Extended Adherence to Adjuvant Endocrine Therapy in Breast Cancer Survivors: Ritualization of Adherence

Background: Hormone-receptor positive breast cancer survivors traditionally were prescribed adjuvant endocrine therapy (AET) for five years at the completion of definitive therapies. The duration of treatment continues to be explored with recommendations indicating that eight to ten years may be more effective in the prevention of breast cancer recurrence. Non-adherence rates are as high as 50% disruption or discontinuation before the recommendation of the provider. With extended durations of treatment, non-adherence rates will continue to be a challenge, impacting the incidence of breast cancer recurrence in these women.

Aims: 1). Describe the experience of post-menopausal breast cancer survivors as they transition from acute to chronic management of breast cancer.
2). Identify conditions that support or are barriers to adherence to AET in post-menopausal breast cancer survivors.
3). Generate a grounded theory about post-menopausal breast cancer survivors’ decision-making and other conditions that impact adherence.

Methods: Grounded Theory utilizing dimensional analysis was employed. Twenty-one post-menopausal hormone-receptor positive breast cancer survivors, more than three years out from definitive treatment, were recruited. Three Virginia oncology clinics and Facebook support groups were utilized for recruitment. Data collection and data analysis occurred simultaneously. Data-analysis occurred in four phases: initial coding, focused coding, axial coding, and selective coding. Memo-writing was used to support emerging conceptualizations.

Findings: Through this constructivist grounded theory study the central perspective of ritualization of adherence was discovered. Women built a foundation that included arming themselves with accurate information, viewing their breast cancer as a chronic condition, utilizing the support of spouses and healthcare providers, and building a healthy lifestyle as a survivor that led them to divergent paths towards adherence or non-adherence. Non-adherence was facilitated by disruptions to routines and side effects, where-as adherence included a continual recommitment process. They lastly built a means of self-protection that included their belief in the power of the medication, their personal values and belief system, and a consequential message that they were strong enough, which overarched their decision to adhere and fueled the ritualization process.

Conclusion: Throughout this study, participants described the perspective of ritualization of adherence as a way of explaining what conditions and contexts led to adherence and non-adherence in the extended duration of AET use. Based on the findings in this study, nurses and other healthcare providers are able to target specific areas of education and practice in order to improve the experiences and quality of life of post-menopausal breast cancer survivors. Additionally, this study informs researchers and policy-makers in order to target and improve breast cancer survivorship care.