metastases
- Increased risk of breast cancer recurrence
- Decreased disease-free survival
- Increased risk of mortality
As a healthcare provider, it has been recognised that you can have a significant effect on your patients’ adherence by delivering interventions where necessary.1
Factors affecting adherence to adjuvant therapy1
Patient-related, therapy-related, or health care system–associated factors may affect adherence and non-adherence is usually a result of a combination of these factors.
To identify patients who are likely to be non-adherent and who may benefit from more careful monitoring and support, recognition of the factors associated with lower adherence is important. Consider how as a healthcare professional, you can address these factors to improve patient adherence to therapy:
Healthcare provider-related factors1
- Importance of adherence may not be emphasised
- Potential difficulties of long-term adherence may not be discussed
- Lack of patient support in dealing with side effects
- Patient may not be satisfied with health care provider
Patient-related factors1
- Remembering to take medication (older and younger age groups associated with non-adherence)
- Poor awareness of therapeutic benefit
- Inconvenience
- Difficulty swallowing pills
- Depression
- Antidepressant use
- Mastectomy
- Lack of belief in treatment
Treatment-related factors1
- Drug adverse effects
- Side effects may be underestimated by physician
- Unexpected effects associated with non-adherence
CONVERSATION TOPIC
Side effects of treatment
Side effects of adjuvant treatment can contribute to a patient’s decision to cease their medication, particularly if the patient is unprepared for the severity of the side effects or if they have not been educated on how best to manage them.
In a study of 881 women on adjuvant tamoxifen, adherence was significantly lower among women who experienced side effects about which they had not been informed in advance than among women who had been informed about possible side effects (62% vs. 85%, p < 0.0001).11 Physicians may underestimate side effects or may selectively mention only side effects for which they are likely to see difficulties.1
Also, if symptoms related to the underlying disease are absent and if the patient perceives that the medication may no longer be necessary or that the perceived benefits no longer outweigh the side effects and risks experienced, then the patient may make a conscious decision not to follow the physician’s recommendation in the long term.11
CONVERSATION TOPIC
Quality of Life on treatment
A recent study showed that 1/3 of patients said their oncologist never ask about their quality of life at follow-up appointments.7 Keeping up with how your patients are feeling while on their treatment, making suggestions on how to ease the side effects and reaffirming the benefits of adjuvant therapy can help your patients understand the need to adhere to treatment.7
It has been recommended that, in order to enhance HCP-patient communication, quality of life should be regularly and formally assessed with validated, early breast cancer-specific quality of life questionnaires that closely monitor treatment side effects.7
Perceptions of quality of life often differ between patients and healthcare professionals.7 For example, a patient may think getting out of bed with a headache each day amounts to a poor quality of life, whereas HCPs might consider that to be good on a clinical scale. Open conversations with your patients can help to discern what they look for in an acceptable quality of life while undergoing treatment. This will also allow your patients to understand what you would consider an acceptable quality of life.
Closing the patient knowledge gap: communicating the risk of recurrence
It’s important that you and your patients are aligned on the goals of treatment, potential side effects and their impact on quality of life so that your patients adhere to treatment, reducing their risk of recurrence.
External resources:
For healthcare professionals:
One Education – Develop your soft skills
The development of soft skills is vital in healthcare. These skills can help to set patients’ minds at ease, as well as help manage HCP stress and burnout.
Cancer Research UK - Health professionals resources
Access Cancer Research UK’s evidence-based information, tools and resources to support you in delivering best practice in prevention and early diagnosis.
Cancer Focus – Cancer conversations course
An e-learning module to help healthcare professionals empower parents to communicate with their children about their cancer. You will need to register.
Breast Cancer Now
Visit Breast Cancer Now’s website for helpful resources, research updates, evidence-based information and support tools tailored for healthcare professionals. Stay up to date with the latest advancements and enhance your breast cancer care expertise to better support your patients.
For patients:
Macmillan Cancer Support – Support for your patients
Information about treatment, money, mental health and more, this guide can help you in the support of your breast cancer patients.
OWise – The patient breast cancer app
OWise supports patients from their first diagnosis. It provides safe and reliable information while collating valuable insights about their day-to-day wellbeing to assist healthcare professionals in making informed decisions about ongoing treatment.
Footnotes:
*Data were collected between July 2020 and May 2021 via a cross-sectional international online survey of 277 oncologists, 225 oncology nurses and 467 patients with HR+/HER2− advanced breast cancer.
**Recurrence is considered ‘late’ when it recurs 10-32 years from the primary breast cancer diagnosis.
References
- Verma S, Madarnas Y, Sehdev S, Martin G, Bajcar J. Patient adherence to aromatase inhibitor treatment in the adjuvant setting. Curr Oncol. 2011 May;18 Suppl 1(Suppl 1):S3-9. doi: 10.3747/co.v18i0.899. PMID: 21698059; PMCID: PMC3119895. [Last accessed: February 2024]
- Yvonne Wengström, Matti Aapro, Susanna Leto di Priolo, Helena Cannon, Vasoulla Georgiou, Patients’ knowledge and experience of adjuvant endocrine therapy for early breast cancer: A European study, The Breast, Volume 16, Issue 5, 2007, Pages 462-468, ISSN 0960-9776, https://doi.org/10.1016/j.breast.2007.02.007. [Last accessed: February 2024]
- BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4085 (Published 12 June 2012) [Last accessed: February 2024]
- Rosso R, D'Alonzo M, Bounous VE, Actis S, Cipullo I, Salerno E, Biglia N. Adherence to Adjuvant Endocrine Therapy in Breast Cancer Patients. Curr Oncol. 2023 Jan 21;30(2):1461-1472. doi: 10.3390/curroncol30020112. PMID: 36826073; PMCID: PMC9955792. [Last accessed: February 2024]
- Witteveen A, Vliegen IMH, Sonke GS et al (2015) Personalisation of breast cancer follow-up: a time-dependent prognostic nomogram for the estimation of annual risk of locoregional recurrence in early breast cancer patients. Breast Cancer Res Treat 152:627–636. doi:10.1007/s10549-015-3490-4 [Last accessed: February 2024]
- Rikke Nørgaard Pedersen, Buket Öztürk Esen, Lene Mellemkjær, Peer Christiansen, Bent Ejlertsen, Timothy Lee Lash, Mette Nørgaard, Deirdre Cronin-Fenton, The Incidence of Breast Cancer Recurrence 10-32 Years After Primary Diagnosis, JNCI: Journal of the National Cancer Institute, Volume 114, Issue 3, March 2022, Pages 391–399, https://doi.org/10.1093/jnci/djab202 [Last accessed: February 2024]
- Fatima Cardoso, Julie Rihani, Victoria Harmer, Nadia Harbeck, Ana Casas, Hope S Rugo, Peter A Fasching, Adam Moore, Joanna de Courcy, Purnima Pathak, Sina Haftchenary, Dawn Aubel, Eva Schumacher-Wulf, Quality of Life and Treatment-Related Side Effects in Patients With HR+/HER2− Advanced Breast Cancer: Findings From a Multicountry Survey, The Oncologist, Volume 28, Issue 10, October 2023, Pages 856–865, https://doi.org/10.1093/oncolo/oyad207 [Last accessed: February 2024]
- Smith SG, Green SMC, Ellison R, et al Refining and optimising a behavioural intervention to support endocrine therapy adherence (ROSETA) in UK women with breast cancer: protocol for a pilot fractional factorial trial BMJ Open 2023;13:e069971. doi: 10.1136/bmjopen-2022-069971 [Last accessed: February 2024]
- Inotai A, Ágh T, Maris R, et al. Systematic review of real-world studies evaluating the impact of medication non-adherence to endocrine therapies on hard clinical endpoints in patients with non-metastatic breast cancer. Cancer Treat Rev. 2021;100: 102264. doi: 10.1016/j.ctrv.2021.102264. [Last accessed: February 2024]
- Chirgwin JH, Giobbie-Hurder A, Coates AS, et al. Treatment Adherence and Its Impact on Disease-Free Survival in the Breast International Group 1-98 Trial of Tamoxifen and Letrozole, Alone and in Sequence. J Clin Oncol. 2016;34(21): 2452-9. doi: 10.1200/JCO.2015.63.8619. [Last accessed: February 2024]
- Fallowfield L. Acceptance of adjuvant therapy and quality of life issues. Breast. 2005;14:612–16. doi: 10.1016/j.breast.2005.08.012. [Last accessed: February 2024]