Smith S G, Sestak I, Forster A, Partridge A, Side L, Wolf M S, Horne R, Wardle J, Cuzick J
Wolfson Institute of Preventive Medicine, Queen Mary University of London, London Health Behaviour Research Centre, University College London, London, UK
Wolfson Institute of Preventive Medicine, Queen Mary University of London, London.
Ann Oncol. 2016 Apr;27(4):575-90. doi: 10.1093/annonc/mdv590. Epub 2015 Dec 8.
Preventive therapy is a risk reduction option for women who have an increased risk of breast cancer. The effectiveness of preventive therapy to reduce breast cancer incidence depends on adequate levels of uptake and adherence to therapy. We aimed to systematically review articles reporting uptake and adherence to therapeutic agents to prevent breast cancer among women at increased risk, and identify the psychological, clinical and demographic factors affecting these outcomes.
Searches were carried out in PubMed, CINAHL, EMBASE and PsychInfo, yielding 3851 unique articles. Title, abstract and full text screening left 53 articles, and a further 4 studies were identified from reference lists, giving a total of 57. This review was prospectively registered with PROSPERO (CRD42014014957).
Twenty-four articles reporting 26 studies of uptake in 21 423 women were included in a meta-analysis. The pooled uptake estimate was 16.3% [95% confidence interval (CI) 13.6-19.0], with high heterogeneity (I(2) = 98.9%, P < 0.001). Uptake was unaffected by study location or agent, but was significantly higher in trials [25.2% (95% CI 18.3-32.2)] than in non-trial settings [8.7% (95% CI 6.8-10.9)] (P < 0.001). Factors associated with higher uptake included having an abnormal biopsy, a physician recommendation, higher objective risk, fewer side-effect or trial concerns, and older age. Adherence (day-to-day use or persistence) over the first year was adequate. However, only one study reported a persistence of ≥ 80% by 5 years. Factors associated with lower adherence included allocation to tamoxifen (versus placebo or raloxifene), depression, smoking and older age. Risk of breast cancer was discussed in all qualitative studies.
Uptake of therapeutic agents for the prevention of breast cancer is low, and long-term persistence is often insufficient for women to experience the full preventive effect. Uptake is higher in trials, suggesting further work should focus on implementing preventive therapy within routine care.
预防性治疗是降低乳腺癌风险增加女性患癌风险的一种选择。预防性治疗降低乳腺癌发病率的有效性取决于足够的治疗接受率和依从性。我们旨在系统回顾报告乳腺癌风险增加女性接受和依从预防乳腺癌治疗药物情况的文章，并确定影响这些结果的心理、临床和人口统计学因素。
在PubMed、CINAHL、EMBASE和PsychInfo中进行检索，共得到3851篇独特的文章。通过标题、摘要和全文筛选，最终留下53篇文章，另外从参考文献列表中又确定了4项研究，总计57篇。本综述已在PROSPERO（CRD42014014957）上进行了前瞻性注册。
纳入了24篇报告对21423名女性进行26项接受情况研究的文章进行荟萃分析。汇总的接受率估计为16.3%[95%置信区间（CI）13.6 - 19.0]，异质性较高（I² = 98.9%，P < 0.001）。接受率不受研究地点或药物影响，但在试验中[25.2%（95% CI 18.3 - 32.2）]显著高于非试验环境[8.7%（95% CI 6.8 - 10.9）]（P < 0.001）。与较高接受率相关的因素包括活检异常、医生建议、客观风险较高、副作用或试验担忧较少以及年龄较大。第一年的依从性（日常使用或持续用药）较好。然而，只有一项研究报告5年时持续用药率≥80%。与较低依从性相关的因素包括分配使用他莫昔芬（与安慰剂或雷洛昔芬相比）、抑郁、吸烟和年龄较大。所有定性研究都讨论了乳腺癌风险。
预防乳腺癌治疗药物的接受率较低，长期持续用药往往不足以使女性充分获得预防效果。试验中的接受率较高，这表明进一步的工作应侧重于在常规护理中实施预防性治疗。
