Oncology providers’ perspectives on endocrine therapy prescribing and management

Figures & data

Table 1 Final codebook descriptions and exemplary quotes

Code	Definition	Exemplary quotes
Age-based decision making	Description of how age influences prescribing behavior	“I think when you’re dealing with the more elderly women, I think quality of life is a more prominent feature and wondering, not worrying so much about the quantity. But when you’re dealing with younger women, it’s much more focused on kind of getting rid of the cancer and keeping it gone forever. So, there’s sort of a shift depending on the age and just temperament of the patient.”
Beliefs in line with behavior	Discussion of how patients’ beliefs are concordant/discordant with medication behavior	“Some of those patients just refuse to take anything. Some of them are pretty happy with surgical therapy. You know, they have an operation, they cut it out, they think they’re cured and no matter how much data you talk to them they just don’t want to take a pill.”
Comorbid conditions	Discussion of the influence of comorbidities on medication behavior	“So, earlier this month I saw a younger woman with DCIS. And you would normally consider tamoxifen but she has a history of recurrent venous- thrombo-embolic disease and I felt the chemo-prevention was outweighed by the risks of thrombo-embolic disease.”
Compelling arguments	Includes responses to “what is the most compelling argument for ET initiation?”	“And so, I almost stand on top of my head to beg them, you know […] And the things that I’ll tell them is that sometimes you’ll get an 85-, 90-year-old female to come in and there’s cancer growing all up their chest and you can put them on an aromatase inhibitors if they’re ER- or PR-positive. And that’s not chemotherapy. And all the disease will go away within a few months’ time. So, I’ll give them these extreme examples to try to show ‘this is how important this is’.”
Coping	Includes management strategies for reported patient side effects	“Well, with tamoxifen I try to stay away from any of the [antidepressants] that can have interference with tamoxifen metabolism. So, I tend to select Lexapro Effexor sometimes if the issue is more hot flashes than mood disorder. Then Effexor can be helpful. […] And then some folks just have hot flashes primarily at nighttime. Sometimes we’ll try Neurontin. And then I usually talk to people about, you know, exercise. You know, there’s data out there for acupuncture if they’re inclined toward that type of intervention. And oftentimes they’ll just get better with time, so encouraging just sticking it out and let’s see if it gets better. Or just environmental changes, you know, ‘What do you wear at night? What kind of sheets do you put on? Do you have a fan in your room,’ you know, things like that.”
Cost	Discussion of cost as a barrier or facilitator for ET use	“But nowadays, you know, all of them come in generic. So, they’re a whole lot cheaper. But, see, in the years past they might have been $450 a month; Femara was.”
Double-edged sword	Discussion of risks balanced with benefits	“I think most of them are weighing the wanting to get rid of the breast cancer. That’s probably their primary motivation. I think secondarily they’re thinking about issues of life expectancy and then I think it’s quality of life.”
Fear	Perceived patients’ fears influence on medication behavior	“Most people, they’re more scared about their breast cancer and so they want to be on these drugs.”
Fertility	Fertility as contraindicated to ET use	“We refer them to fertility specialists. We have a clinic and they go over the issues too. And I’ve had a handful of people who’ve gone off tamoxifen and gotten pregnant.”
Information seeking	Includes discussion of informational materials that providers use, including verbal, audio, and visual materials	“I think they use, patients tell me – I don’t know if they’re called ‘chat rooms’ or online, you know, kind of forums where people talk about their breast cancer diagnosis and their treatment. Patients get a lot of information from other breast cancer patients.”
Informational materials	Information that providers provide to improve adherence (eg, information from a study or a trial)	“We sit them and explain it but they get educational materials too. Anything that you can give for visual stimulation and also auditory. You know, sometimes I think it’s good to have a tape recording of your teaching of it and then they can listen to that tape recording again.”
Interventions	Intervention opportunities that providers use to get patients to initiate/adhere to ET	“We run a clinical trial in the office where they can sign for this clinical trial where they’ll get text messages to remind them every day or I will set up their iPhone for a daily reminder, you know, if they have that.”
Provider frustrations	Provider-reported challenges for influencing patient adherence	“We have a lot of alternative people … And they have such a mindset on the alternative medications that they won’t pick up what regular medicine does. And you try to teach the fool out of it. But this is few and far between.”
No-brainer	Discussion of the “obvious choice” of ET	“Most are pretty on board with it. I think, most (wouldn’t you?), when we’re talking about invasive cancer, I think most are scared of their breast cancer, and understandably so. So, I think most are willing to give a pill a try.”
Perceived (non) adherence	Discussion of how big of a problem nonadherence/persistence may be for their patients	“I would give you a guess [of nonadherence] would be 15%–20%.”
Perceived (non) initiation	Discussion of how big of a problem noninitiation may be for their patients	“Every once in a while you’ll have somebody like that [noninitiator]. You know, I’m just talking about a very, very small population.”
Perceived reasons for (non) adherence	Provider-perceived reasons for nonadherence/persistence among patients	“I’ve even had people skip it for long plane rides and things. So, I can’t come down too hard. But I do say ‘Look, in general it’s best to take all that’.”
Perceived reasons for (non) initiation	Provider-perceived reasons for noninitiation among patients	“[Some women are] looking at herbal things. And they don’t like taking regular medications. And so, sometimes they’re so holistic and so out there, you know, that they don’t want to pick up a medication [ET] like that.”
Prescribing decision making	Includes which patients get what/when, contraindications	“Postmenopausal, we generally go with the orals and it’s usually based on (several?) studies. So, most of our patients will be offered Arimidex first, since it was first and then depending on tolerance, they might get – in terms of an adjuvant setting, they might get switched over to one of the other hormonal therapies if they didn’t tolerate Arimidex.”
Provider dismissiveness	Dismissing side effects and concerns of patients, discussion of misattribution of side effects with ET among patients	“And, admittedly, there is a population of folks out there who – you know, I don’t want to in any way belittle their side effects but I think there’s a population who are looking for some sort of side effect to attribute to the medication as an excuse not to take it.”
Provider risk communication	Includes discussion of risk perception, risk of side effects, and cancer risk scores	“Usually you can sort of like draw a scale and say ‘OK, here’s the one thousandth chance that you’re going to get uterine cancer from tamoxifen if that’s what you’re worried about. Here’s, on the other side, your chance of dying from breast cancer will be changed by 100–1,000.’ So I say ‘Well, would you rather have $100 or one dollar? Which is more?’ And I’ll say ‘Well, then, this is what you want to do.’ And there’s usually some way you can get through and make sense of it.”
Rare complications	Discussion of rare complications to ET	“We know there’s endometrial cancer, blood clots.”
Reminders	Discussion of risk of side effects	“I tell them to put it in a place so that when they do their repetitive daily action, such as brushing their teeth or blow drying their hair or showering or whatever, they will see it and take it. Or use a pill box with Monday through Friday kind of thing.”
Research gap and recommendations	Perceived research gaps and recommendations	“I guess the only thing that I’m hopeful for, and I think there are some studies ongoing, are trying to understand who we can predict to be the patients who are going to be poorly tolerant of the aromatase inhibitors; either clinical factors or even, you know, sniff analysis and pharmaco-genomic studies will really help us, our pharmaco-genomic studies will really help us understand who may be less tolerant so we can go ahead and start intervention programs ahead of time.”
Risk of recurrence	Discussion of risk of recurrence	“You can calculate the risk of recurrence. The words ‘high,’ ‘low risk,’ you know, mean many different things.”
Risk of side effects	Discussion of risk of side effects	“You know, most people want to know what the side effects and risks are.”
Shared decision making	Description of shared decision-making process around ET	“I mean I think modern breast cancer therapy is very much a collaborative doctor–patient situation for most of us. I mean, you know, I think it’s pretty rare for somebody to sort of give me the impression that she wanted to go ahead and proceed with therapy, take the prescription and then not do it.”
Side effects: cognition	Description of patient report of cognitive side effects, includes things such as cognitive lapses, due to ET	“I’ve had a few patients that they feel like they’re […] in a fog.”
Side effects: cosmetic	Description of patient experiences with hair loss and other cosmetic issues due to ET	“I would say cosmetic symptoms … changes in hair pattern. Those are always disturbing.”
Side effects: hot flashes	Description of experiences with hot flashes due to ET	“So, for the tamoxifen, you know, for the younger women, hot flashes is probably the number one.”
Side effects: joint/bone pain	Description of experiences with joint/bone due to ET; also includes leg cramps	“So, they tend to have more trouble. And then the joint pains is the other main symptomatic issue. And the classic, from my reading of the literature and my experience, what I think is the classic is the hand, you know, swelling and pain, stiffness in the hands.”
Side effects: mood	Description of experiences with mood swings/mental health issues associated by patients with ET; also includes leg cramps	“So, and actually mood disturbance too, you know, feeling irritable. I think that probably is real to some extent for some folks.”
Side effects: other	Discussion of other side effects attributed by patients to ET	“I’ve had a few patients that they feel like they’re nauseous while taking the medicine.”
Side effects: overwhelming	Instances when patients explicitly discuss side effects as “overwhelming” or quit ET because the side effects are overwhelming	“Other patients have tried it for a brief period of time and just felt like they don’t tolerate it. They have joint aches and pains that are just unbearable and tamoxifen wouldn’t be an option for them due to previous clotting or stroke history after trying all the AIs.”
Side effects: sexual function	Description of patient experiences with sexual function due to ET	“No. It’s more about – the other big issue on both of them is obviously loss of libido, vaginal dryness, lack of interest, and then how to deal with that. So, I generally have a sexuality conversation with all the patients and ask them how that’s going and if they’re having any symptoms or any problems.”
Side effects: weight gain	Description of patient experiences with weight gain due to ET	“Sometimes we’ll see some weight gain. The literature doesn’t suggest that they’re going to have weight gain, but I definitely see it.”

Abbreviations: AIs, aromatase inhibitors; ET, endocrine therapy; DCIS, ductal carcinoma in situ; ER, estrogen receptor; PR, progesterone receptor.

Table 2 Descriptive characteristics of oncology providers interviewed

Characteristics	Mean, %
Age (years)	47.8
Provider role (%)
Medical doctor	70.0
Nurse practitioner	20.0
Physicians assistant	10.0
Years since training	17.3
Patient mix (% breast cancer patients)	68.0
Patient load (per week)	32.9
Practice setting (%)
Urban	40.0
Rural	5.0
Suburban	55.0
Academic (vs nonacademic) (%)	55.0

Table 3 Salience of coded concepts in interview data

Code	Code frequency	% Providers who mentioned code
Coping	94	100
Perceived (non) initiation	52	100
Perceived reasons for (non) adherence	59	100
Prescribing decision making	90	100
Provider risk communication	77	100
Side effects: hot flashes	40	100
Perceived (non) adherence	36	95
Side effects: joint/bone pain	42	95
Risk of recurrence	41	90
Perceived reasons for (non) initiation	60	80
Compelling arguments	17	75
Risk of side effects	36	75
Side effects: other	20	55
Side effects: sexual function	14	50
Double-edged sword	14	45
Informational materials	15	45
Rare complications	9	45
Side effects: overwhelming	9	45
Research gap and recommendations	10	40
Information seeking	9	35
Beliefs in line with behavior	9	30
Fertility	6	30
Reminders	9	30
Side effects: mood	7	30
Age-based decision making	8	25
Provider frustrations	5	25
Provider dismissiveness	9	20
Shared decision making	6	20
Side effects: cosmetic	4	20
Side effects: cognition	4	15
Fear	2	10
Interventions	3	10
No-brainer	2	10
Side effects: weight gain	3	10
Comorbid conditions	2	5