Research Article| Volume 62, 102259, February 2023

Facing points of view: Representations on adjuvant endocrine therapy of premenopausal patients after breast cancer and their healthcare providers in France. The FOR-AD study

Published:December 26, 2022DOI:


      • Long-term adherence is a challenge for people prescribed with adjuvant endocrine therapy.
      • The FOR-AD study helps understand the benefits and disadvantages of this treatment for patients, but also for HCP.
      • This study highlights the importance of the patient/HCP relationship in adhering to adjuvant ET.
      • Participants suggest the role of a nurse navigator to improve the care process and facilitate the patient/HCP relationship.



      Adjuvant endocrine therapy (ET) for 5–10 years is the backbone of the therapeutic strategy in patients with hormone receptor positive (HR+) early breast cancer (BC). However, long-term adherence to adjuvant ET represents a major challenge for most patients. According to prior studies, side effects of adjuvant ET are an important reason for poor adherence. In contrast, better communication and relational bond between patients and healthcare providers (HCPs) may improve adherence. The FOR-AD (Focus on non-adherence) study aimed at better understanding the representation of adjuvant ET by patients and their HCPs, in order to improve the care process.


      Three focus groups of premenopausal women (receiving adjuvant ET for variable amount of time) and two focus groups of HCPs (including oncologists, pharmacists, and nurses) were conducted, each including around ten participants. Thematic analyses using a general inductive approach were constructed to report participants’ representations.


      Two main themes emerged across groups, and appeared of major importance.
      Representations on adjuvant ET were often homogenous within each group, but differed between patients and their HCPs. The relationship between both groups was considerably discussed, particularly its importance in facilitating adherence to adjuvant ET. Suggestions on improving the care process were also given, such as systematically including psychologists in follow-up care paths and having a nurse navigator follow patients under treatment with adjuvant ET.


      The present qualitative exploration may help buildi future tailored interventions to improve adherence to adjuvant ET, in particular regarding the role of nurse navigators.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Oncology Nursing
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • AlOmeir O.
        • Patel N.
        • Donyai P.
        Adherence to adjuvant endocrine therapy among breast cancer survivors: a systematic review and meta-synthesis of the qualitative literature using grounded theory.
        Support. Care Cancer. 2020; 28: 5075-5084
        • Arch J.J.
        • Crespi C.M.
        • Levin M.E.
        • Genung S.R.
        • Nealis M.
        • Mitchell J.L.
        • et al.
        Randomized controlled pilot trial of a low-touch remotely-delivered values intervention to promote adherence to adjuvant endocrine therapy among breast cancer survivors.
        Ann. Behav. Med. 2022; 56: 856-871
        • Barron T.I.
        • Cahir C.
        • Sharp L.
        • Bennett K.
        A nested case-control study of adjuvant hormonal therapy persistence and compliance, and early breast cancer recurrence in women with stage I-III breast cancer.
        Br. J. Cancer. 2013; 109: 1513-1521
        • Blanchette P.S.
        • Lam M.
        • Richard L.
        • Allen B.
        • Shariff S.Z.
        • Vandenberg T.
        • Earle C.C.
        Factors associated with endocrine therapy adherence among post-menopausal women treated for early-stage breast cancer in Ontario, Canada.
        Breast Cancer Res. Treat. 2020; 179: 217-227
        • Brier M.J.
        • Chambless D.L.
        • Gross R.
        • Chen J.
        • Mao J.J.
        Perceived barriers to treatment predict adherence to aromatase inhibitors among breast cancer survivors.
        Cancer. 2017; 123: 169-176
        • Cañadas-De la Fuente G.A.
        • Gómez-Urquiza J.L.
        • Ortega-Campos E.M.
        • Cañadas G.R.
        • Albendín‐García L.
        • De la Fuente‐Solana E.I.
        Prevalence of burnout syndrome in oncology nursing: a meta-analytic study.
        Psycho Oncol. 2018; 27: 1426-1433
        • Cardoso F.
        • Kyriakides S.
        • Ohno S.
        • Penault-Llorca F.
        • Poortmans P.
        • Rubio I.T.
        • Zackrisson S.
        • Senkus E.
        Early breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.
        Ann. Oncol. 2019; 30: 1194-1220
        • Case M.A.B.
        Oncology nurse navigator: ensuring safe passage.
        Clin. J. Oncol. Nurs. 2011; 15: 33
        • Cazzaniga M.E.
        • Giordano M.
        • Bandera M.
        • Cassani C.
        • Bounous V.
        • Lania A.
        • Pagani O.
        Managing menopausal symptoms in young women with breast cancer: when medicine is not all. The Take Care Project.
        Clin. Breast Cancer. 2021; 21: 547-560
        • Early Breast Cancer Trialists' Collaborative Group
        Aromatase inhibitors versus tamoxifen in early breast cancer: patient-level meta-analysis of the randomised trials.
        Lancet. 2015; 386: 1341-1352
        • Fink A.K.
        • Gurwitz J.
        • Rakowski W.
        • Guadagnoli E.
        • Silliman R.A.
        Patient beliefs and tamoxifen discontinuance in older women with estrogen receptor-positive breast cancer.
        J. Clin. Oncol. 2004; 22: 3309-3315
        • Santé Publique France
        Cancer du sein.
        (Available at :)
        • Franzoi M.A.
        • Agostinetto E.
        • Perachino M.
        • Del Mastro L.
        • de Azambuja E.
        • Vaz-Luis I.
        • et al.
        Evidence-based approaches for the management of side-effects of adjuvant endocrine therapy in patients with breast cancer.
        Lancet Oncol. 2021; 22: 303-313
        • Gagné M.
        • Lauzier S.
        • Lemay M.
        • Loiselle C.G.
        • Provencher L.
        • Simard C.
        • Guillaumie L.
        Women with breast cancer’s perceptions of nurse-led telephone-based motivational interviewing consultations to enhance adherence to adjuvant endocrine therapy: a qualitative study.
        Support. Care Cancer. 2022; 30: 4759-4768
        • Greenlee H.
        • DuPont‐Reyes M.J.
        • Balneaves L.G.
        • Carlson L.E.
        • Cohen M.R.
        • Deng G.
        • et al.
        Clinical practice guidelines on the evidence‐based use of integrative therapies during and after breast cancer treatment.
        CA Cancer J. Clin. 2017; 67: 194-232
        • Gudenkauf L.M.
        • Ehlers S.L.
        Psychosocial interventions in breast cancer survivorship care.
        Breast. 2018; 38: 1-6
        • Haggstrom L.R.
        • Vardy J.L.
        • Carson E.K.
        • Segara D.
        • Lim E.
        • Kiely B.E.
        Effects of endocrine therapy on cognitive function in patients with breast cancer: a comprehensive review.
        Cancers. 2022; 14: 920
        • Haidinger R.
        • Bauerfeind I.
        Long-Term side effects of adjuvant therapy in primary breast cancer patients: Results of a web-based survey.
        Breast Care. 2019; 14: 111-116
        • Harrow A.
        • Dryden R.
        • McCowan C.
        • Radley A.
        • Radley A.
        • Parsons M.
        • Thompson A.M.
        • Wells M.
        A hard pill to swallow: a qualitative study of women's experiences of adjuvant endocrine therapy for breast cancer.
        BMJ Open. 2014; 4
      1. Kitzinger J. Barbour R. Developing Focus Group Research: Politics, Theory and Practice. Sage, 1999
        • Kjoe P.R.L.M.
        • van der Wall E.
        • Schagen S.B.
        Endocrine therapy with or without CDK4/6 inhibitors in women with hormone-receptor positive breast cancer: what do we know about the effects on cognition?.
        Clin. Breast Cancer. 2021;
        • Laor-Maayany R.
        • Goldzweig G.
        • Hasson-Ohayon I.
        • Bar-Sela G.
        • Engler-Gross A.
        • Braun M.
        Compassion fatigue among oncologists: the role of grief, sense of failure, and exposure to suffering and death.
        Support. Care Cancer. 2020; 28: 2025-2031
        • Lin C.
        • Clark R.
        • Tu P.
        • Bosworth H.B.
        • Zullig L.L.
        Breast cancer oral anti-cancer medication adherence: a systematic review of psychosocial motivators and barriers.
        Breast Cancer Res. Treat. 2017; 165: 247-260
        • Liu Y.
        • Malin J.L.
        • Diamant A.L.
        • Thind A.
        • Maly R.C.
        Adherence to adjuvant hormone therapy in low-income women with breast cancer: the role of provider–patient communication.
        Breast Cancer Res. Treat. 2013; 137: 829-836
        • Llarena N.C.
        • Estevez S.L.
        • Tucker S.L.
        • Jeruss J.S.
        Impact of fertility concerns on tamoxifen initiation and persistence.
        J. Natl. Cancer Inst. 2015; 107: djv202
        • Mausbach B.T.
        • Schwab R.B.
        • Irwin S.A.
        Depression as a predictor of adherence to adjuvant endocrine therapy (AET) in women with breast cancer: a systematic review and meta-analysis.
        Breast Cancer Res. Treat. 2015; 152 (doi : 1007/s10549-015-3471-7): 239-246
        • McCowan C.
        • Wang S.
        • Thompson A.M.
        • Makubate B.
        • Petrie D.J.
        The value of high adherence to tamoxifen in women with breast cancer: a community-based cohort study.
        Br. J. Cancer. 2013; 109: 1172-1180
        • Meneveau M.O.
        • Keim-Malpass J.
        • Camacho T.F.
        • Anderson R.T.
        • Showalter S.L.
        Predicting adjuvant endocrine therapy initiation and adherence among older women with early-stage breast cancer.
        Breast Cancer Res. Treat. 2020; 184: 805-816
        • Murphy C.C.
        • Bartholomew L.K.
        • Carpentier M.Y.
        • Bluethmann S.M.
        • Vernon S.W.
        Adherence to adjuvant hormonal therapy among breast cancer survivors in clinical practice: a systematic review.
        Breast Cancer Res. Treat. 2012; 134: 459-478
        • National Cancer Institute
        Online Dictionary of Cancer Terms.
        2021 (December 10)
        • Nestoriuc Y.
        • Von Blanckenburg P.
        • Schuricht F.
        • Barsky A.J.
        • Hadji P.
        • Albert U.S.
        • Rief W.
        Is it best to expect the worst? Influence of patients’ side-effect expectations on endocrine treatment outcome in a 2-year prospective clinical cohort study.
        Ann. Oncol. 2016; 27: 1909-1915
        • Partridge A.
        • Wang P.S.
        • Winer E.P.
        • Avorn J.
        Nonadherence to adjuvant tamoxifen therapy in women with primary breast cancer.
        J. Clin. Oncol. 2003; 21: 602-606
        • Partridge A.H.
        • Fasse K.
        • Stanton A.L.
        • Jones A.
        • Bright E.
        • Petrie K.J.
        Abstract P5-12-13: what Goes through Your Mind when You Think about Your Medication? Thoughts about Endocrine Medication and Treatment Adherence.
        San Antonio Breast Cancer Symposium, San Antonio, TX2016
        • Pistill i B.
        • Paci A.
        • Ferreira A.
        • Di Meglio A.
        • Poinsignon V.
        • Bardet A.
        • et al.
        Serum detection of nonadherence to adjuvant tamoxifen and breast cancer recurrence risk.
        J. Clin. Oncol. 2020; 38: 2762-2772
        • Rivers A.S.
        • Sanford K.
        • Elkins G.
        • Carpenter J.S.
        • Rand K.L.
        • Bartlett Ellis R.J.
        Attitudinal and social predictors of adherence to oral endocrine therapy: a psychometrically-informed model.
        J. Health Psychol. 2022; 27: 913-922
        • Rosenberg S.M.
        • Stanton A.L.
        • Petrie K.J.
        • Partridge A.H.
        Symptoms and symptom attribution among women on endocrine therapy for breast cancer.
        The Oncologist. 2015; 20: 598-604
        • Ruddy K.
        • Mayer E.
        • Partridge A.
        Patient adherence and persistence with oral anticancer treatment.
        CA Cancer J. Clin. 2009; 59: 56-66
        • Saunders B.
        • Sim J.
        • Kingstone T.
        • Baker S.
        • Waterfield J.
        • Bartlam B.
        • et al.
        Saturation in qualitative research: exploring its conceptualization and operationalization.
        Qual. Quantity. 2018; 52: 1893-1907
        • Shanafelt T.
        • Adjei A.
        • Meyskens F.L.
        When your favorite patient relapses: physician grief and well-being in the practice of oncology.
        J. Clin. Oncol. 2003; 21: 2616-2619
        • Smith J.A.
        Qualitative psychology: a practical guide to research methods.
        Sage. 2015;
        • Stewart D.W.
        • Shamdasani P.
        Online focus groups.
        J. Advert. 2017; 46: 48-60
        • Thomas D.R.
        A general inductive approach for analyzing qualitative evaluation data.
        Am. J. Eval. 2006; 27: 237-246
        • Toivonen K.I.
        • Oberoi D.
        • King-Shier K.
        • Piedalue K.A.L.
        • Rash J.A.
        • Carlson L.E.
        • Campbell T.S.
        Both “vitamin L for life” and “one milligram of satan”: a multi-perspective qualitative exploration of adjuvant endocrine therapy use after breast cancer.
        Curr. Oncol. 2021; 28: 2496-2515
        • Tong A.
        • Sainsbury P.
        • Craig J.
        Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.
        Int. J. Qual. Health Care. 2007; 19: 349-357
        • Trufelli D.C.
        • Bensi C.G.
        • Garcia J.B.
        • Narahara J.L.
        • Abrão M.N.
        • Diniz R.W.
        • et al.
        Burnout in cancer professionals: a systematic review and meta-analysis.
        Eur. J. Cancer Care. 2008; 17: 524-531
        • Underwood E.A.
        • Rochon P.
        • Moineddin R.
        • Lee P.E.
        • Wu W.
        • Pritchard K.I.
        • Tierney M.C.
        Cognitive sequelae of endocrine therapy in women treated for breast cancer: a meta-analysis.
        Breast Cancer Res. Treat. 2018; 168: 299-310
        • van Beusekom M.
        • Cameron J.
        • Bedi C.
        • Banks E.
        • Harris R.
        • Humphris G.
        Using Co-design with breast cancer patients and radiographers to develop “KEW” communication skills training.
        Front. Psychol. 2021; 12
        • van Herk-Sukel M.P.
        • van de Poll-Franse L.V.
        • Voogd A.C.
        • Nieuwenhuijzen G.A.
        • Coebergh J.W.W.
        • Herings R.
        Half of breast cancer patients discontinue tamoxifen and anyendocrine treatment before the end of the recommended treatment period of 5 years: a population-based analysis.
        Breast Cancer Res. Treat. 2010; 122: 843-851
        • Verbrugghe M.
        • Verhaeghe S.
        • Decoene E.
        • De Baere S.
        • Vandendorpe B.
        • Van Hecke A.
        Factors influencing the process of medication (non-)adherence and (non-)persistence in breast cancer patients with adjuvant antihormonal therapy: a qualitative study.
        Eur. J. Cancer Care. 2017; 26
        • von Blanckenburg P.
        • Schuricht F.
        • Albert U.S.
        • Rief W.
        • Nestoriuc Y.
        Optimizing expectations to prevent side effects and enhance quality of life in breast cancer patients undergoing endocrine therapy: study protocol of a randomized controlled trial.
        BMC Cancer. 2013; 13: 1-10
        • Waingort E.
        Everything you always wanted to know about focus group research but were afraid to ask.
        Qual. Rep. 2013; 18
        • World Health Organization
        (Available at :)
        Date: 2021
        Date accessed: September 21, 2021