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EBC: Strategies for Adherence
Strategies to Maintain Adherence and Persistence to Oral Therapies in Early Breast Cancer

Released: April 13, 2023

Reshma Mahtani
Reshma Mahtani, DO
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Key Takeaways
  • Despite the preference for oral anticancer medications over IV therapies, nonadherence and nonpersistence to oral therapies remain challenges, with barriers that are multifactorial.
  • Reduced adherence and persistence is directly linked to worse outcomes in early breast cancer.
  • Interventions that have been shown to improve adherence and persistence include shared decision-making, motivational interviewing, optimizing patient education, and using a multidisciplinary team approach to care.

On March 3, 2023, the FDA approved abemaciclib in combination with endocrine therapy for the adjuvant treatment of adults with hormone receptor‒positive/HER2-negative, node-positive early breast cancer at high risk of recurrence. The previous approval for abemaciclib included the same high-risk population, but with the additional requirement of a Ki-67 score 20%. The updated approval was based on statistically significant and clinically relevant improvements in invasive disease‒free survival and distant relapse‒free survival from the randomized phase III monarchE study of endocrine therapy ± abemaciclib. With the removal of the Ki-67 testing requirement and the availability of data with longer-term follow-up, a significant number of patients will be offered adjuvant abemaciclib for 2 years. Educating patients regarding the efficacy and benefits of the medication, managing toxicities appropriately, and identifying and addressing barriers to use are imperative. Although oral anticancer therapies have been shown to be effective, their full benefits often are not realized because of medication nonadherence and nonpersistence.

Barriers to Adherence and Persistence With Oral Therapies
Medication adherence is defined as the extent to which a patient acts in accordance with the prescribed interval and dose of a medication regimen. Nonadherence can be intentional (an active process in which the patient decides to forgo the prescribed therapy) or unintentional (a passive process related to forgetfulness, carelessness, or circumstances beyond the patient’s control). Medication persistence is defined as the duration of time from initiation to discontinuation of therapy. Addressing barriers to adherence and persistence with oral therapies is crucial, as these are directly linked to increased morbidity and mortality.

Various factors can contribute to adherence issues. Patient-reported barriers include age, access to medication, education, inadequate social support, and personal beliefs. Factors specific to the medication include adverse events (AEs), pill burden, dosing frequency, and the frequency of assessment/monitoring visits. Another critical factor is trust in the prescribing healthcare professional (HCP), which correlates significantly with the strength of patient‒HCP communication. Finally, the presence of other conditions—such as depression, anxiety, history of mental illness, and prior noncompliance—also is a contributory factor. Factors contributing to adherence also exist for the prescribing HCP, including time and resource constraints, difficulty identifying related AEs, and a lack of knowledge of alternative treatments.

Interventions for Increasing Adherence and Persistence
Shared decision-making involves the bilateral flow of information, in which HCPs convey relevant disease-related information and education on identification and management of AEs while patients contribute their thoughts and values. Shared decision-making is linked to care quality and has been shown to increase patient satisfaction and commitment to the treatment course via education surrounding the connection between AE management and adherence to therapy.

Motivational interviewing also has been shown to be an effective method to improve adherence and persistence. In these sessions, the patient’s internal motivation for behavior change is assessed in a patient-centered, nonjudgmental, and empathic manner. These sessions allow barriers to be identified and addressed (eg, medication access issues and socioeconomic factors). Other members of the multidisciplinary healthcare team—such as advanced practice providers, social workers, pharmacists, and nurse navigators—can be very helpful in mitigating these barriers.

Downloadable Patient Resource: AE Overview and Strategies for Adherence
Patient education on AE management and the importance of adherence to therapy is crucial. CCO’s downloadable patient resource is a valuable tool for educating patients about questions they should ask their healthcare team after diagnosis and during therapy planning, as well as what to expect for possible AEs associated with endocrine therapies and abemaciclib. The resource provides advice on when to call an HCP and practical tips to follow to improve adherence and persistence. 

In my practice, I often employ shared decision-making and motivational interviewing in patient care. I have found these to be effective strategies in developing a treatment plan that results in improved patient education and awareness regarding the risks and benefits of treatment, as well as a better understanding of AE management. Taking care of patients involves a team approach, and the importance of the multidisciplinary team cannot be overstated. Downloadable and easily accessible resources with summarized information that can be provided to patients have been valuable tools for improving adherence and persistence in my patients.

Your Thoughts?
What methods do you use to improve patient adherence to oral therapy in your clinical practice? Answer the polling question below and join the conversation in the discussion box.

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In your practice, which of the following methods do you use to educate patients and improve adherence to oral therapies for breast cancer?

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