Pilot Study of PACHA Program to Enhance Adherence to Adjuvant Endocrine Therapy Among Breast Cancer Survivors

Pilot Study of a Community Pharmacy-Based Program to Enhance Adherence to Adjuvant Endocrine Therapy Among Breast Cancer Survivors

The goal of this randomized controlled pilot study is to assess the feasibility, acceptability, and preliminary effects of the PACHA program designed for women having an adjuvant endocrine therapy (AET) after hormone-sensitive breast cancer. PACHA (programme en Pharmacie pour l'ACcompagnement des femmes ayant de l'Hormonothérapie Adjuvante) is a community pharmacy-based program aimed at optimizing the experience of AET and its use. The main questions it aims to answer are :

• Does the program have an effect on factors expected to influence AET adherence?
• Is the program acceptable?
• Is the implementation of the program feasible?
• What is the feasibility of procedures for carrying out a full-scale study?

Participating community pharmacies will be randomized. Pharmacists working in pharmacies assigned to the PACHA group (33 pharmacies) will receive web-based training and manuals to use during their consultations with women having an AET. Recruited women attending these pharmacies will also have access to information and resources about AET (videos, evidence-based booklet). Pharmacists practicing in pharmacies assigned to the control group (33 pharmacies) will provide usual care.

This is a cluster randomized controlled pilot trial using mixed methods (quantitative and qualitative). A cluster consists of a pharmacy, its pharmacists and its patients with adjuvant endocrine therapy (AET) prescription who have agreed to participate. Participating pharmacies will be randomly assigned to two groups. In the first group, pharmacists will provide usual services to women (control group). In the second group, pharmacist and women will have access to the PACHA program in addition to the usual services (intervention group).

The PACHA program consists, for the pharmacists, of:

• A 85-minutes web-based training to prepare the pharmacists for delivery of the intervention. The program comprises three main sections led by experts: 1) a review of AET pharmacotherapy; 2) information on AET consultation based on the principles of motivational interviewing and video simulations of AET consultations according to program tools and expert feedback of these simulations, and 3) access to materials geared to participating women (web-video capsules about AET, self-management strategies for coping with specific AET side effects and list of resources). The web-based training can be completed in one or more sessions. Pharmacists who complete the program will receive continuing education credits. The PACHA pharmacists will have to complete this program in the weeks after randomization.
• Standardized consultation guide based on motivational interviewing to guide AET consultations (by phone or in person). This standardized consultation guide outlines the key steps that the pharmacist must cover during the AET consultation and follows the usual sequence of consultation in pharmacy. This consultation guide is to be used in the first month and 4 months after randomization, or more frequently according to a woman's situation.
• Evidence-based web sheets describing (non)pharmacological strategies to cope with side effects (e.g. hot flashes) and other AET-related concerns (e.g. sexuality) and to guide the consultation.

For the women, the PACHA program consists of:

• Web video capsules to inform women about AET. These video capsules cover how to and why take tamoxifen or an aromatase inhibitor, the possible side effects and strategies to cope with these side effects and, finally, medication intake and daily activities (e.g. diet). This also includes testimonies of women who had breast cancer and an AET.
• Evidence-based web sheets describing (non)pharmacological strategies to cope with side effects (e.g. hot flashes) and other AET-related concerns (e.g. sexuality) in a version adapted for the woman.
• List of web resources available for women to help cope with side effects and other AET-related concerns.

Participation in the study will take place over a period of 6 months. The study will be carried out in approximately 66 pharmacies in the Quebec province (33 will be assigned to the control group and 33 to the intervention group), which include approximately 132 women (66 in the control group and 66 in the intervention group). At the end of the follow-up, pharmacists and women in the control group can, if desired, receive certain tools offered in the intervention group.

Pharmacists and participating women will be asked to completed two questionnaires: the first before randomization and the second at the end of the follow-up 6 months later.

At the end of the study, 20-30 pharmacists and 20-30 patients will be invited to take part in a semi-directed individual interview (qualitative component) in order to gather their point of view and their experience with the care and services received in relation to AET.

The characteristics of pharmacies, pharmacists and patients in the intervention and control groups will be compared. Indicators of acceptability and feasibility will be measured (e.g. recruitment and participation and retention rates). Generalized Estimating Equation (GEE) regression models will be used to compare patterns of changes in scores of factors expected to influence AET experience and adherence in the two groups and between study entry and 6 months later. The main analyzes will be performed on a intention-to-treat basis. For the qualitative component, a thematic analysis will be carried out based on the transcriptions of the semi-structured interviews. The quantitative and qualitative results will be used to optimize the PACHA program, its implementation and to design, if the results support this, a large-scale randomized controlled trial.

Inclusion Criteria:

For pharmacies :

• In the province of Quebec, Canada
• At least one pharmacist agrees to take charge of the project in their pharmacy
• At least one women has initiated adjuvant endocrine therapy (AET) in the last 6 months in the pharmacy

For pharmacists :

• Practicing in a pharmacy in the province of Quebec
• Provide consent

For women :

• 18 years old or older
• Were diagnosed with a first non-metastatic, hormone-sensitive breast cancer
• Received and AET prescription for the first time in the last 6 months
• Are fluent in French
• Have internet access
• Provide consent

Exclusion Criteria:

For women :

• Live in a residential facility where AET is not self-managed