A Systematic Review and Meta-Analysis of Interventions to Promote Adjuvant Endocrine Therapy Adherence Among Breast Cancer Survivors

Abstract

PURPOSE Adjuvant endocrine therapy (AET) adherence among breast cancer survivors is often suboptimal, leading to higher cancer recurrence and mortality. Intervention studies to promote AET adherence have burgeoned, more than doubling in number since this literature was last reviewed. The current aim is to provide an up-to-date systematic review and meta-analysis of interventions to enhance AET adherence and to identify strengths and limitations of existing interventions to inform future research and clinical care. METHODS Systematic searches were conducted in three electronic databases. Studies were included in the systematic review if they examined an intervention for promoting AET adherence among breast cancer survivors. Studies were further included in the meta-analyses if they examined a measure of AET adherence (defined as compliance or persistence beyond initiation) and reported (or provided upon request) sufficient information to calculate an effect size. RESULTS Of 5,045 unique records, 33 unique studies representing 375,951 women met inclusion criteria for the systematic review. Interventions that educated patients about how to manage side effects generally failed to improve AET adherence, whereas policy changes that lowered AET costs consistently improved adherence. Medication reminders, communication, and psychological/coping strategies showed varied efficacy. Of the 33 studies that met the inclusion criteria for the systematic review, 25 studies representing 367,873 women met inclusion criteria for the meta-analysis. The meta-analysis showed statistically significant effects of the adherence interventions overall relative to study-specified control conditions (number of studies [k] = 25; odds ratio, 1.412; 95% CI, 1.183 to 1.682; P = .0001). Subgroup analyses showed that there were no statistically significant differences in effect sizes by study design (randomized controlled trial v other), publication year, directionality of the intervention (unidirectional v bidirectional contact), or intervention type. CONCLUSION To our knowledge, this is the first known meta-analysis to demonstrate a significant effect for interventions to promote AET adherence. The systematic review revealed that lowering medication costs and a subgroup of psychosocial and reminder interventions showed the most promise, informing future research, policy, and clinical directions.

Clinical factors associated with patterns of endocrine therapy adherence in premenopausal breast cancer patients

“…Specific medications that appeared to increase the risk of declining adherence included psycholeptics, psychoanaleptics, and analgesics. In a recent systematic review of AET adherence interventions, some approaches, such as psychosocial and reminder interventions, had some promise in promoting adherence [ 36 ]. However, the authors concluded that more powerful approaches would be needed to improve efficacy [ 36 ].…”

“…In a recent systematic review of AET adherence interventions, some approaches, such as psychosocial and reminder interventions, had some promise in promoting adherence [ 36 ]. However, the authors concluded that more powerful approaches would be needed to improve efficacy [ 36 ]. Our study provides further evidence of the subgroups of women who may benefit the most from these types of interventions.…”

Developing questions to assess and measure patients’ perceived survival benefit from adjuvant endocrine therapy in breast cancer: a mixed methods pilot study

“…The problem is that there are significant knowledge gaps in this area as we do not yet have an effective educational intervention for teaching patients about adjuvant endocrine therapy, we do not know if an educational intervention will improve adherence as this research is limited and thus outcomes are not known [ 57 ]. Other interventions to improve adherence of adjuvant endocrine therapy have had modest success and thus improving adherence in this patient population is possible and thus worth pursing [ 58 ]. Research is needed to develop an easy to implement adjuvant endocrine therapy educational intervention that would improve adherence and outcomes.…”

A pilot randomised controlled trial of acceptance and commitment therapy for medication decision‐making and quality of life in women with breast cancer: The ACTION trial

“…3,[10][11][12] These interventions often focus on educating women about AET. 13 Education may be essential, but insufficient by itself in helping women navigate the broader emotional and psychological challenges that occur with side-effects which undermine adherence. AET side effects may present tangible and distressing reminders of cancer, at a time when women are expecting to return to the life they experienced before diagnosis.…”

“…Existing interventions for supporting adherence to AET are mostly ineffective 3,10–12 . These interventions often focus on educating women about AET 13 . Education may be essential, but insufficient by itself in helping women navigate the broader emotional and psychological challenges that occur with side‐effects which undermine adherence.…”