Around 90% of breast cancer patients are diagnosed at an early stage and approximately 70%, are hormone receptor-positive and HER2-negative (HR+/HER2-). Despite advancements in adjuvant endocrine therapy, 20-30 % of early-stage BC patients relapse within the first decade post-surgery. Recent clinically meaningful therapeutic option for these patients has been cyclin-dependent kinases 4/6 inhibitors (CDK4/6 inhibitors). Abemaciclib and ribociclib, were assessed in the adjuvant setting, both showing improvement in IDFS. Abemaciclib has been approved by the FDA and EMA for HR+/HER2- early breast cancer at high risk of disease recurrence and is the first addition to Slovenian treatment regimen in routine clinical practice. Poor medication adherence can directly affect the effectiveness of treatment for early HR+/HER2- breast cancer. While adherence data in patients treated with aromatase inhibitors are available, the adherence rate in patients with early HR+/HER2- breast cancer taking abemaciclib is unclear. In this study, investigators hypothesize that patients receiving abemaciclib in combination with aromatase inhibitors will have a lower medication adherence and higher discontinuation rate compared to those receiving aromatase inhibitors alone. It is expected that patient with better quality of life, cognitive functioning and more positive attitude towards their therapy will demonstrate higher medication adherence rate. Adherence rate will also be affected by other factors, such as age and prior treatments.
Breast cancer (BC) is the most prevalent malignant tumour in women, with an estimated 2.308 million new cases and over 665,000 deaths globally in 2022. Around 90% of patients are diagnosed at an early stage and the majority of these cases, approximately 70%, are hormone receptor-positive and HER2-negative (HR+/HER2-). Despite advancements in adjuvant endocrine therapy that significantly lower recurrence and mortality rates, 20-30 % of early-stage BC patients experience relapse within the first decade post-surgery. Around 12% of patients with HR+/HER2- BC belong to high-risk population with 5-years invasive disease-free survival (IDFS) of 70.2% vs 90.0% in non-high-risk. The most recent clinically meaningful therapeutic option for these patients has been cyclin-dependent kinases 4/6 inhibitors (CDK4/6 inhibitors). Endocrine therapy combined with CDK4/6 inhibitors (abemaciclib, palbociclib, and ribociclib) is now the standard, most effective, and recommended treatment for these patients in the first or subsequent lines of treatment for advanced disease. Two CDK4/6 inhibitors, abemaciclib and ribociclib, have been assessed also for use in the adjuvant setting (MonarchE and NATALEE study). Both studies showed improvement in IDFS of combined endocrine therapy and CDK4/6 inhibitor vs endocrine therapy alone. Abemaciclib has been approved by both the FDA and EMA for patients with HR+/HER2- early breast cancer at high risk of disease recurrence and has therefore recently been added to Slovenian current regimen for this indication in routine clinical practice. Non-adherence to adjuvant therapy may compromise the efficacy of combined treatment in preventing disease recurrence and mortality. Some historical data report that only 60-70% of patients with early BC adhere to adjuvant therapy, making adherence a significant challenge. Key factors influencing adherence to cancer treatment include the perceived benefits of the treatment, the setting in which the treatment is administered (at home or in a hospital), the associated risks, the impact on quality of life, and the costs involved. Non-adherence often arises because patients do not experience the immediate benefits. With no visible or measurable signs of the disease and no physical symptoms of the disease, as is the case in patients receiving adjuvant treatment, and given that many would not have experienced a relapse even without adjuvant therapy, patients are much more likely to discontinue treatment if they experience adverse events/reactions (AE). Adherence to treatment with CDK4/6 inhibitors in combination with aromatase inhibitors differs from some other systemic treatments due to the continuous treatment regimen that lasts for several years without interruption. In early BC, it lasts two (abemaciclib) or three (ribociclib) years and is associated with some specific AEs. Aromatase inhibitors are associated with arthralgias, myalgias, and joint stiffness, whereas CDK4/6 inhibitors with myelotoxicity, hepatotoxicity and gastrointestinal symptoms (especially diarrhoea caused by abemaciclib). The duration of treatment, five or more vs two years (aromatase inhibitors as monotherapy vs abemaciclib in combination with aromatase inhibitors, respectively), may lead to different discontinuation rates. Despite the growing amount of real-world experiences with combined treatment with aromatase inhibitors and abemaciclib in the adjuvant setting, there is currently a lack of literature specifically exploring how patient adherence and attitudes are influenced by this combination. This gap underscores the need for further research to fully understand the impact of these therapies on medication adherence. Poor medication adherence can directly affect the effectiveness of treatment for early HR+/HER2- breast cancer. While data on medication adherence in patients taking aromatase inhibitors are available, the adherence rate in patients with early HR+/HER2- breast cancer taking abemaciclib remains unclear. Due to the differing characteristics of these treatment modalities, particularly their distinct safety profiles, medication adherence and persistence may vary between them. It is hypothesized that patients receiving abemaciclib in combination with aromatase inhibitors will have a lower medication adherence and higher discontinuation rate compared to those receiving aromatase inhibitors alone. It's also expected that patient with better quality of life, better cognitive functioning and more positive attitude towards their therapy will demonstrate higher medication adherence rate. Additionally, it's anticipated that other factors, such as age and prior treatments, will also contribute to adherence rates.
Study Type
OBSERVATIONAL
Enrollment
319
Medication adherence in proportion of days covered (PDC)
The primary aim of this study is to determine medication adherence among HR+/HER2- early BC patients undergoing adjuvant therapy with aromatase inhibitors, either alone or in combination with abemaciclib. Medication adherence will be assessed using a combination of Medication Adherence Report Scale (MARS-5), "missed dose" questions and pill count data expressed in Proportion of Days Covered (PDC). MARS-5 scale is a self-reported questionnaire scaling from 1-5 (1=always forget, to 5=never forget) addressing non-adherence behaviors, where higher scores indicate better adherence (25 points suggests full adherence). Those with a PDC of 80% or higher will be classified as adherent, while those with a PDC below 80% will be classified as non-adherent.
Time frame: Month 3 after starting dose
Medication adherence in proportion of days covered (PDC)
The primary aim of this study is to determine medication adherence among HR+/HER2- early BC patients undergoing adjuvant therapy with aromatase inhibitors, either alone or in combination with abemaciclib. Medication adherence will be assessed using a combination of Medication Adherence Report Scale (MARS-5), "missed dose" questions and pill count data expressed in Proportion of Days Covered (PDC). MARS-5 scale is a self-reported questionnaire scaling from 1-5 (1=always forget, to 5=never forget) addressing non-adherence behaviors, where higher scores indicate better adherence (25 points suggests full adherence). Those with a PDC of 80% or higher will be classified as adherent, while those with a PDC below 80% will be classified as non-adherent.
Time frame: Month 6 after starting dose
Quality of life, assessed with QLQ-C30, affecting medication adherence
Secondary aim to explore how quality of life (QoL) measured by EORTC QLQ-C30, impacts medication adherence. QLQ-C30 is a questionnaire of 30 questions (functional scales, symptom scales, single-item measures and global health status) converted into 0-100 scale. For functional and global scales, higher scores reflect better functioning or quality of life (score \>70 may indicate good functioning, \<70 indicating impaired functioning), whereas higher score in symptom scale represents greater severity of symptoms (\>30 typically considered clinically significant, indicating notable symptom burden, \<30 suggest mild or manageable symptoms). A change in 10 points or more is generally regarded as clinically meaningful change.
Time frame: Baseline visit
Quality of life, assessed with QLQ-C30, affecting medication adherence
Secondary aim to explore how quality of life (QoL) measured by EORTC QLQ-C30, impacts medication adherence. QLQ-C30 is a questionnaire of 30 questions (functional scales, symptom scales, single-item measures and global health status) converted into 0-100 scale. For functional and global scales, higher scores reflect better functioning or quality of life (score \>70 may indicate good functioning, \<70 indicating impaired functioning), whereas higher score in symptom scale represents greater severity of symptoms (\>30 typically considered clinically significant, indicating notable symptom burden, \<30 suggest mild or manageable symptoms). A change in 10 points or more is generally regarded as clinically meaningful change.
Time frame: Month 3
Quality of life, assessed with QLQ-C30, affecting medication adherence
Secondary aim to explore how quality of life (QoL) measured by EORTC QLQ-C30, impacts medication adherence. QLQ-C30 is a questionnaire of 30 questions (functional scales, symptom scales, single-item measures and global health status) converted into 0-100 scale. For functional and global scales, higher scores reflect better functioning or quality of life (score \>70 may indicate good functioning, \<70 indicating impaired functioning), whereas higher score in symptom scale represents greater severity of symptoms (\>30 typically considered clinically significant, indicating notable symptom burden, \<30 suggest mild or manageable symptoms). A change in 10 points or more is generally regarded as clinically meaningful change.
Time frame: Month 6
Quality of life, assessed with QLQ-BR23, affecting medication adherence
Secondary aim to explore how quality of life (QoL) measured by QLQ-BR23 (breast cancer specific module) questionnaire impacts medication adherence. QLQ-BR23 is a 23 question set (functional and symptom scales), transformed into 0-100 scale where higher scores in functional scales attest for better functioning whereas higher scores in symptom scales indicate greater symptom burden. For functional and global scales, higher scores reflect better functioning or quality of life (score \>70 may indicate good functioning, \<70 indicating impaired functioning), whereas higher score in symptom scale represents greater severity of symptoms (\>20-30 typically considered clinically significant, indicating notable symptom burden).
Time frame: Baseline visit
Quality of life, assessed with QLQ-BR23, affecting medication adherence
Secondary aim to explore how quality of life (QoL) measured by QLQ-BR23 (breast cancer specific module) questionnaire impacts medication adherence. QLQ-BR23 is a 23 question set (functional and symptom scales), transformed into 0-100 scale where higher scores in functional scales attest for better functioning whereas higher scores in symptom scales indicate greater symptom burden. For functional and global scales, higher scores reflect better functioning or quality of life (score \>70 may indicate good functioning, \<70 indicating impaired functioning), whereas higher score in symptom scale represents greater severity of symptoms (\>20-30 typically considered clinically significant, indicating notable symptom burden).
Time frame: Month 3
Quality of life, assessed with QLQ-BR23, affecting medication adherence
Secondary aim to explore how quality of life (QoL) measured by QLQ-BR23 (breast cancer specific module) questionnaire impacts medication adherence. QLQ-BR23 is a 23 question set (functional and symptom scales), transformed into 0-100 scale where higher scores in functional scales attest for better functioning whereas higher scores in symptom scales indicate greater symptom burden. For functional and global scales, higher scores reflect better functioning or quality of life (score \>70 may indicate good functioning, \<70 indicating impaired functioning), whereas higher score in symptom scale represents greater severity of symptoms (\>20-30 typically considered clinically significant, indicating notable symptom burden).
Time frame: Month 6
Belief about medications affecting medication adherence
Secondary aim to explore how beliefs about medicines (Beliefs about medicines questionnaire- BMQ) impacts medication adherence. BMQ consists of specific and general scale, each item rated on 5-point Likers scale ranging from 1-5 (1=strongly agree, 5= strongly disagree) summing into a total score. Higher scores on specific necessity scale suggest patients strongly believe medication is essential for maintaining their health. Higher score on concerns scale indicate patients concern about medication's negative aspect, potentially leading to lowed adherence. High scores in general harm and overuse scales reflect strong beliefs in medicines in general, are harmful or overused, potentially affecting adherence.
Time frame: Baseline visit
Belief about medications affecting medication adherence
Secondary aim to explore how beliefs about medicines (Beliefs about medicines questionnaire- BMQ) impacts medication adherence. BMQ consists of specific and general scale, each item rated on 5-point Likers scale ranging from 1-5 (1=strongly agree, 5= strongly disagree) summing into a total score. Higher scores on specific necessity scale suggest patients strongly believe medication is essential for maintaining their health. Higher score on concerns scale indicate patients concern about medication's negative aspect, potentially leading to lowed adherence. High scores in general harm and overuse scales reflect strong beliefs in medicines in general, are harmful or overused, potentially affecting adherence.
Time frame: Month 3
Belief about medications affecting medication adherence
Secondary aim to explore how beliefs about medicines (Beliefs about medicines questionnaire- BMQ) impacts medication adherence. BMQ consists of specific and general scale, each item rated on 5-point Likers scale ranging from 1-5 (1=strongly agree, 5= strongly disagree) summing into a total score. Higher scores on specific necessity scale suggest patients strongly believe medication is essential for maintaining their health. Higher score on concerns scale indicate patients concern about medication's negative aspect, potentially leading to lowed adherence. High scores in general harm and overuse scales reflect strong beliefs in medicines in general, are harmful or overused, potentially affecting adherence.
Time frame: Month 6
Cognitive functioning affecting medication adherence
Secondary aim is to explore how cognitive functioning (Functinal Assessment of Cancer Therapy- Cognitive Function (FACT-Cog) impacts medication adherence. FACT-Cog consists of 37 items, divided into perceived cognitive impairments (PCI), abilities (PCA), comments form others (OTH) and impact on quality of live (QOL). Each item is scored on Likert scale from 0-4 (==never, 4=several times a day), whereas higher scores indicate better cognitive function or fewer perceived cognitive problems, higher sum of scores represent better perceived cognitive functioning.
Time frame: Baseline visit
Cognitive functioning affecting medication adherence
Secondary aim is to explore how cognitive functioning (Functinal Assessment of Cancer Therapy- Cognitive Function (FACT-Cog) impacts medication adherence. FACT-Cog consists of 37 items, divided into perceived cognitive impairments (PCI), abilities (PCA), comments form others (OTH) and impact on quality of live (QOL). Each item is scored on Likert scale from 0-4 (==never, 4=several times a day), whereas higher scores indicate better cognitive function or fewer perceived cognitive problems, higher sum of scores represent better perceived cognitive functioning.
Time frame: Month 3
Cognitive functioning affecting medication adherence
Secondary aim is to explore how cognitive functioning (Functinal Assessment of Cancer Therapy- Cognitive Function (FACT-Cog) impacts medication adherence. FACT-Cog consists of 37 items, divided into perceived cognitive impairments (PCI), abilities (PCA), comments form others (OTH) and impact on quality of live (QOL). Each item is scored on Likert scale from 0-4 (==never, 4=several times a day), whereas higher scores indicate better cognitive function or fewer perceived cognitive problems, higher sum of scores represent better perceived cognitive functioning.
Time frame: Month 6
Previous treatment affecting medication adherence
Secondary aim is to explore how factors related patient's previous treatment impact medication adherence. Previous treatment data will be gathered and descriptively presented along measured study data.
Time frame: Baseline visit
Adverse events affecting medication adherence
Secondary aim is to explore how adverse events (AE) impact medication adherence. AEs will be gathered throughout the duration of the study, assessed per seriousness, severity, causality and expectancy and descriptively presented. it is expected patients with more AEs are much more likely to discontinue treatment, more AEs tent to lead to higher medication non-adherence.
Time frame: Baseline visit
Adverse events affecting medication adherence
Secondary aim is to explore how adverse events (AE) impact medication adherence. AEs will be gathered throughout the duration of the study, assessed per seriousness, severity, causality and expectancy and descriptively presented. it is expected patients with more AEs are much more likely to discontinue treatment, more AEs tent to lead to higher medication non-adherence.
Time frame: Month 3
Adverse events affecting medication adherence
Secondary aim is to explore how adverse events (AE) impact medication adherence. AEs will be gathered throughout the duration of the study, assessed per seriousness, severity, causality and expectancy and descriptively presented. it is expected patients with more AEs are much more likely to discontinue treatment, more AEs tent to lead to higher medication non-adherence.
Time frame: Month 6
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