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Association between self-report adherence measures and oestrogen suppression among breast cancer survivors on aromatase inhibitors
lobular hyperplasia or LCIS), and the reported RR of 9 was actually very close to that established for LCIS (RR ¼ 8). Conversely, the lack of cancer events in women with atypical ductal hyperplasia may be attributed to the small sample size, but this raises the question of biological differences in the lobular and ductal phenotypes of high-risk lesions, their progression to cancer, and the relationship of these lesions with age. On the basis of these studies, one can confidently conclude that young women with high-risk lesions have a 6- to 8-fold increased risk of breast cancer, and this risk deserves increased attention. This risk highlights the need for further study in this
patient population to understand why patients younger than 35 years with atypical hyperplasia or LCIS may be at higher risk than older women with these same findings. The McEvoy and colleagues study expanded on a topic that needs ongoing investigation and captured an important point: young women with atypical hyperplasia or LCIS need close follow-up but do not always receive it, as shown by their 62% follow-up rate. There are no clear recommendations for follow-up in this subset of patients; such recommendations should be another focus of future work.
Association between self-report adherence measures and oestrogen suppression among breast cancer survivors on aromatase inhibitors
cer who were prescribed AI therapy. Participants self-reported AI adherence by completing the following: (1) a single item asking whether they took an AI in the last month, (2) a modified Morisky Medication Adherence Scale8 (MMAS-8) and (3) the Visual Analog Scale (VAS). Serum estrone and estradiol were analysed using organic solvent extraction and Celite column partition chromatography, followed by radioimmunoassay. Results.dTen percent of participants reported they had not taken an AI in the last month and among this group, median estrone (33.2 pg/ml [interquartile range (IQR) ¼ 22.3]) and estradiol levels (7.2 pg/mL [IQR ¼ 3.3]) were significantly higher than those in participants who reported AI use (median estrone ¼ 11.5 pg/mL [IQR ¼ 4.9]; median estradiol ¼ 3.4 pg/mL [IQR ¼ 2.1]; p < 0.001). This relationship held when controlling for race and AI drug type.
Brier MJ, Chambless D, Gross R, et al (Univ of Pennsylvania, Philadelphia; Univ of Pennsylvania, School of Medicine, Philadelphia; et al) Eur J Cancer 51:1890-1896, 2015
Purpose.dPoor adherence to oral adjuvant hormonal therapy for breast cancer is a common problem, but little is known about the relationship between self-report adherence measures and hormonal suppression. We evaluated the relationship of three self-report measures of medication adherence and oestrogen among patients on aromatase inhibitors (AIs). Materials and Methods.dWe recruited 235 women with breast can-
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References 1. Degnim AC, Visscher DW, Berman HK, et al. Stratification of breast cancer risk in women with atypia: a Mayo cohort study. J Clin Oncol. 2007;25:2671-2677. 2. King TA, Pilewskie M, Muhsen S, et al. Lobular carcinoma in situ: a 29year longitudinal experience evaluating clinicopathologic features and breast cancer risk. J Clin Oncol. 2015; http://dx.doi.org/10.1200/ JCO.2015.61.4743.
B. L. Murphy, MD A. C. Degnim, MD
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 1 2016
Conclusions.dA single-item monthly-recall adherence measure for AIs was associated with oestrogen serum levels. This suggests that patient-reported monthly adherence may be a useful measure to identify early non-adherence behaviour and guide interventions to improve patient adherence to hormonal treatment. My grandfather always used to say, “Ask the patient, not the doctor,” and of course, he was right. The emphasis on patient-reported outcomes and the repeated examples of the discordance between when doctors rate toxic effects (usually they underrate) and when patients self-report what they experience are well known and prove the point. This simple but powerful study by Brier and colleagues is another example. Non-adherence to AIs is a problem because the side effects of these drugs, primarily arthralgia and
vaginal dryness, are estimated to occur in as many as 30% of patients and may have a negative effect on mortality.1 In the Brier and colleagues study, 235 women on AIs were queried about adherence in 3 ways: (1) by 1 question (“Have you taken an AI in the last month?”), (2) by a self-reported adherence scale, and (3) by a visual analog scale. Around the same time, their total estrone and estradiol were measured. About 10% of the study population reported that they had not taken the AI during the past month. The measure showing the best correlation between non-adherence and higher estrogen levels, which is expected when women are not taking their AI, was the single, simple yes-or-no question. In my opinion, the major
study limitationdthat it was cross-sectional in design and was a prospective, longitudinal study to validate the 1 question as a measure of non-adherencedwas needed. Nonetheless, these data are consistent with other examples of single items, including a single-item quality-of-life question that predicts overall survival in lung cancer,2 other examples in quality of life,3 and an emotional burnout measure.4 So, a simple question is sometimes the best kind. C. L. Shapiro, MD
References 1. Hershman DL, Shao T, Kushi LH, et al. Early discontinuation and nonadherence to adjuvant hormonal
therapy are associated with increased mortality in women with breast cancer. Breast Cancer Res Treat. 2011;126:529-537. 2. Sloan JA, Zhao X, Novotny PJ, et al. Relationship between deficits in overall quality of life and non-smallcell lung cancer survival. J Clin Oncol. 2012;30:1498-1504. 3. Bush SH, Parsons HA, Palmer JL, Li Z, Chacko R, Bruera E. Singlevs. multiple-item instruments in the assessment of quality of life in patients with advanced cancer. J Pain Symptom Manage. 2010;39: 564-571. 4. West CP, Dyrbye LN, Satele DV, Sloan JA, Shanafelt TD. Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment. J Gen Intern Med. 2012; 27:1445-1452.
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 1 2016
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patient population to understand why patients younger than 35 years with atypical hyperplasia or LCIS may be at higher risk than older women with these same findings. The McEvoy and colleagues study expanded on a topic that needs ongoing investigation and captured an important point: young women with atypical hyperplasia or LCIS need close follow-up but do not always receive it, as shown by their 62% follow-up rate. There are no clear recommendations for follow-up in this subset of patients; such recommendations should be another focus of future work.
Association between self-report adherence measures and oestrogen suppression among breast cancer survivors on aromatase inhibitors
cer who were prescribed AI therapy. Participants self-reported AI adherence by completing the following: (1) a single item asking whether they took an AI in the last month, (2) a modified Morisky Medication Adherence Scale8 (MMAS-8) and (3) the Visual Analog Scale (VAS). Serum estrone and estradiol were analysed using organic solvent extraction and Celite column partition chromatography, followed by radioimmunoassay. Results.dTen percent of participants reported they had not taken an AI in the last month and among this group, median estrone (33.2 pg/ml [interquartile range (IQR) ¼ 22.3]) and estradiol levels (7.2 pg/mL [IQR ¼ 3.3]) were significantly higher than those in participants who reported AI use (median estrone ¼ 11.5 pg/mL [IQR ¼ 4.9]; median estradiol ¼ 3.4 pg/mL [IQR ¼ 2.1]; p < 0.001). This relationship held when controlling for race and AI drug type.
Brier MJ, Chambless D, Gross R, et al (Univ of Pennsylvania, Philadelphia; Univ of Pennsylvania, School of Medicine, Philadelphia; et al) Eur J Cancer 51:1890-1896, 2015
Purpose.dPoor adherence to oral adjuvant hormonal therapy for breast cancer is a common problem, but little is known about the relationship between self-report adherence measures and hormonal suppression. We evaluated the relationship of three self-report measures of medication adherence and oestrogen among patients on aromatase inhibitors (AIs). Materials and Methods.dWe recruited 235 women with breast can-
82
References 1. Degnim AC, Visscher DW, Berman HK, et al. Stratification of breast cancer risk in women with atypia: a Mayo cohort study. J Clin Oncol. 2007;25:2671-2677. 2. King TA, Pilewskie M, Muhsen S, et al. Lobular carcinoma in situ: a 29year longitudinal experience evaluating clinicopathologic features and breast cancer risk. J Clin Oncol. 2015; http://dx.doi.org/10.1200/ JCO.2015.61.4743.
B. L. Murphy, MD A. C. Degnim, MD
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 1 2016
Conclusions.dA single-item monthly-recall adherence measure for AIs was associated with oestrogen serum levels. This suggests that patient-reported monthly adherence may be a useful measure to identify early non-adherence behaviour and guide interventions to improve patient adherence to hormonal treatment. My grandfather always used to say, “Ask the patient, not the doctor,” and of course, he was right. The emphasis on patient-reported outcomes and the repeated examples of the discordance between when doctors rate toxic effects (usually they underrate) and when patients self-report what they experience are well known and prove the point. This simple but powerful study by Brier and colleagues is another example. Non-adherence to AIs is a problem because the side effects of these drugs, primarily arthralgia and
vaginal dryness, are estimated to occur in as many as 30% of patients and may have a negative effect on mortality.1 In the Brier and colleagues study, 235 women on AIs were queried about adherence in 3 ways: (1) by 1 question (“Have you taken an AI in the last month?”), (2) by a self-reported adherence scale, and (3) by a visual analog scale. Around the same time, their total estrone and estradiol were measured. About 10% of the study population reported that they had not taken the AI during the past month. The measure showing the best correlation between non-adherence and higher estrogen levels, which is expected when women are not taking their AI, was the single, simple yes-or-no question. In my opinion, the major
study limitationdthat it was cross-sectional in design and was a prospective, longitudinal study to validate the 1 question as a measure of non-adherencedwas needed. Nonetheless, these data are consistent with other examples of single items, including a single-item quality-of-life question that predicts overall survival in lung cancer,2 other examples in quality of life,3 and an emotional burnout measure.4 So, a simple question is sometimes the best kind. C. L. Shapiro, MD
References 1. Hershman DL, Shao T, Kushi LH, et al. Early discontinuation and nonadherence to adjuvant hormonal
therapy are associated with increased mortality in women with breast cancer. Breast Cancer Res Treat. 2011;126:529-537. 2. Sloan JA, Zhao X, Novotny PJ, et al. Relationship between deficits in overall quality of life and non-smallcell lung cancer survival. J Clin Oncol. 2012;30:1498-1504. 3. Bush SH, Parsons HA, Palmer JL, Li Z, Chacko R, Bruera E. Singlevs. multiple-item instruments in the assessment of quality of life in patients with advanced cancer. J Pain Symptom Manage. 2010;39: 564-571. 4. West CP, Dyrbye LN, Satele DV, Sloan JA, Shanafelt TD. Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment. J Gen Intern Med. 2012; 27:1445-1452.
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 1 2016
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