Adherence to Adjuvant Hormonal Therapy and Associated Factors Among Women with Breast Cancer [Response To Letter]

Dear editor

We appreciate the Editor-in-Chief for allowing us to respond to comments from Bekele et al. We also express our appreciation to Bekele et al for the attention on our study entitled ‘Adherence to adjuvant hormonal therapy and associated factors among women with breast cancer attending the Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia’. Hereby, we provide a point-by-point response to the comments raised by Bekele et al from the following aspects.

For the first suggestion of Bekele et al as they were a clinical pharmacy specialist by profession will make them to enrich their study by addressing our suggestion and limitation as well. They appreciated our study on the importance of assessing the adherence to adjuvant hormonal therapy in developing countries like Ethiopia.¹ They should acknowledge that it is the first study in Ethiopia regarding adherence to adjuvant hormonal therapy.

For the second suggestion of Bekele et al on the need of using different methodological approaches, following the authors’ recommendation, as we also recommended on the use of different methods including follow up study and as adherence study is multifaceted there are so many factors that can affect the patients’ adherence to adjuvant hormonal therapy that need to be identified.

Appropriate medication adherence could result in a reduction of the recurrence and mortality rates among women diagnosed with breast cancer.² Despite this, many studies reported poor adherence to hormonal therapy.^3,4

For the third suggestion of Bekele et al listed that the authors only assess the rate of medication adherence. We would like enlighten Bekele et al that we have not only tried to assess the rate of adherence but also tried to identify factors affecting it. On the other hand, I agree with Bekele et al that we have not studied the outcome or impact of adherence on breast cancer recurrence and mortality, we also strongly recommend others to consider it.

We also believed that the impact of non-adherence on the treatment outcomes of breast cancer should be studied at the large. We support the fact that Bekele et al studied using retrospectively reviewing the patients’ charts as per our recommendation. Therefore, I believe and expect a huge number of non-adherences if conducted prospectively. We agree on their recommendation that a future researchers should assess the adherences prospectively by using a validated tool. Even though the design we used was cross-sectional, but we had checked patient chart review retrospectively.

About the fourth suggestion of Bekele et al, on the authors identifying the therapeutic communication and side effects of the drug as predictors of adherence. I strongly support the idea that a clinical pharmacy intervention in the study area to tackle any medication-related problems. Furthermore, effective patient healthcare provider communication was significantly associated with adherence to Tamoxifen and Aromatase inhibitors.⁵ On the other hand, we the authors only assessed whether the patients had experienced side effects or not but not the predictors for the occurrences of side effects as these variables need a follow-up study.

According to a study done by Brito et al found that the rate of adherence to hormonal therapy was lower among alcohol drinkers.⁶ We the authors of the paper tried to assess the magnitudes of social drug uses like smoking a cigarette and drinking alcohol. However, we left the variable because it was not fit for binary logistic regression analysis as it violates cross-tabulation. Besides, the nature of the variables was so unwelcoming to our culture and respondents were not willingly responded to it.

As per the suggestion of providing quality pharmaceutical care service globally could satisfy the demands of the patients that might increase the adherences.⁷ Hence, the effect of increased patient satisfaction on treatment adherence should be studied at large. We strongly suggest Bekele et al to use more recent data because ref number 7 was studied in 2001. However, we believed that patient satisfaction increases with increasing adherence by reducing morbidity and mortality among breast cancer patients.⁸

As per comorbidity, the authors believe that those having comorbid illness likely to be non-adhered. We authors also support Bekele et al idea that multiple drugs prescription (polypharmacy) and the presence of comorbidity can reduce the patient’s adherence.⁹ On contrary, study conducted by Liu et al revealed that those with at least one comorbid illness were having odds of increasing adherence.⁵ Therefore, we the authors’ should recommend to use Charlson Comorbidity Index (CCI) to assess the presence of comorbidity and we should also pay special attention to those patients with multiple comorbidity.

Lastly, we the authors recommended specifically for health care workers to distribute the leaflets, the use of alarm as an alert for the elderly, and creation of adherence counselling to scale up adherence. Furthermore, Bekele et al recommended the establishment of the drug information centre at the hospital to address issues that affect patient adherence to the medication.