Education Is Not Enough To Encourage HR+ Breast Cancer Survivors to Take Adjuvant Endocrine Therapy


Stronger interventions are needed to improve adjuvant treatment rates among breast cancer survivors.

Joanna Arch, PhD

Joanna Arch, PhD

If clinicians want to significantly improve endocrine therapy adherence rates in hormone-receptor positive breast cancer survivors, they will need to do more than just educate their patients, according to findings from a meta-analysis published in the Journal of Clinical Oncology.1

Although approximately 80% of patients with hormone receptor-positive tumors are prescribed 5 to 10 years of adjuvant endocrine therapy following chemotherapy surgery and radiation, 40% will discontinue treatment early and approximately one third of patients will take their treatments less than prescribed.1,2

The analysis showed that education strategies, including pamphlets and verbal explanations, were insufficient in persuading patients to comply with their prescribed treatment. More assertive interventions, such as text reminders to take their medicine, behavioral therapy or psychological counseling, and cost-cutting policy changes that require insurance companies to cover pills at the same levels as infusions, were needed to inspire real change.2

“Education in and of itself is not enough. That is a clear finding,” Joanna Arch, PhD, professor of psychology and neuroscience at the University of Colorado, said in a press release. “Most oncologists, I believe, don’t realize how low adherence is for these women. They assume that if they write the prescription, it’s being taken.”

As the authors note in the study, tamoxifen and aromatase inhibitors are expensive and are associated with several adverse events, including weight gain, sexual dysfunction, musculoskeletal pain, depression, and fatigue. Despite this, they are known to be effective: they have been demonstrated to reduce the risk of recurrence by up to 50% in hormone-receptor positive patients. Vice versa, patients who cannot adhere to their treatment plan face a 49% increase in all-cause mortality.1

With numerous advancements with oncologic agents, more providers have become interested in promoting at-home adherence with oral therapies. As such, investigators conducted a review of 25 studies representing 368,000 women survivors.2

One study included in the review used the patient’s own goals to motivate them to continue treatment. Patients were asked to pinpoint a specific motivation for taking their medicine—whether it was attending a family member’s graduation, hiking a mountain, or going on a special trip, and create a sticker online that represents that goal, with the words, “I take this for…” Patients attached these stickers to their pill boxes. In the first month of this study, patients who had the stickers were more likely to take their pills than those with no stickers.

One key takeaway from the research is that only a small percentage of interventional research is aimed at key risk factors for non-adherence, according to the study authors, who note that despite strong evidence tying depression with non-adherence, only 4 out of 33 focal interventions targeted depression, anxiety, or negative affective attitudes. Further, they did not identify any studies focused on leveraging social support or patient-physician rapport. Investigators concluded that addressing mental health may be a crucial aspect in improving treatment attitudes.1

Ultimately, the review showed that intervening in general can help improve adherence rates by 1.5 (OR, 1.412; 95% CI, 1.183-1.682; P = .0001). However, authors argued that more can be done for patients.1,2

“Our bottom-line finding is that there are strategies that do work in supporting women to take these life-extending medications, and that we as a cancer care community need to do better,” Arch said.2


  1. Bright EE, Finkelstein LB, Nealis MS, et al. A systematic review and meta-analysis of interventions to promote adjuvant endocrine therapy adherence among breast cancer survivors. Published online August 2, 2023. J Clin Oncol. doi:10.1200/JCO.23.00697
  2. Marshall L. Why breast cancer survivors don’t take their meds, and what can be done about it. News release. University of Colorado Boulder. August 28, 2023. Accessed September 5, 2023.
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