Breast Cancer and Cancer

¶ … treatment using the drug, tamoxifen, and higher mortality rates in females aged over forty years. The peer-reviewed papers employed for this study reveal a dynamic scrutiny of the aforementioned link. Quantitative as well as qualitative research works have been utilized, with a comparison and contrast made of the most apt methodology employed by the researchers. The end goal is ascertaining whether or not it is a risky decision to not adhere to tamoxifen treatment and how much information patients possess with regard to the drug and its effects.

The Research Question and its Importance

After the diagnosis of her health condition, Ms. Jones is prescribed tamoxifen as medication. For an entire year, Ms. Jones fails to consume this prescribed drug. Upon revisiting the hospital after a year of not complying with this recommended treatment plan, she is told that her cancer has reappeared and is much more lethal than before. She is told that she has only 6 months to live. Further, Ms. Jones claims a number of her relatives have also succumbed to this disease in the past, indicating a family history of cancer. Thus, she is worried that this disease will be the chief causative factor of her looming death. The sections that follow aim at ascertaining whether or not mortality due to breast cancer is accelerated if the patient fails to adhere to the medication prescribed.

Research Question

Does non-compliance with 'taxomifen' treatment lead to increased risk of mortality in elderly females diagnosed with breast cancer?

PICO Framework and Description of Each Element of the Research Question using the PICO Framework

P (Population): breast cancer patients

I (Intervention): Tamoxifen

C (Comparison): non-compliance

O (Outcome): heightened mortality risks

According to the ACS (American Cancer Society), breast cancer is one of the most frequently witnessed forms of cancer to be diagnosed, and is also the second greatest cause of death. Roughly two hundred thousand females receive breast cancer diagnoses per annum, with 40,000 succumbing to it (averagely), according to 2010 estimates (ACS, 2010). While progress has been achieved with respect to eliminating the disease, in the form of timely ailment predictions/diagnoses and therapeutic interventions, this form of cancer apparently reappears in 30% of patients, largely on account of their non-compliance with the prescribed tamoxifen chemotherapy. As it is an estrogen hormone-dependent growth, it commences and develops swiftly (Banerjee et al., 2003).

In the opinion of Chang (2012), tamoxifen is a major component of estrogen receptor positive (ER+) breast cancer therapy. Besides being employed for more than three decades, the drug is currently utilized in the form of chemo-preventer for females highly vulnerable to developing breast cancer. This triphenylethylene derivative is pharmacologically grouped among SERMs (selective estrogen receptor modulators) which is a uterine agonist but an antagonist when it comes to the breast. The drug is most frequently utilized as a chemotherapeutic agent to treat individuals suffering from ER+ breast cancer that accounts for nearly 70% of all surfacing cases. Tamoxifen functions in the form of a partial antagonist in the breasts (which are hormonesensitive), hampering estrogen receptor function by vying with the hormone to bind to the receptor (Banerjee et al., 2003). The bound estrogen receptor complex disallows gene activation by estrogen, resulting in estrogenic impact inhibition; estrogenic impacts are responsible for the development and spread of cancer cells (Chang et al., 2007). A number of ER+ cancer patients are intrinsically resistant to hormone treatment, irrespective of high estrogen receptor levels. A large number of patients suffering from localized cancer and almost every patient suffering from advanced forms of the disease and display initial positive response to tamoxife treatment gradually develop acquired (de novo) resistance to the drug (EBCTCG, 2005). Intriguingly, a number of patients who suffer relapse when on tamoxifen medication will display response to diverse kinds of hormonal manipulations. These include aromatase inhibitors or estrogen receptor antagonists/downregulators. This indicates that estrogen receptor is still a critical contributor to the advancement of breast cancer (Pike et al., 1993; Forbes et al.,2008; Mouridsenet al., 2009)

While the molecular processes which underlie tamoxifen medication resistance are still unclear, numerous mechanisms like differential metabolic tamoxifen activation, variations of crosstalk between growth factor-facilitated and estrogen receptor signaling pathways, estrogen receptor expression/function loss, dynamic oxidative stress responses, and the existence of estrogen receptor (-) cancer stem cells, have been suggested.

Significance of the Research Question to Nursing/Midwifery Practice

According to Chang (2012), tamoxifen is the most commonly recognized chemotherapy for females. In spite of its widespread recognition, there is a lack of its utilization among women. This paper aims at ascertaining the reasons underlying female non-compliance with amoxifen therapy and the effect this non-compliance has on their mortality rates, by acquiring insights into dynamics of tamoxifen-related knowledge (i.e., information regarding and attitude towards the medication, side-effects of medication consumption, etc.). This information is crucial to oncologists in devising strategies for decreasing tamoxifen resistance. Understanding the effect resistance to chemotherapy has on mortality rates is essential for oncologists in order to understand the reasons behind breast cancer mortalities. Furthermore, understanding the dynamics influencing chemotherapy resistance in patients may aid in preventing the actions by strategizing diverse measures.

Key Words and Combinations

P

I

C

O

Breast cancer patient

Breast cancer

Cancer

Breast

Breast cancer elderly women

Elderly women

Women

Pre-menopause

Post menopause

Elderly women

Aged women

Age

Tamoxifen medication

Anti-estrogen resistance

Estrogen resistance

Chemoprevention

Chemotherapy

Chemotherapy resistance

Tamoxifen advances

Tamoxifen estrogen

Taxomifen for breast cancer

Treatment

Breast cancer prevention

Estrogen

Medicine

Estrogen receptor resistance

Non-adherence

Adherence

Continuation

Discontinuation

Withdrawal

Recurrence

Resistance to drugs

Effects of tamoxifen

Side effects

Tamoxifen*effects

Oncology

Local recurrence

Increased mortality risk

Increased mortality rate

Death

Mortality reduction

Treatment

Breast cancer reoccurrence risk

Breast cancer reoccurrence

Search Strategy

Databases

PubMed

PubMed Central

Cochrane

Results- The Peer Reviewed Articles

1. Banning M (2012). Adherence to adjuvant therapy in post-menopausal breast cancer patients: a review cc_1295 1..10

https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0052637/

2. Kaplan, C. P., Kim, S. E., Wong, S. T., Sawaya, G. F., Walsh, J. M. E., & Perez-Stable, E. J. (2012). Willingness to use tamoxifen to prevent breast cancer among diverse women. Breast Cancer Research and Treatment, 133(1), 357 -- 366. http://doi.org/10.1007/s10549-012-1960-5

3. Fagerlin, A., Zikmund-Fisher, B. J., Smith, D. M., Nair, V., Derry, H. A., McClure, J. B., . . . Ubel, P. A. (2010). Women's decisions regarding tamoxifen for breast cancer prevention: Responses to a tailored decision aid. Breast Cancer Research and Treatment, 119(3), 613 -- 620. http://doi.org/10.1007/s10549-009-0618-4

4. De Souza, B. F., de Moraes, J. A., Inocenti, A., dos Santos, M. A., Silva, A. E. B. de C., &Miasso, A. I. (2014). Women with breast cancer taking chemotherapy: depression symptoms and treatment adherence. Revista Latino-Americana de Enfermagem, 22(5), 866 -- 873. http://doi.org/10.1590/0104-1169.3564.2491

5. Forbes S. A., Bhamra G, Bamford S, Dawson E, Kok C, Clements J, Menzies A, Teague JW, Futreal PA, Stratton MR. (2008) The Catalogue of Somatic Mutations in Cancer (COSMIC). Pubmed retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18428421

Table 1: Qualitative Studies

Article

Reference

(Authors and publication date)

Methodology

(i.e.: ethnography, phenomenology,)

Population

(how many participants, age, gender, disease, etc.)

Issue

(What was being studied)

Context

(What was the study setting?)

Outcome

(What were the main findings in relation to the issue?)

1

Fagerlin, A., Zikmund-Fisher, B. J., Smith, D. M., Nair, V., Derry, H. A., McClure, J. B., . . . Ubel, P. A. (2010).

Exploratory research

Females (aged between 40 and 74 years), highly susceptible to contracting primary breast cancer within the subsequent five years from a couple of large hospitals

Females' decisions with regard totamoxifento prevent breast cancer: Reactions to a personalized decision aid

A couple of hospitals or healthcare facilities

This is the most large-scale research work thus far to assess female preferences when it comes to consuming tamoxifen as well as one among the largest researches to have assessed the effect personalized decision support has. After looking at the decision aid, females exhibited sound awareness and grasp of the advantages and risks of consuming tamoxifen. A majority, however, did not display any interest in consuming it to prevent breast cancer.

Table 2: Observational Quantitative Studies

Article

Reference

(Authors and publication date)

Study Design

(i.e.: cohort)

Population

(How many participants, age, gender, disease, etc.?)

Issue

(e.g. the thing that is being measured)

Context

(What was the study setting?)

Outcome

(What was reported in relation to what was measured)

1

Banning M (2012).

Cohort study

Coupled with some experimental studies, randomized controlled trials, research papers and qualitative studies

Older females (50+ years of age). 4 research works involve females aged below fifty years

Taken from 871 handwritten and typed research articles

Adjuvant treatment compliance among post-menopausal patients of breast cancer

The research context was papers published from January 1999 to March 2011

Existing proofs on the evaluation of adjuvant treatment compliance among post-menopausal patients suggests that treatment compliance rates might be suboptimal. Thus, treatment effectiveness is doubtful and might elevate risks of disease reappearance whilst decreasing chances of survival.

2

Kaplan, C. P., Kim, S. E., Wong, S. T., Sawaya, G. F., Walsh, J. M. E., & Perez-Stable, E. J. (2012)

Screening, face-to-face interviews, multiple regression and telephonic survey

Females aged between fifty and eighty years, belonging to diverse ethnic groups (Whites, African-Americans, Asians, and Latinas)

Chemoprevention for preventing breast cancer development in highly vulnerable females remains limited in spite of clinical proofs demonstrating its advantages

Females taken from ambulatory practice

Over 40% of females reported they would probably consume tamoxifen if they were classified as highly susceptible, whereas 31% were unsure of whether they would consume such drugs. Less-literate Asian females lacking insurance coverage displayed a more positive attitude towards consuming the medication. Knowledge regarding the medicine as well as numeracy was linked to readiness to consume tamoxifen. With increased knowledge regarding the medication, patients displayed lesser likelihood of taking it. Numerous factors which impact chemoprevention medicine intake ability aren't related to awareness of risk/ benefit perception.

3

De Souza, B. F., de Moraes, J. A., Inocenti, A., dos Santos, M. A., Silva, A. E. B. de C., &Miasso, A. I. (2014).

A cross-sectional research using quantitative approach

112 females being administered chemotherapy

Breast cancer patients being administered chemotherapy: signs of depression and compliance with treatment

Pharmacy of Chemotherapy Center belonging to a large Brazilian university hospital

1.78% and 12.50% of patients reported "severe" and "moderate" depression, respectively. 10.59% were not on antidepressant treatment. A relationship of statistical significance was discovered between antidepressant usage and depression levels. 46.43% of study subjects reflected non-adherence. Conclusion: Study findings reveal a need for routinely screening for signs of depression and chemotherapy compliance in breast cancer patients, to allow for timely diagnosis and proper patient-focused treatment, besides improving the quality of life of patients.

Discussion

Banning (2012) based her paper on cohort studies and critical evaluation skills program. Her research was conducted with the aid of Advanced Google Scholar (search engine), Medline, PsychoInfor, Pubmed, Cochrane, British Nursing Index and other such databases. The keywords utilized were: "postmenstrual women", "older women", "breast cancer", "breast cancer patients", "tamoxifen", "compliance", and "adherence". Added methods included the employment of experimental studies, randomized controlled trials, research papers and quantitative studies. Searches were limited to English language resources. The research context was papers published from January 1999 to March 2011 as these are the most recent and offer the most valuable insights. 187 papers were utilized in all (these included hand-searched as well as electronically-searched papers). For enhancing data validity, the above articles were scanned. The research population was, chiefly, elderly females (aged 50+ years). A few papers, however, did use participants aged below fifty years.

Kaplan and coworkers (2012) studied females aged between fifty and eighty years, belonging to diverse ethnic groups (Whites, African-Americans, Asians, and Latinas) who had, within the past couple of years, visited any primary care doctor for seeking information on tamoxifen risks, advantages, and potential side-effects. Further, the researchers wished to determine factors associated with medication consumption readiness. The research made use of screening, face-to-face interviews, multiple regression and telephonic surveys to analyze demographics, health knowledge, history of breast cancer, and readiness to consume tamoxifen.