Facilitators and barriers to reducing chemotherapy for early-stage breast cancer: a qualitative analysis of interviews with patients and patient advocates

Abstract

Background As the combination of systemic and targeted chemotherapies is associated with severe adverse side effects and long-term health complications, there is interest in reducing treatment intensity for patients with early-stage breast cancer (EBC). Clinical trials are needed to determine the feasibility of reducing treatment intensity while maintaining 3-year recurrence-free survival of greater than 92%. To recruit participants for these trials, it is important to understand patient perspectives on reducing chemotherapy. Methods We collected qualitative interview data from twenty-four patients with Stage II-III breast cancer and sixteen patient advocates. Interviews explored potential barriers and facilitators to participation in trials testing reduced amounts of chemotherapy. As the COVID-19 pandemic struck during data collection, seventeen participants were asked about the potential impact of COVID-19 on their interest in these trials. Interviews were audio-recorded and transcribed, and researchers used qualitative content analysis to code for dominant themes. Results Seventeen participants (42.5%) expressed interest in participating in a trial of reduced chemotherapy. Barriers to reducing chemotherapy included (1) fear of recurrence and inefficacy, (2) preference for aggressive treatment, (3) disinterest in clinical trials, (4) lack of information about expected outcomes, (5) fear of regret, and (6) having young children. Facilitators included (1) avoiding physical toxicity, (2) understanding the scientific rationale of reducing chemotherapy, (3) confidence in providers, (4) consistent monitoring and the option to increase dosage, (5) fewer financial and logistical challenges, and (6) contributing to scientific knowledge. Of those asked, nearly all participants said they would be more motivated to reduce treatment intensity in the context of COVID-19, primarily to avoid exposure to the virus while receiving treatment. Conclusions Among individuals with EBC, there is significant interest in alleviating treatment-related toxicity by reducing chemotherapeutic intensity. Patients will be more apt to participate in trials testing reduced amounts of chemotherapy if these are framed in terms of customizing treatment to the individual patient and added benefit—reduced toxicities, higher quality of life during treatment and lower risk of long-term complications—rather than in terms of taking treatments away or doing less than the standard of care. Doctor-patient rapport and provider support will be crucial in this process.

Oncologist-Reported Barriers and Facilitators to Enrolling Patients in Optimization Trials That Test Less Intense Cancer Treatment

“…1 By contrast, one of the strongest facilitators for optimization trial participation was recommendation by the physician to participate in the trial. 2 This finding underscored the importance of the physician's role in trial recruitment, which has been previously reported as a key driver in more traditional clinical trials. 3 Optimization trials may be uniquely accessible to community oncology practices because of the use of standard-of-care medications, which are available on-site and do not require learning new side effect profiles.…”

“…1 By contrast, one of the strongest facilitators for optimization trial participation was recommendation by the physician to participate in the trial. 2 This finding underscored the importance of the physician's role in trial recruitment, which has been previously reported as a key driver in more traditional clinical trials. 3…”

Where are the inequalities in colorectal cancer care in a country with universal healthcare? A systematic review and narrative synthesis

“…There was strong evidence that patients from more deprived areas were less likely to receive chemotherapy or combination adjuvant chemotherapy. Trust in clinicians, financial and employment factors, social support, adequate communication and provision of information are critical in influencing the use of chemotherapy 58–61. These, among other uncaptured factors such as comorbidity or frailty, could be responsible for the observed inequalities.…”

“…Trust in clinicians, financial and employment factors, social support, adequate communication and provision of information are critical in influencing the use of chemotherapy. [58][59][60][61] These, among other uncaptured factors such as comorbidity or frailty, could be responsible for the observed inequalities.…”

“Clinical trials are space travel”: Factors of psychological response to recurrence among oncologists enrolling patients in treatment optimization trials

“…This qualitative sub‐study is part of a larger project evaluating oncologist perspectives on optimization‐focused clinical trials for breast cancer patients. 2 , 5 Purposive sampling techniques were utilized to identify a balanced convenience sample of oncologists according to setting, gender, ethnicity, age, years of experience, and geographic location. In‐depth sample methodology and oncologist characteristics are described elsewhere.…”