Original articlesBehavioral and psychological predictors of chemotherapy adherence in patients with advanced non-small cell lung cancer☆
Introduction
The standard of care for patients diagnosed with advanced non-small cell lung cancer (NSCLC) includes some form of chemotherapy, which may consist of platinum-based doublets, a single agent, or oral epidermal growth factor receptor–tyrosine kinase inhibitors (EGFR–TKIs) [1]. However, treatment with any of these anticancer regimens often leads to impairing side effects (such as cytopenia, emesis, and nephrotoxicity) that compromise patient adherence to chemotherapy. Of these, hematologic toxicities most commonly cause infusion dose delays, though some data suggest that neutropenia may actually serve as a useful biological marker of chemotherapy dose intensity for patients with advanced NSCLC [2]. Therefore, identifying dose-limiting factors is critical not only for maximizing chemotherapy delivery but also for evaluating patient response to treatment.
While hematologic-related dose delays are well documented, few data regarding the effects of behavioral and psychological variables on chemotherapy adherence exist [3]. Investigators have linked some of these factors, such as quality of life [4], smoking behavior [5], and mood symptoms [6], to worse mortality among patients with NSCLC, which may be mediated through poor adherence to treatment. Up to 40% of patients with NSCLC report smoking at the time of diagnosis [7], increasing the risk of thromboembolic events [8] and infections [9], factors that potentially complicate adherence. Also, patients experiencing psychological difficulties may be less adherent to cancer therapy, perhaps due to exacerbations of treatment side effects. Researchers have observed that anxiety symptoms are related to delayed emesis and poorer response to antinausea medication after use of platinum-based chemotherapy [10].
To further research in this area, we examined the following: (a) the frequency of chemotherapy dose delays and reductions in a sample of patients with advanced NSCLC and (b) the extent to which behavioral and psychological factors relate to treatment adherence.
Section snippets
Patient selection
The data for this observational study came from a pilot investigation of early palliative care services for patients with newly diagnosed advanced NSCLC. Eligible participants included patients within 8 weeks of diagnosis of Stage IIIb (with pericardial or pleural effusions) or Stage IV NSCLC. These disease stages are considered incurable and treated with similar protocols. Participants also had to be greater than 18 years old, literate in English, and of high performance status (i.e., Eastern
Sample characteristics
Fifty participants were consecutively enrolled for the original palliative care trial. Although four patients withdrew from the study, all baseline self-report and 6-month chart review data were available for this analysis, with no data lost to follow-up. Ninety-four percent of participants (n=47) had newly diagnosed Stage IV NSCLC, with 6% having Stage IIIb disease (with effusions). The demographic characteristics of the sample are listed in Table 1; all participants identified themselves as
Discussion
As expected, one of the strongest predictors of chemotherapy dose delays and reductions in this homogeneous sample of patients with advanced NSCLC was neutropenia. Adjusting for the hematologic toxicity, other significant predictors of poor chemotherapy adherence included current smoking and elevated anxiety. The mechanism by which smokers are more likely to have chemotherapy dose delays or reductions remains unclear. Yet, smoking is associated with worse medical outcomes, including mortality
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This work was supported by NIH/NCI R03 CA128478 (Greer), NIH/NCI K23 CA115908 (Pirl), and an investigator-initiated research grant from Amgen (Temel).