NewsMakers
Why breast cancer survivors don’t take their medication, and what can be done
For roughly 80% of breast cancer survivors, treatment doesn’t end with surgery, radiation and chemotherapy. Instead, for the next five to 10 years, doctors recommend that they take medication to block sex hormones, which can fuel tumor growth and spark recurrence.
For roughly 80% of breast cancer survivors, treatment doesn’t end with surgery, radiation and chemotherapy. Instead, for the next five to 10 years, doctors recommend that they take medication to block sex hormones, which can fuel tumor growth and spark recurrence.
The drugs are life-saving: They’ve been shown to cut risk of cancer recurrence by as much as half in patients with hormone receptor-positive tumors (HR+)—the most common form of breast cancer. Yet despite their promised benefits, 40% of patients stop taking them early and a third take them less frequently than directed.
New CU Boulder research, published this month in the Journal of Clinical Oncology, sheds light on why that is and what doctors and the health care system can do about it.
It found that, overall, interventions can increase medication adherence by nearly 1.5 times. But some strategies work better than others.
“Our bottom-line finding is that there are strategies that do work in supporting women to take these life-extending medications, and that we as a cancer care community need to do better,” said senior author Joanna Arch, a professor in the Department of Psychology and Neuroscience and member of the CU Cancer Center on the Anschutz Medical Campus.
Arch noted these so-called “adjuvant endocrine therapies,” like the estrogen-blockers Tamoxifen and aromatase inhibitors, can be costly and come with a host of side effects, including weight gain, sexual side effects, joint pain, depression and sleeplessness.
“Imagine going from your normal estrogen activity to little or no estrogen within days. That’s what these medications do,” she said. “But the women who take them as prescribed also have lower recurrence rates and live longer. It’s a dilemma.”
As more next-generation cancer drugs, including chemotherapy agents, shift from infusions provided in a clinic to oral therapies taken at home, the medical community has grown increasingly interested in developing ways to make sure patients take their pills.
In a sweeping meta-analysis, Arch and her colleagues analyzed 25 studies representing about 368,000 women to gain insight into what works and what doesn’t.
Educational pamphlets are not enough
The study found that cost-cutting policy changes, such as providing generic alternatives or requiring insurance companies to cover pills at the same level as infusions, consistently worked. Such “oral parity laws” have been passed in 43 states in recent years.
In one study, participants were asked to create stickers to put on their pill boxes.
Mobile apps and texts to remind patients to take their medication and psychological/coping strategies also yielded modest improvements.
The study’s findings around managing side effects were complicated: Simply educating women on side effects, via pamphlets or verbal explanations, generally failed to increase the likelihood that women took their medication as directed.
But things such as physical therapy, exercise and behavioral counseling aimed at alleviating or managing side effects often worked.
“Education in and of itself is not enough. That is a clear finding,” said Arch, suggesting that doctors write referrals to practitioners who specialize in side effects and follow up with appointment reminders. “Most oncologists, I believe, don’t realize how low adherence is for these women. They assume that if they write the prescription, it’s being taken.”
Addressing mental health is key
One study included in the meta-analysis was Arch’s own.
In it, women were asked to identify their primary motivation for taking their medication—whether it was living to see their child or grandchild grow up, pursuing their art or running a marathon someday. Via an online program, they created a sticker with a photo representing that goal, and the words “I take this for…” below it. Then, they stuck it on their pill box.
Participants were more likely to take their pills, at least for the first month, than those who didn’t.
“Even just a tiny thing like this can help,” said Arch.
Notably, very few studies looked at whether treating depression can help. Arch, aiming to fill this gap, recently launched her own pilot trial.
“One of the most consistent predictors of not adhering to any medication is depression,” she said. “Depression taps motivation.”
The new Journal of Clinical Oncology study is the first meta-analysis to show that interventions can be helpful, and that’s important, said Arch, because insurance companies need data to make decisions about what to cover.
But the study also showed that the effects are relatively modest and that there is room for improvement.
Arch said she hopes the study will spark more research into novel ways to support survivors:
“We have a lot of work to do.”
NewsMakers
Telling people they might lose motivates more than telling them they might win, research shows
How managers choose to frame problems directly influences employees’ motivation to speak up at work. For managers, this is an insightful approach for building more open and collaborative teams.
Athletes say they hate to lose more than they love to win. New research finds the same sentiment is shared in organizations.
A Virginia Tech researcher and his colleagues discovered that when managers frame work problems as a potential loss, employees are more likely to take action than when those problems are framed as potential gains. The research also revealed that when the potential loss impacts a larger group, employees are more likely to take action in the form of speaking up to a supervisor in hopes of finding a solution. The findings were recently published in the Journal of Applied Psychology.
For managers, this research suggests that framing work problems as potential losses can influence employees to speak up more.
“Employee voice occurs when suggestions are made to improve organizational functioning,” said Phil Thompson, associate professor in the Pamplin College of Business Department of Management. “From an organizational perspective, the positive outcomes of employee voice include improved performance, effectiveness, and workplace safety. From an employee level, speaking up is positively related to creativity, innovation, engagement, and ethical behavior.”
At its core, this research shows that how managers choose to frame problems directly influences employees’ motivation to speak up at work. For managers, this is an insightful approach for building more open and collaborative teams.
“When managers say, ‘If we don’t get this done, not only will you lose the $5,000 bonus, but everybody in this work group is going to lose a $5,000 bonus,’ it magnifies an employee’s motivation to act in a proactive way,” said Thompson. “This suggests that framing work problems as what will be collectively lost – compared to what can be individually lost – makes employees want to speak up more.”
Thompson was part of a research team led by Jeffery Thomas and Jonathan Booth from The London School of Economics and Mark Bolino from Oklahoma University. Together they analyzed responses from nearly 2,000 full-time employees, MBA students, and employee-supervisor pairs for their experience in situations where work problems were framed as either a gain or a loss. Across three different studies, framing something as a loss yielded employees to voice a work suggestion more.
For example, a manager dealing with a reputational crisis of their team, such as a product quality issue, can frame the problem in a way to spark helpful employee suggestions on how to resolve the issue. For example, instead of saying “if this product has great quality, our company will look really good” a manager saying “if this product is not up to quality standards, our reputation will be damaged” carries more weight for the team. When this reputational risk is shared by everyone, employees are more willing to step forward to help the problem.
In the first study, participants were asked to think about a problem at work that was significant for them. From there, they were randomly assigned to write about the potential losses or gains from that problem. They were also asked to indicate how likely they were to talk about these problems to their supervisor. Participants who reflected on their potential losses showed a 16 percent higher willingness to speak up compared to those who focused on the potential gains.
When it came to the MBA students, they read a fictional performance review scenario where a workplace problem was described. They then rated how willing they would be to speak up about that scenario if they were in the situation. One example suggested that the entire team might fall short of its goals if an issue was not addressed. This specific scenario yielded the most likelihood of speaking up 35 percent more than the scenario’s suggesting that only they would miss their goal, supporting the research’s findings that an employee is more likely to speak up when the loss impacts more people.
The third study looked at employee-supervisor pairings to understand how these relationships play out in the real world. Using pairings from across three industries, employees reported a workplace problem they encountered and their supervisor rated how often that employee spoke up on the job. While the first two studies involved hypothetical scenarios, this real-world evidence showed that employees were 8-10 times more likely to speak up when issues were framed as a potential collective loss compared with a potential collective gain.
“This research is really geared toward managers so they can facilitate and understand how and why their employees will speak up,” said Thompson. “You can talk about the issue, but it always ends in terms of how we frame things.”
NewsMakers
Yoga practice could reduce blood pressure in people with obesity
People who practiced yoga had a significant decrease in blood pressure, with systolic blood pressure lowered by an average of 4.35 mmHg and diastolic blood pressure by 2.06 mmHg.
Practicing yoga could help people with overweight or obesity improve their cardiometabolic health, according to a study in the open-access journal PLOS Global Public Health by Widya Wasityastuti from the University of Edinburgh, Scotland, and colleagues.
Yoga is a popular form of exercise around the world, and is a gentle and accessible form of exercise for many people. To better understand the potential health benefits of yoga, the authors of this study performed a meta-analysis, examining 30 studies of yoga for its cardiometabolic benefits. They focused on studies which examined outcomes for blood pressure, lipid profiles, glucose homeostasis, markers of inflammation, and measures of antioxidants, and those which examined people with body-mass index over 23 for Asian countries, and 25 for other countries, indicating that participants had overweight or obesity. Of the 30 studies considered, 23 were conducted in Asian countries, while the remaining studies were from the United States, Germany, and Australia.
Across the 30 studies and a total of 2,689 participants, the authors found that people who practiced yoga had a significant decrease in blood pressure, with systolic blood pressure lowered by an average of 4.35 mmHg and diastolic blood pressure by 2.06 mmHg. They also found modest beneficial effects on low- and high-density lipoproteins, types of cholesterol that have been linked to an increased risk of stroke.
The authors note that the studies analyzed were not specifically recruiting people with obesity, and there was no dose-response measured, so it is unknown how much yoga is needed to produce these effects, though the studies they analyzed favored practice of at least 180 minutes per week.
The studies also focused heavily on Asian participants, and practitioners with comorbidities were excluded from analysis. Finally, it’s important to note that due to the nature of this study, causality cannot be confirmed here despite the correlations found.
Further studies will be needed to understand whether yoga can provide similar benefits to other populations, as well as people with co-morbidities such as diabetes or heart disease.
The authors suggest that while more high-quality trials are needed, the meta-analysis supports potential benefits of yoga for cardiometabolic health in people with overweight and obesity.
The authors summarize: “Our review suggests that yoga may offer a helpful additional option for improving some aspects of cardiometabolic health in adults with overweight or obesity, particularly blood pressure.”
They add: “Yoga is often seen mainly as a wellbeing practice, but our findings suggest it may also support certain cardiometabolic health outcomes in adults with overweight or obesity.”
NewsMakers
Stress, BMI, and hormones linked to earlier puberty in girls
Higher levels of key steroid hormones—combined with elevated stress and body mass index (BMI)—are associated with earlier onset of puberty in girls.
Higher levels of key steroid hormones—combined with elevated stress and body mass index (BMI)—are associated with earlier onset of puberty in girls, according to a new study at Columbia University Mailman School of Public Health.
The findings are published in The Journal of Clinical Endocrinology & Metabolism.
Elevated prepuberty urinary levels of glucocorticoids, androgens, and progesterone were strongly linked to accelerated breast development (thelarche). Girls with high glucocorticoid levels alongside high BMI and stress entered puberty an average of seven months earlier than peers with lower levels.
“While stress and BMI have long been recognized as independent predictors of puberty, few studies have examined how they interact with a girl’s hormones,” said Lauren Houghton, PhD, assistant professor of Epidemiology at Columbia Mailman School, and first author. “Our findings challenge conventional research that has largely focused on estrogen and body size, highlighting instead the role of stress and androgens – typically thought of as male hormones– in shaping pubescent development.”
The strongest associations were observed for progesterone, androgens, and glucocorticoids, indicating that multiple hormonal pathways—not just estrogen—play a critical role in the timing of puberty.
For example:
- Higher glucocorticoid, androgen, and progesterone metabolites were associated with earlier onset of puberty
- Elevated androgens and progesterone were also linked to a longer duration of puberty
- Estrogen metabolites were associated with delayed onset, not acceleration
- The effects of hormones on puberty timing were significantly modified by BMI and stress levels.
Notably, the associations were consistent regardless of family history of breast cancer.
“Our objective was to identify the full set of hormonal patterns linked to accelerated puberty and test whether BMI and stress modify this relationship,” said Houghton, who is also assistant professor at the Herbert Irving Comprehensive Cancer Center at Columbia. “We predicted that girls with elevated BMI and stress would experience the earliest onset—and that the stress response shifts during this key time for girls.”
The researchers drew on data from the LEGACY Girls Study, a cohort of 1,040 girls ages 6 to 13 recruited across the U.S. States and Canada. Participants were followed every six months with clinical assessments, questionnaires, and biospecimen collection.
The analysis included 327 girls who were at the pre-puberty stage at baseline and provided urine samples at least one year before the onset of puberty. Houghton and colleagues measured a comprehensive panel of steroid metabolites using first-morning urine samples and tracked puberty development using validated clinical scales.
Mothers of the girls completed an Internalizing Composite Scale, which includes subscales for anxiety, depression, and other at-risk status. They also provided information on girls’ family history of all cancers as well as on pregnancy and infancy, including birth weight and their child’s race and ethnicity. Trained research staff measured height and weight twice every 6 months.
“Unlike prior research, this study simultaneously examined hormonal patterns, BMI, and psychosocial stress—captured through standardized behavioral assessments—within the same cohort,” said senior author Mary Beth Terry, PhD, professor of Epidemiology at Columbia Mailman School, and the Herbert Irving Cancer Center, and Silent Spring Institute. “Interestingly, we also learned that the associations were consistent regardless of family history of breast cancer.”
The findings may help explain the ongoing trend toward earlier puberty and point to actionable prevention strategies, observed the authors.
“Stress-reducing interventions and healthy lifestyle changes may help delay early puberty and improve long-term health outcomes,” said Houghton. ‘Because early puberty is linked to increased breast cancer risk later in life, the results have important implications for both pediatric care and public health.”
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