Evaluation of patients’ adherence to chemotherapy for breast cancer

Adewale O Adisa, Olukayode O Lawal, Abdul RK Adesunkanmi

Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife,

Nigeria.

Correspondence to: Dr. Adewale O. Adisa; Department of Surgery;Obafemi Awolowo University

Teaching Hospitals Complex, Ile-Ife, Nigeria. E-mail: [email protected]. Tel: +2348033889425

SUMMARY

The study aimed to establish the common reasons for non-adherence to drug
treatment among breast cancer patients at the Obafemi Awolowo University
Teaching Hospitals Complex, Ile-Ife, Nigeria over a ten-year period (Jan 1993 -
Dec 2002). Patients’ adherence and reasons for non-adherence to chemotherapy
were evaluated using descriptive statistics. Two hundred and twenty-five breast
cancer patients including 199 females and 6 males with breast cancer were
recruited. 12(5.3%) patients had Stage I disease while 126 (56%) were in stage
IV. The non-adherence rate was 80.9% and 111(73%) of the non-adherent
patients were eventually not seen again. Of the one hundred and one patients
who gave reasons for non-adherence, 45% complained of financial difficulties;
18% thought they were well enough; 15% were fearful of subsequent operation
and 11% were unable to further bear the drug side effects. In conclusion, the
study demonstrated poor economic status of the patients as one of the major
reasons for non-adherence to cancer chemotherapy in Nigeria. Government
subsidy of breast cancer treatment, improved health education and advocacy
complemented by home visiting to encourage hospital attendance would be
required for better adherence to chemotherapy.

[Afr J Health Sci. 2008; 15:22-27]

Introduction chemotherapeutic agents can only be realised

if patients comply with their use. Compared
The burden of breast cancer in developing with the developed countries, patients’
countries is enormous [1]. A twofold increase compliance with chemotherapy in developing
has been reported in the incidence in Ibadan, countries has been shown to be poorer [14-17].
Nigeria and in Kampala, Uganda in the recent More recently, the more authority-
past [2,3]. A more aggressive disease course laden term “compliance” is largely being
has also been noted as reported from Jos in replaced with the term “adherence” in the
northern Nigeria where most patients literature due to increase in patient autonomy.
presented with high grade invasive ductal Many health care providers prefer the word
carcinoma which were oestrogen receptor “adherence”, because "compliance" suggests
(ER) and progesterone receptor (PR) negative that the patient is passively following the
but p53 positive [4]. The patients also doctor's orders and that the treatment plan is
commonly present late, with advanced disease not based on an established therapeutic
and are frequently lost to follow up early in agreement between the patient and the
management with poor overall survival rate in physician The most commonly cited definition
different centres across Africa [1,5,9]. of adherence is ‘the extent to which a person’s
The major role of chemotherapy in the behaviour coincides with medical or health
management of breast cancer and its efficacy advice’. [18,19] The aim of this study was to
in prolonging survival has been well determine the level of adherence to
documented [10-13]. The beneficial effects of chemotherapy as well as factors that may

22 African Journal of Health Sciences, Volume 15, Number 1, January- March 2008
influence this among breast cancer patients in another eleven refused chemotherapy even
our environment. after adequate counselling. On the whole, 188
of the 225 patients had chemotherapy. Of
Materials and Methods these, 59 (31.4%) had neo-adjuvant
chemotherapy alone, 81 (43.1%) had adjuvant
A review of the clinical records of chemotherapy while 48 (25.5%) had both neo-
histologically proven cases of breast cancer adjuvant and adjuvant chemotherapy. CMF
seen over a ten year period of January 1993 combination chemotherapy
through December 2002 at the Ife Hospital (Cyclophosphamide, Methotrexate and 5-
Unit of the Obafemi Awolowo University Fluorouracil) was used in 149 patients, while
Teaching Hospitals Complex (OAUTHC), Ile- CAF (Cyclophosphamide, Adriamycin and 5-
Ife, South-West Nigeria was carried out. Fluorouracil) was used in combination for 21
Those whose hospital records were incomplete patients. CMF with Vincristine (CMFV) was
were excluded. Demographic and clinical used in 12 patients. 92 (48.9%) patients had
information including treatment records were Tamoxifen prescribed along with their
studied. Chemotherapeutic agents received, chemotherapy. (Table II)
the numbers of courses, patient’s adherence as The non-adherence rate was 80.9%
well as details of non-adherence were further (152 of 188) and a pattern of non-adherence
studied. was seen across all age groups, chemotherapy
A patient was considered to be non- combinations and disease stage. Forty (21.3%)
adherent if they did not present for two patients defaulted before the end of the first
consecutive doses of chemotherapy. Patients course while 95 (50.5%) patients defaulted
who had dose reduction and/ or omission due within the first three courses of chemotherapy.
to inadequate haematological profile or poor Also, we found that at one year after
clinical condition were not included as defaulting, 111(73%) of these patients had not
defaulters. The patients who missed their returned for further treatment and many were
medications due to no fault of theirs either subsequently lost to follow up. Only 7 patients
because of unplanned public holidays or other came back to continue treatment within a
reasons beyond their control were excluded month of defaulting.
from the study. The data were subjected to The reasons for non-adherence were
descriptive analyses. available in only 101 cases. Of these, 45
(45%) were noted to have defaulted due to
financial constraints, 18 (18%) patients
Results because they felt well; 15 (15%) because of
fear of subsequent operation; 11 (11%) did so
There were 225 cases of breast cancer seen because of unbearable drug side effects, while
during the study period. Majority (97.3%) 19(19%) patients defaulted for various other
were females and 6 were males. The ages reasons.
ranged from 26 to 86 years with a mean of 48 The group of patients (N= 18) who
(SD: 12.3) years. More than one quarter of the were non-adherent because they felt well were
patients were under 40years of age, with aged between 30-45years and 16 of them had
69(30.6%) being 40-49years old, and stage I and II diseases. Nine had neo-adjuvant
13(5.8%) 70years and above. There were more chemotherapy with very good response and
lesions on the right (47.1%) than the left indeed 5 out of them had a dramatic response
(44.1%). Twenty patients (8.9%) had bilateral with non-palpable tumours after the first
breast involvement at presentation. Using the course of chemotherapy. The remaining 9 had
American Joint Committee on Cancer (AJCC) mastectomy but defaulted before, during or
staging system, 12 (5.3%) patients presented after the first course of adjuvant
in Stage I, 28 (12.4%) in stage II, 59 (26.2%) chemotherapy. Twelve patients of this group
in stage III and 126 (56%) in stage IV (Table were lost to follow up while 6 re-presented
I). Presentation at advanced stage was again with stage IV disease.
recorded for all age groups. In the final analysis, 51patients
Twenty-six patients who presented in (22.6%) died during the course of treatment,
very poor clinical condition died before 22 (9.8%) patients were referred for
chemotherapy could be instituted while radiotherapy, 15 (6.7%) re-presented with

African Journal of Health Sciences, Volume 15, Number 1, January- March 2008 23
recurrence after initial treatment, 5 (2.3%) 5years without any recurrence), while 132
were adjudged to be cured of the disease (58.7%) patients were lost to follow-up.
(having attended follow-up clinic for over

Table 1: Age and Stage at Presentation of Women with Breast Cancer in Ile-Ife, Nigeria.
Age Stage at Presentation
(Yr) N StageI StageII StageIII StageIV
<30 6 2 - 1 3
30-39 50 1 6 14 29
40-49 69 4 11 14 40
50-59 49 4 7 15 23
60-69 38 1 3 8 26
70-79 11 - 1 6 4
≥80 2 - - 1 1

Table 2: Use of Chemotherapy in Women with Breast Cancer in Ile-Ife, Nigeria.

Drugs Used No (%) Neo-Adjuvant Adjuvant
CMF 149 (79.3%) 112 52
CAF 21 (11.2%) 9 12
CAMF 12 (6.4%) 2 10
CMFV 6 (3.2%) 1 5
Tamoxifen 92 (48.9%) 70 42

Table 3: Reasons for Non-Adherence with Chemotherapy Schedule

Reason No Percentage
Financial Difficulty 45 45%
Feels Well 18 18%
Fear of Operation 15 15%
Drug Side Effects 11 11%
Others 19 19%
(No reasons were given for non-adherence in 51 patients)

Discussion countries [7-9,21,22]. This may be due to poor

awareness of the disease among the population
The findings in this study suggesting a high as well as low level of organised public
incidence of breast cancer in young women enlightenment and screening programmes in
with more than one quarter of the patients most developing countries. Okobia et al
being below 40years of age has been the reported a poor knowledge of breast cancer
experience of others in previous studies across among rural dwelling women in Nigeria with
Nigeria [7,8,20]. The reason why breast cancer only a minority practising breast self
tends to occur in younger age groups in examination and clinical breast examination
Africans is not yet known. It may however be [20]. A study in South Africa found that 77%
related to the young population of most of the of black women presented with Stages III and
African countries just like other developing IV disease while only a few who reportedly
countries. practised self breast examination presented
The problem of late presentation in the with stage I disease [23].
hospital, a common phenomenon among In view of the late stages of
patients in developing countries, was also presentation, chemotherapy played a major
observed in this study. One hundred and role in the management of the patients. In this
twenty-six patients (56%) presented with stage study more than 83% of the patients had
IV disease. Similar findings have also been chemotherapy as neo-adjuvant or adjuvant
reported in many studies on breast cancer treatment or a combination of both. 81 patients
across Nigeria and in other developing had neo-adjuvant chemotherapy to downstage

24 African Journal of Health Sciences, Volume 15, Number 1, January- March 2008
the tumour preparatory for surgery while 130 recurrent nausea and vomiting that
patients had adjuvant chemotherapy. This is necessitated admission for rehydration and
largely due to the fact that a large number of they subsequently defaulted.
the patients presented late thus precluding It is of interest that 15 patients
initial surgery. Combination chemotherapy defaulted after counselling for mastectomy. In
was used in all the patients. The combination Africa, many women find it difficult to accept
of Cyclophosphamide, Methotrexate and 5- the option of mastectomy [27]. A study in
Fluorouracil (CMF) was used in most of the Egypt observed that most of the women were
patients in this study. Anthracycline-based primarily concerned with keeping their breasts
combinations, which are common in regardless of the disease stage [28]. It is
developed countries, were used in only 11% of possible that the relatively young age of many
the patients in this study largely due to its high of the women in this study, lack of
cost. Similarly patients were not placed on understanding by their spouses, the general
newer chemotherapeutic agents such as the fear of surgery and anaesthesia as well as the
Taxanes as they were largely unavailable and relatively low rate of breast reconstruction
unaffordable to most of our patients. surgeries were responsible for not readily
Since there is no health welfare consenting to mastectomy. Furthermore
scheme in place in Nigeria during the period because most of the patients present with
of the study, the burden of procuring advanced disease, the option of breast
expensive chemotherapeutic agents was borne conserving surgeries is not usually available
by the patients and their relations. Significant for them.
proportion of the patients being agrarian and It is also worthy of note that the group
generally poor, could not afford the estimated of 18 patients that defaulted for reason of
average cost of US$100 for procuring a course being better were young adults with operable
of CMF chemotherapy. This probably affected disease stages. One half of them were on neo-
patients’ adherence to the chemotherapy adjuvant chemotherapy with significant effects
schedule in most instances. Indeed 45% of including complete regression in five patients.
patients who gave reasons for non-adherence The paradox of wellness and non-adherence is
to chemotherapy cited financial constraint as a difficult problem, as these patients would
the problem. In the experience of the authors, probably have benefited more from
many of the patients in the environment are chemotherapy use. It is possible that religious
unable to procure more than the first course of belief in faith healing that is common in the
chemotherapy and are usually not able to environment and the initial tumour
continue with the schedule. Perhaps if cancer disappearance led to default based on bad
treatment were to be subsidized again by the advice.
government (as was the case in the early 1980s The clinic attendance by the patients
in our part of the country) perhaps there would was also a problem. More than one-half (132,
be significant improvement in the rate of non- representing 58.7%) of the patients were lost
adherence. to follow-up at different points in the course of
In a study of patients adherence to their treatment. This observation is similar to
chemotherapy for breast cancer carried out at findings in many studies from developing
Sussex, United Kingdom, 55% of patients countries [29-30]. Problems confronting the
receiving chemotherapy were noted not to patients ranging from financial difficulties to
have adhered to medications either the prolonged denial of the illness as well as
unintentionally (due largely to forgetfulness) the strong superstitious belief in the use of
or intentionally (due to drug side effects and traditional and or spiritual healing approaches
difficulty swallowing tablets) [24]. Drug side may contribute to this. The poor follow-up
effects have also been given as reason for non- made it difficult to assess the efficacy of
adherence among women taking Tamoxifen chemotherapy as well as the final outcome in
[25,26]. In the current series, 11 patients many of the patients. Health education and
(5.8%) reported intentional non-adherence advocacy as well as home visiting and tracing
because of drug side effects. Some of these of breast cancer patients may reduce this
were young women who had severe alopecia problem.
and skin hyperpigmentation which were
cosmetically unacceptable. Two of them had

African Journal of Health Sciences, Volume 15, Number 1, January- March 2008 25
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11. Adjuvant systemic therapy for women
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