Self-management strategies adopted by breast cancer survivors to improve their adherence to tamoxifen.
To the Editor: With increasing use of oral anticancer agents, concerns about adherence to prescribed regimens become an important issue in oncology (1). Adjuvant tamoxifen treatment, which is delivered to women with breast cancer after surgery, chemotherapy and radiotherapy, is a good example. Rates of adherence to tamoxifen have been found to range from 45% to 100%, with adherence gradually decreasing with each passing year in the course of 5 years and most of discontinuations occurring during the first year of follow-up (2). Previous studies have focused mainly on the factors contributing to nonadherence to the treatment. Discontinuation of the treatment was found, for example, to be associated with extremes of age, negative or neutral beliefs about the value of the treatment, and experiencing burdensome side-effects (1,3,4). The aim of the present qualitative patientfocused study was to document how women deal with their drug-taking on a daily basis, and what self-management strategies they adopt to improve their adherence to the treatment in the long run. As far as we know, this issue has not been investigated so far. In-depth interviews (N = 34), 40–60 minutes length, were conducted with women recruited consecutively from the consultations at two regional cancer centers, defined as primary breast cancer patients to whom tamoxifen had been prescribed (average age: 49 range: 35–64). At the time of the interview, 28 women were taking tamoxifen, 2 had discontinued the treatment, and 4 had refused it. The interview covered: onset and history of the disease; women’s experience of previous treatments; side-effects experienced; relationships with the clinic and ⁄ or staff; women’s understanding and expectations of the treatment; their views about their future health; and their medication practices, with special emphasis on the self-management strategies adopted to remind themselves to take their daily tamoxifen. The interviews were audiotaped and transcribed verbatim. Analysis was based on the constant comparative method. Initial coding frame was generated from the text, and all themes were subsequently examined in the context of each woman’s interview, as well as across the whole data set. Self-management strategies for not forgetting to take the drug were analyzed. Women described how they tried to integrate the treatment into their everyday lives, so that they would take their tablets routinely. This goal was achieved by associating them with a daily activity, or with other daily medications, or by keeping the tablets in specific places. Those who were already taking other medication tended to associate their tamoxifen tablets with their other daily drugs. This finding confirms previous reports that women taking multiple drugs apply their prescriptions more regularly than those taking only tamoxifen tablets (5). The present results also indicate that the routines women adopted with tamoxifen were based upon those previously set up with other ‘‘hormonal’’ treatments, such as oral contraceptives or hormonal replacement therapy. Previous use of the contraceptive pill or hormone replacement therapy therefore tends to improve adherence to tamoxifen. When tamoxifen was their sole medication, the self-management strategies adopted to prevent women from forgetting to take their daily tablet resulted in integrating it into their everyday lives like an ordinary thing, ingesting them just like ordinary food, and keeping the tablets in a specific place just like other everyday goods. This process of appropriation made it possible for women to avoid thinking about their cancer every time they took their tamoxifen. Therefore, with tamoxifen as with other long-term treatments (6), integrating the drug-taking habit into patients’ everyday life promotes long-term adherence. The places where medicines are kept correspond to various modes of perception of these drug-objects and to the importance attached to them (7). Keeping tamoxifen Address correspondence and reprint requests to: Isabelle Pellegrini, PhD, INSERM UMR912, 232, Bd Ste-Marguerite, IPC, B.P. 156, 13273 Marseille Cedex 9, France, or e-mail: isabelle.pellegrini@inserm.fr.