original article
`
`Annals of Oncology 17: 205–210, 2006
`doi:10.1093/annonc/mdj044
`Published online 20 October 2005
`
`Patients’ preference for administration of endocrine
`treatments by injection or tablets: results from
`a study of women with breast cancer
`
`L. Fallowfield*, L. Atkins, S. Catt, A. Cox, C. Coxon, C. Langridge, R. Morris & M. Price
`
`Sussex Psychosocial Oncology Group, Cancer Research UK, Brighton and Sussex Medical School, University of Sussex, Sussex, UK
`
`Received 28 June 2005; revised 4 August 2005; accepted 14 September 2005
`
`article
`original
`
`Background: Endocrine therapies for advanced breast cancer include tablets and intramuscular injections. When
`treatments have similar efficacy and tolerability profiles, addressing preferences about routes of administration is
`important.
`Patients and methods: Two hundred and eight women >2 years post-breast cancer diagnosis were interviewed
`about their preferences for daily tablets or monthly intramuscular injections. Health-care professionals treating the
`women estimated patients’ preferences.
`Results: Sixty-three per cent of patients preferred tablets, 24.5% preferred the injection and 12.5% had no
`preference. The most cited reasons for tablet preference were convenience and dislike of needles; for injection
`preference, adherence and convenience. Variables associated with preferences were body mass index, educational
`level, attitudes towards injections and efficacy perceptions. Estimates about patients’ preferences by health-care
`professionals varied widely. When asked to imagine scenarios where injections produced fewer hot flushes, or where
`two injections monthly improved efficacy, injection preference increased to 60.6% and 74.5%, respectively.
`Disturbingly, 50% of patients admitted they sometimes forgot or chose not to take their current oral medication.
`Conclusions: The majority of breast cancer patients preferred hormone therapy via daily tablets rather than monthly
`injections. Information about side-effects or improved efficacy altered these preferences. Adherence to treatment
`cannot be assumed; patients’ preferences about drug administration may influence this.
`Key words: breast cancer, fulvestrant injections, patient preferences, tablet adherence
`
`introduction
`
`Current and newly formulated endocrine therapies designed for
`patients with advanced breast cancer include tablets (e.g.
`tamoxifen, anastrozole, letrozole and exemestane) and
`intramuscular injections (e.g. fulvestrant) [1]. Where different
`treatments have broadly similar efficacy and tolerability profiles
`(e.g. tamoxifen and fulvestrant) [2], addressing patient
`preferences regarding the different routes of administration is
`important, especially as patients and health professionals may
`not share similar views about treatments [3, 4].
`A better understanding of patients’ preferences is fundamental
`to the shared model of medical decision-making, acknowledged
`as the preferred practice in determining treatment [5, 6].
`Formulating plans that recognise patients’ preferences enhances
`satisfaction and is associated with improved adherence [7].
`Consideration must be given not only to concerns about the
`benefits and costs of different treatments, but also practical
`
`*Correspondence to: Prof. L. Fallowfield, Sussex Psychosocial Oncology Group,
`Cancer Research UK, Brighton & Sussex Medical School, University of Sussex, Sussex
`BN1 9QG, UK. Tel: +44-1273-873015; Fax: +44-1273-873022;
`E-mail: L.J.Fallowfield@sussex.ac.uk
`
`implications [8]. Issues such as the ease of getting to a pharmacy,
`opening containers and remembering to take drugs all interfere
`with daily life, influencing how and when patients take their
`medication. Despite this, patients’ understanding or concerns
`about treatment are rarely explored [7] and why patients choose
`particular treatments is poorly investigated [9].
`Palliative oncology studies report that provided that efficacy
`is equivalent, most patients prefer oral treatment rather than
`insertion of central venous lines [4, 10, 11]. Factors influencing
`choice include convenience, problems with intravenous lines or
`needles, the environment in which the therapy is administered
`and concerns about side-effects [4, 10–12]. One of these studies
`employed a randomised crossover design and found different
`reasons for patients’ preferences before and after they had
`experienced each treatment [11]. Initially, choices were
`dominated by toxicity fears, but after experiencing both oral and
`intravenous treatment, patients were more likely to indicate
`specific administration-related features.
`Generally, health-care professionals consider that patients
`dislike injections, and consequently they are more likely to
`prescribe oral treatments, although true injection phobias,
`rather than dislike, only affect between 3% and 10% of the
`
`ª 2005 European Society for Medical Oncology
`
`1
`
`EX2120
`Eli Lilly & Co. v. Teva Pharms. Int'l GMBH
`IPR2018-01427
`
`

`

`original article
`
`population [13, 14]. Injection site pain may be relevant in
`extremely thin patients, so body mass index (BMI) might be
`a further factor influencing preferences.
`The potential for non-adherence is a major disadvantage of
`oral treatment. Patient adherence to oral anticancer medication
`is variable and difficult to predict [15, 16]. In one study of
`women prescribed adjuvant tamoxifen for breast cancer, nearly
`one-quarter risked inadequate clinical benefit due to poor
`adherence [16].
`Women with breast cancer are often older, with comorbidities
`that necessitate the taking of many other drugs. One more tablet
`might not be viewed as a burden, but if tablet swallowing is
`difficult, a monthly injection might be seen as more desirable.
`Personality may also influence treatment choice and
`adherence, for example patients who have a sense of control
`over their treatment are more likely to choose oral therapy
`[4, 10, 11]. Anxiety is another factor that may potentially affect
`preferences. A putative benefit of monthly injections is more
`regular contact with a specialist nurse, which some patients,
`especially those with high anxiety, may value. Conversely, high
`anxiety might be associated with unwillingness to have extra
`contact with the clinic [17].
`The objectives of the study reported here were: to elicit
`women’s preferences for different routes of administration of
`hormone treatments for breast cancer, namely oral tablets or
`a monthly intramuscular injection, and to determine the factors
`associated with preferences. Additionally, the breast cancer
`clinicians and specialist nurses in participating centres were
`surveyed to elicit which of the treatments they thought their
`patients would prefer and reasons for their patients’ choices.
`
`materials and methods
`
`participants and recruitment
`Participants were a convenience sample of women with early or advanced
`breast cancer currently in remission or with stable disease. All were at least 2
`years post-diagnosis and were currently receiving or had previous experience
`of at least one drug for breast cancer. The women were attending one of six
`outpatient clinics for routine follow-up. Clinics were chosen by the
`researchers in different parts of the UK to ensure a geographical spread of
`different socioeconomic groupings. Health-care professionals, usually the
`specialist nurse or treating clinician, identified potentially eligible patients
`fulfilling the broad criteria above, prior to their consultations. Consecutive,
`potentially eligible patients were then given written information by
`a researcher and invited to participate in the study. Those interested were
`telephoned and consenting patients were interviewed in their own homes by
`a trained researcher, using a semi-structured interview schedule. Written
`consent included permission for the interview to be audiotaped. The study
`had approval from multicentre and local research ethics committees.
`
`interview content
`Most interviews lasted under 1 hour, during which sociodemographic
`information was collected, together with details about current and previous
`breast cancer treatment and concurrent medication for comorbidities.
`Patients were asked about journey length to the clinic, ease and method of
`travelling, physical difficulties, convenience of attending clinics, and their
`relationship with clinic doctors and nurses. They were asked about their
`views on the efficacy of injections versus tablets and if any aspects of their
`current medication were difficult. Specific issues about oral medication were
`elicited including: whether or not they found swallowing tablets difficult,
`
`Annals of Oncology
`
`if they ever forgot to take tablets, if they ever chose not to take tablets as
`prescribed and why, and if tablet taking interfered with their daily life. They
`were also asked about injections: previous experiences, anxiety and whether
`they had ever had a needle phobia.
`Patients were then read a scenario: ‘Imagine that you were going to be
`offered one of two new treatments that were designed to help prevent breast
`cancer from getting worse. Both these treatments would be equally effective
`and similar in terms of side-effects. One treatment would be a tablet taken by
`mouth once a day and you would continue to see your doctor for check-ups
`every 3–6 months. The other treatment would be an injection into the
`buttock, which is administered once monthly at your breast clinic by the
`nurse. You would continue to see your doctor every 3–6 months.’
`Patients’ preferences for tablets or injections were obtained immediately
`after hearing the scenario and then again after reflecting further on the
`benefits and disadvantages of both treatments. To ascertain the strength
`of preferences two final follow-up questions were posed. Patients were asked
`if preferences would remain the same if (i) the injection caused fewer hot
`flushes and (ii) an injection into both buttocks controlled the cancer better.
`
`questionnaires
`Participants completed two short standardised questionnaires, the State-
`Trait Anxiety Inventory (STAI) [18] and the Multidimensional Health Locus
`of Control Scale (MHLOC) [19]. The MHLOC assesses respondents’
`perceptions of control over their illness and the extent to which they feel
`powerful others and chance factors influence their general health.
`
`health-care professionals’ estimations of their
`patients’ preferences
`Twelve health-care professionals, comprising eight consultant oncologists
`and four specialist breast care nurses from the participating clinics, were sent
`questionnaires with the main patient scenario and follow-up variations
`(if injections caused fewer hot flushes or greater efficacy could be achieved
`with one injection in each buttock). They then estimated the proportion
`of patients who would opt for injections, tablets or have no preference,
`and reasons for these preferences.
`
`statistical analysis
`Data were analysed using Statistical Package for the Social Sciences
`(SPSS). The t-test was used to examine differences between group means
`and the v2-test to examine differences in proportions.
`Audiotapes were checked by an independent researcher and
`inconsistencies resolved prior to analysis. Reasons for preferences were split
`into agreed thematic categories by a consensus group of three researchers.
`
`results
`
`Two hundred and seventy women expressed interest in the
`study of whom 208 (77%) were interviewed and completed
`questionnaires (35 refused when contacted and 27 were not
`contactable within the time-frame of the study). Patient
`characteristics are shown in Table 1. Most were married (62%)
`and educated up to secondary school level (53.9%). Mean STAI
`were slightly higher than the norms for women aged 50–69 years
`(31.79 and 32.20) [18], but similar to those for women with
`breast cancer [20]. MHLOC scores were similar to those seen in
`chronic patient populations and did not differ significantly
`between preference groups.
`Sixty-one respondents were taking four or more tablets a day
`for any illness or condition and 28 were not on any medication.
`Almost two-thirds (131 of 208; 63%) were currently receiving
`medication for their breast cancer (Table 2), the majority taking
`
`206 | Fallowfield et al.
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`Annals of Oncology
`
`Table 1. Patient characteristics
`
`Characteristic
`
`Mean age, years [SD (range)]
`Mean BMI, kg/m2 [SD (range)]
`Education [n (%)]
`Secondary
`Further
`Higher
`Partnership status [n (%)]
`Single
`Married
`Living with partner
`Separated/divorced
`Widowed
`Trait mean anxiety
`[SD (range)]
`State mean anxiety
`[SD (range)]
`Multidimensional health locus of control
`Internal mean [SD (range)]
`Chance mean [SD (range)]
`Powerful others mean [SD (range)]
`
`original article
`
`All patients
`(n = 208)
`
`Injection preference
`(n = 51)
`
`Tablet preference
`(n = 131)
`
`No preference
`(n = 26)
`
`59.72 [11.51 (32–88)]
`26.43 [5.04 (17–42)]
`
`58.27 [12.35 (34–81)]
`28.57 [5.88 (20–42)]
`
`59.02 [11.21 (32–88)]
`25.69 [4.63 (17–42)]
`
`66.08 [9.43 (51–86)]
`25.95 [4.17 (19–34)]
`
`111 (53.9)
`41 (19.9)
`54 (26.2)
`
`24 (11.6)
`129 (62.0)
`5 (2.4)
`24 (11.5)
`26 (12.5)
`
`35 (70.0)
`6 (12.0)
`9 (18.0)
`
`6 (11.8)
`31 (60.8)
`2 (3.9)
`6 (11.7)
`6 (11.8)
`
`60 (46.1)
`30 (23.1)
`40 (30.8)
`
`14 (10.7)
`86 (65.6)
`3 (2.3)
`13 (9.9)
`15 (11.5)
`
`16 (61.6)
`5 (19.2)
`5 (19.2)
`
`4 (15.4)
`12 (46.2)
`0 (0)
`5 (19.2)
`5 (19.2)
`
`37.82 [10.50 (20–72)]
`
`39.49 [10.33 (23–63)]
`
`37.72 [10.58 (20–72)]
`
`35.13 [10.24 (22–59)]
`
`38.45 [9.94 (20–72)]
`
`39.85 [8.91 (24–59)]
`
`38.56 [10.09 (20–72)]
`
`35.08 [10.66 (21–57)]
`
`23.73 [5.14 (11–34)]
`18.26 [5.28 (8–34)]
`19.06 [6.21 (6–36)]
`
`23.66 [5.07 (11–32)]
`18.81 [5.21 (9–28)]
`20.00 [5.06 (10–30)]
`
`23.70 [5.38 (11–34)]
`17.95 [5.26 (10–34)]
`18.33 [6.27 (6–36)]
`
`24.00 [4.08 (14–31)]
`18.83 [5.64 (8–30)]
`21.08 [7.42 (7–36)]
`
`SD, standard deviation; BMI, body mass index.
`
`either tamoxifen (34.6%) or anastrozole (17.3%). Five patients
`were receiving injections (excluding intravenous infusions) and
`four patients were receiving chemotherapy.
`The majority had no physical disabilities affecting their ability
`to get around (195 of 208; 93.8%) and most (191 of 207; 92.3%)
`found attendance at clinics easy and convenient, even though
`111 of 207 (53.6%) said the journey took more than 30 min.
`Most reported good relationships with their doctors (203 of
`207; 98.1%) and nurses (193 of 198; 97.5%).
`When asked if they thought that tablets or injections were
`more effective in general, 92 of 200 (46%) respondents said they
`did not know and 55 of 200 (27.5%) thought that both methods
`were equally effective; 44 of 200 (22%) considered injections to
`be more effective and nine of 200 (4.5%) felt that better efficacy
`was likely from tablets.
`Most patients had no problems swallowing tablets (184 of
`208; 88.5%) and said that tablet taking did not interfere with
`everyday life (183 of 194; 94.3%). However, approximately half
`said that they sometimes forgot (94 of 193; 48.7%) or
`deliberately omitted (25 of 191; 13.1%) taking their tablets at
`times. Approximately one-third (78 of 208; 37.5%) said they
`were generally anxious about having injections; 36 of 208
`(17.3%) said that feelings of anxiety or dislike of needles might
`cause them to avoid injections if possible. However, true needle
`phobia, rather than anxiety or dislike, was reported by 28 of 208
`(13.5%) of patients at some time.
`Immediately after hearing the scenario, most patients (131 of
`208; 63%) preferred daily tablets to the monthly injection,
`almost one-quarter (51 of 208; 24.5%) preferred injections and
`26 of 208 (12.5%) had no preference.
`Patients gave 256 reasons for their initial preferences, which
`were grouped into 12 thematic categories (Table 3).
`
`Table 2. Summary of current medication for breast cancer
`
`Drug
`
`na (% total sample)
`
`Endocrine, antibody or
`bisphosphonate therapy
`
`Chemotherapy
`
`Tamoxifen
`Anastrozole
`Exemestane
`Letrozole
`Zoledronic acid
`Goserelin
`Megestrol
`Trastuzumab
`Fulvestrant
`Leuprorelin
`Capecitabine
`Paclitaxel
`Vinorelbine
`Not named
`
`72 (34.6)
`36 (17.3)
`9 (4.3)
`6 (2.9)
`4 (1.9)
`3 (1.4)
`3 (1.4)
`2 (1.0)
`1 (0.5)
`1 (0.5)
`1 (0.5)
`1 (0.5)
`1 (0.5)
`1 (0.5)
`
`aEight patients were taking two drugs and one patient was taking three drugs.
`
`Convenience was the most common reason for choosing tablets,
`followed by a dislike of needles. A few patients commented that
`they would rather have an injection if it could be given at home
`or by their general practitioner rather than at the cancer clinic.
`Convenience was also the most common reason cited for
`preferring injections, followed by the desire to ensure adherence.
`An exploratory analysis was performed to determine which
`factors affected preferences. Patients who expressed an initial
`preference for injections or tablets (n = 182) were compared.
`Patients educated up to secondary school level were twice as
`likely to choose injections (35 of 95; 36.8%) as those educated
`beyond this level (15 of 85; 17.6%) (v2 = 8.24; P = 0.004).
`
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`original article
`
`Table 3. Reasons for initial preferences
`
`Annals of Oncology
`
`Categories
`
`Convenience
`Clinical contact
`Control
`Adherence
`Side-effects
`Pain
`Efficacy
`No preference
`Psychological
`Swallowing/tablet taking
`Needle dislike
`Financial
`
`Injection (n = 51)
`[n (%a)]
`
`Tablet (n = 131)
`[n (%a)]
`
`No preference (n = 26)
`[n (96%)]
`
`Total (n = 208)
`[n (%a)]
`
`24 (47.1)
`3 (5.9)
`1 (2.0)
`22 (43.1)
`2 (3.9)
`0 (0)
`5 (9.8)
`0 (0)
`7 (13.7)
`4 (7.8)
`0 (0)
`0 (0)
`
`92 (70.2)
`0 (0)
`10 (7.6)
`1 (0.8)
`3 (2.3)
`10 (7.6)
`6 (4.6)
`1 (0.8)
`13 (9.9)
`9 (6.9)
`23 (17.6)
`2 (1.5)
`
`2 (7.7)
`0 (0)
`0 (0)
`1 (3.8)
`1 (3.8)
`0 (0)
`1 (3.8)
`13 (50.0)
`0 (0)
`0 (0)
`0 (0)
`0 (0)
`
`118 (56.7)
`3 (1.4)
`11 (5.3)
`24 (11.5)
`6 (2.9)
`10 (4.8)
`12 (5.8)
`14 (6.7)
`20 (9.6)
`13 (6.3)
`23 (11.1)
`2 (1.0)
`
`aPercentage of respondents who gave multiple reasons for their preference.
`
`Patients who preferred injections had a higher mean BMI than
`those preferring tablets (28.57 versus 25.69; t = 3.14; P = 0.002).
`Neither age, partnership status, anxiety nor any dimensions
`of health locus of control were significantly associated with
`preferences.
`Negative feelings about injections led to self-reported needle
`avoidance in 30 of 131 (22.9%) of the patients who chose the
`tablet option compared with five of 51 (9.8%) of those who
`preferred injections (v2 = 4.05; P = 0.044). Preferences were not
`significantly associated with any other aspects of current
`treatment including convenience and relationship with
`health-care professionals or general views about medication.
`Despite the scenario describing treatments as ‘equally
`effective’, 56 of 182 (30.8%) thought one treatment was better
`than the other. Patients who preferred injections were more
`likely to feel one treatment was better than the other compared
`with patients who preferred tablets (22 of 51, 43.1% versus 34 of
`131, 26%; v2 = 6.51; P = 0.039). Of the 56 patients who thought
`one method was better than the other, 21 of 22 (95.4%) of those
`who preferred injections thought injections were better and
`20 of 34 (58.8%) of those who preferred tablets thought
`tablets were better.
`After weighing up the pros and cons of the different options,
`respondents reconsidered their preferences. This made very little
`difference: 134 of 208 (64.4%) preferred the daily tablet, 55 of
`208 (26.5%) preferred the injection and 19 of 208 (9.1%) had no
`preference. However, varying the side-effects or efficacy of
`treatment options altered preferences. When patients were
`asked to choose again given hypothetical information that
`injections resulted in fewer hot flushes, the proportion choosing
`tablets decreased to 57 of 208 (27.4%), the proportion opting for
`injections increased to 126 of 208 (60.6%) and 25 of 208 (12%)
`remained undecided. When patients were asked to choose
`between a daily tablet and two monthly injections (one in each
`buttock) that would better control the cancer, 155 of 208
`(74.5%) chose injections, 40 of 208 (19.2%) tablets and 13 of
`208 (6.3%) gave no preference.
`Health-care professionals assumed tablets would be more
`popular than injections, but gave a wide range of estimates
`concerning the proportion of patients who would opt for tablets
`
`(41–100%), injections (0–50%) or have no preference (0–20%).
`Estimates concerning patient preferences also varied when the
`side-effects and efficacy of treatments in the scenarios were
`changed. Estimates of the proportion of their patients with
`a needle phobia ranged between 0% and 60%. Most assumed
`that those who chose injections would do so to facilitate
`adherence and those patients who chose tablets would do so
`for reasons of convenience.
`
`discussion
`
`This study, examining patients’ preferences for different routes
`of treatment administration, showed the majority (63%)
`preferred daily tablets rather than monthly injections.
`Nevertheless, a sizeable minority (24.5%) would prefer an
`intramuscular route of administration. These findings are
`similar to a recently reported telephone survey of 260 women
`with metastic breast cancer conducted in the USA [21].
`Analysis of reasons for choice revealed convenience to be an
`important issue whatever preference patients had. Some patients
`commented that they would prefer injections if these could be
`administered by a district nurse or primary care physician rather
`than at the hospital clinic. Although a minority of those who
`opted for tablets cited a general dislike of needles as a reason for
`their choice, only 17.3% of all respondents said that their
`concerns about injections would mean they avoided having one.
`Some patients commented that their negative feelings towards
`injections were more related to their experiences with the side-
`effects of previous intravenous chemotherapy than anything else.
`Patients, even those with life-threatening disease, often fail to
`take their tablets as prescribed; disturbingly, almost half the
`patients currently on oral medication reported forgetting to take
`their tablets from time to time and 13.1% deliberately chose not
`to take them. Indeed one of the primary reasons given by 43.1%
`of the patients who preferred injections was that this method
`would ensure that they received their treatment. It is worth
`considering whether or not the figure for non-adherence might
`in fact be an underestimate. During a face-to-face interview
`patients might have had difficulty revealing that they choose not
`to take their medication, whereas admitting that they forgot is
`
`208 | Fallowfield et al.
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`Annals of Oncology
`
`more acceptable. From a behavioural point of view,
`maintenance of long-term endocrine therapy poses several
`interesting issues; if women remain asymptomatic of breast
`cancer or recurrence then they may not see the value of taking
`pills regularly. If the medication also produces iatrogenic harm
`or unpleasant side-effects, which are relieved by stopping the
`pills, then a reinforcing pattern of non-adherence is set up.
`These issues merit more attention given the huge amount of
`resources spent on treatment.
`Factors significantly associated with preference were BMI,
`educational group, avoidance of injections and perceptions
`about the efficacy of different routes of administration. The
`association of higher BMI with injection preference is logical,
`as thinner patients might well find intramuscular injections
`more uncomfortable. Why those with lower educational
`attainment were twice as likely as those educated to higher
`levels to choose injections is not entirely clear. The finding
`concerning ‘perceived’ efficacy is perhaps surprising as the
`scenario informed patients that both treatments were equally
`effective. Of the 56 patients who thought one treatment was
`more efficacious than the other, almost all (95.4%) of those
`preferring injections thought injections were better, but
`unexpectedly only 58.8% of those preferring tablets thought
`that tablets were better. This suggests that beliefs concerning
`the efficacy of treatments may have been more of an influence
`on preference for those choosing injections. Interestingly,
`efficacy features such as ‘I thought it was a stronger medicine’
`ranked very low overall compared with other reasons for post-
`treatment preferences in a crossover study that asked patients
`to compare palliative treatments for advanced colorectal
`cancer [11].
`The methodology and specific wording used in studies
`may affect treatment preferences [11]. This study asked about
`preferences regarding hypothetical treatment choices, but
`preferences and reasons for them might be different if patients
`had actually experienced both methods of treatment [11].
`The majority of women were on oral medication and only
`five patients were currently receiving injections (excluding
`intravenous infusions) for breast cancer treatment. Prospective
`studies are needed to examine whether preferences are
`related to actual treatment and whether preferences change
`over time [3].
`Other factors expected to be associated with preference
`including: relationship with nurses and doctors at the clinic,
`ease of attending clinics, needle phobia, difficulties swallowing
`tablets, and psychological factors such as health locus of control
`and anxiety, demonstrated no significant association.
`Although convenience was an important reason for treatment
`preference, nearly all the respondents in this study found their
`own breast clinics very convenient and very few reported
`problems regarding their current treatment. Similarly, most said
`their relationships with professionals were very good. The high
`level of satisfaction with health services might explain why no
`associations were found with preferences.
`There was little change in preferences when patients
`reconsidered their choices after reviewing the advantages and
`disadvantages of each treatment option, but varying the
`description of side-effects and efficacy of treatments in the
`scenario produced interesting shifts.
`
`original article
`
`Previous research regarding breast cancer treatment
`preferences has demonstrated the impact of side-effects on
`quality of life and adherence [9, 22]. When patients were
`asked to imagine a scenario where injections would result in
`fewer hot flushes, the proportion of women opting for the
`injection option increased considerably and preferences for
`tablets decreased. Although not life-threatening, hot flushes
`remain an important problem for women treated for breast
`cancer [23].
`When patients were asked to express a preference based on the
`scenario that two injections (one in each buttock) would be
`better at controlling the cancer, the percentages opting for
`injections increased considerably. This finding may be of
`importance should further research demonstrate a benefit with
`higher doses of endocrine treatment that would necessitate the
`administration of two injections. In another study patients with
`incurable cancer were asked about hypothetical preferences for
`oral or intravenous palliative chemotherapy; patients were
`generally not willing to sacrifice efficacy for their preference [10].
`Why patients choose a particular treatment is often poorly
`understood by the health-care professionals treating them [9].
`We asked the clinicians and nurses from the six centres treating
`women in the study which route of administration they thought
`their patients would prefer and reasons for these preferences.
`The health-care professionals correctly assumed that the
`majority of patients would prefer tablets to injections, that
`convenience and adherence would affect patient choice and that
`a preference for injections would increase if this method caused
`fewer side-effects or was more efficacious (even if it necessitated
`two monthly injections rather than one). However, estimates
`varied widely even between health-care professionals working
`within the same clinic with the same patients.
`The individual preferences shown here emphasise the
`importance of good communication concerning available
`treatment options. If different routes of administration exist,
`then these merit appropriate discussion and consideration
`alongside other clinical benefits. Finally, adherence to an oral
`regimen cannot be assumed even when prescribed for patients
`with life-threatening diseases.
`
`acknowledgements
`
`We thank all the the women who generously gave their time
`for interviews and the nurses for help in identifying eligible
`patients. We are grateful to the following clinicians for allowing
`recruitment to take place in their clinics: Dr Peter Barrett-Lee
`(Cardiff), Dr Andrew Wardley (Manchester), Professor Charles
`Coombes (London), Dr George Deutsch (Brighton) and
`Dr Sankha Suvra Mitra (Worthing). We also acknowledge
`the help of Lesley Nichol from Role-call, who helped train the
`interviewers. Rhona McGurk, Belinda Moore and Trudi
`Edginton also assisted with interviews. We acknowledge the
`contributions of Anne Fleissig and Valerie Jenkins, who
`helped with various drafts of the manuscript. L.F., C.L., S.C.,
`A.C. and C.C. are all funded by CR UK. This study was funded
`via an unrestricted educational grant from AstraZeneca. Study
`design, co-ordination, data analysis and interpretation, and
`submission for publication were conducted independently of
`the funding source.
`
`Volume 17 | No. 2 | February 2006
`
`doi:10.1093/annonc/mdj044 | 209
`
`5
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`

`

`original article
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