NUR342 Evidence Based Health Research on Breast Cancer

Sparano, J. A., Gray, R. J., Makower, D. F., Pritchard, K. I., Albain, K. S., Hayes, D. F., ... & Lively, T. (2018). Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. New England Journal of Medicine. doi: 10.1056/NEJMoa1804710.

The major purpose of the study is to evaluate whether the adjuvant therapy along with chemotherapy is effective to the preserve fertility in the patient who survived the breast cancer. According to the author Sparano et al., 2018, Adjuvant chemotherapy reduces the risk of recurrence of breast cancer in younger women compared to the women of mid-age. The benefit of adjuvant chemotherapy predicted based on the reoccurrence score of 21 gene breast cancer assay. The study suggested that up to 85 % of women benefited by the adjuvant chemotherapy of age of 50 years or older but reoccurrence score is low than 25 and effective for younger who has the score lower than 15.

The strength of the paper relies on the study design. The authors conducted the prospective randomized trial with 10,273women with hormone positive respecter along with other factors. However, the limitation of the study is that the authors did not collect the data on the chemotherapy-induced menopause

Dabrosin, C. (2015). An overview of pregnancy and fertility issues in breast cancer patients. Annals of medicine, 47(8), 673-678. https://dx.doi.org/10.3109/07853890.2015.1096953

The major purpose of the study is to evaluate the effect of the adjuvant therapy with the combination of chemotherapy breast cancer survival patients. The study suggested that chemotherapy drugs interrupted the normal cellular processes and arrests the cell division. Therefore, the use of chemotherapy leads to the fertility loss in women with breast cancer. However, most of the women experience fertility loss after the chemotherapy along with premature menopause. The older women are more susceptible to the therapy as compared to the younger women due to fewer amounts of reserved oocytes. They experience the early menopause if they menstruated during the chemotherapy. The hormone-based therapies prevent the loss of the oocyte by suppressing the activity of the ovary during chemotherapy.

The strength of study relies on the choice of study such as survey and literature of 30 other studies and limitation of the study relies on the fact that the researcher did not focus on the primary data rather secondary data and there was no data for randomized trial control.

Dieci, M. V., Ghiotto, C., Barbieri, C., Griguolo, G., Saccardi, C., Gangemi, M., ... & Tasca, G. (2018). Patterns of Fertility Preservation and Pregnancy Outcome After Breast Cancer

at a Large Comprehensive Cancer Center. Journal of Women's Health. 386(9992), 433-443. Doi: 10.1089/jwh.2018.6986

The major purpose of the study is to evaluate the long term outcome of breast cancer survival along with the efficiency of being pregnant. This study assesses the evolution of preservation of fertility over time and reports of the outcome related to the pregnancy of the younger patient. The researchers conducted the study by retrospective cohort with 590 breast cancer patient. The fertility issues identified in the patient who received the chemotherapy because of the breast cancer. Two cohort studies were conducted within 2004- 2006 and 2014-2016 respectively. The fertility issues decreased over the time in the patients due to the adjuvant therapy.

The strength of the study relies on the study design such as retrospective cohort and sample size of 590 breast cancer patient. However, the limitation of the study relies on the fact that it has insufficient data of formal recommendation on correct timing of pregnancy.

Justifying the Evidence

In the paper, the authors conducted a prospective clinical trial with the help of the national cancer institute (, Sparano et al., and 2018). The women who were participated in the clinical trials were in between 18 to 72 with hormone receptor positive. On the basis of 21 gene assay reoccurrence score, women with the score lower than 10 received only endocrine therapies and 

who scored more than 26 assigned to received the chemotherapy along with the endocrine therapy (Sparano et al., 2018). Women with the reoccurrence score of 11 to 26 received either of the therapy randomly chosen. In the prospective study of these women, the results suggested that those women who score in between 11 to 25 on the basis of 21 gene assay, the effect of chemotherapy and chemoendotherapy are nearly similar. This result suggested that the adjuvant therapy is not effective for the individuals who had midrange reoccurrence. On the other hand, women who are 50 years or younger than that and had the scores in between 16 to 25. Adjuvant showed the greater effect than compared to others. The reason partly explained by the fact the anti-estrogenic effect that is correlated with chemotherapy-induced menopause (Cameron et al., 2016). Therefore, pregnancy can be restored. However, the researchers did not collect the data on chemotherapy-induced menopause or the effect of ovarian suppression. Therefore, further research can be needed.

In the paper, Dabrosin, (2015), the author conducted a survey and collected information from and surveys suggested that the mortality rate is more likely higher in case of pregnancy-associated breast cancer compared to women with non-pregnancy associated breast cancer. Although the breast cancer survival rate increased over the year, the issues related to the pregnancy still requires a solution. The data on pregnancy after breast cancer diagnosis suggested the option of fertility preservation found to be safe before starting the chemotherapy, especially in premenopausal women who were diagnosed with early stage of breast cancer. However, the risk of chemotherapy depends on the women the age and type of the chemotherapy received by women. Older women showed the higher risk of premature failure, approximately 61% to 97% compared to the younger women who have the lower risk, approximately 22 to 61% (Dabrosin, 2015). The reason explained by the limited number of oocytes in the ovary in older women 

compared to younger women significant amount of ovarian reserve. The loss can be prevented by administration of adjuvant therapy prior to chemotherapy according to the guideline of the cancer therapy (Crown, et al., 2016). This adjuvant therapy suppresses the activity of ovary during the chemotherapy and prevents the loss.

In the paper, Dieci et al., (2018), The researchers conducted the study by retrospective cohort with 590 breast cancer patient. The fertility issues identified in the patient who received the chemotherapy. Two cohort studies were conducted within 2004- 2006 and 2014-2016 respectively (Dieci et al., 2018). The fertility issues decreased over the time in the patients due to the adjuvant therapy. Within 26 cases in the medical records suggested the successful pregnancy after diagnosis due to fertility preservation. The main fertility issues also observed due to unawareness of physicians which decreases over the years (Crown, et al., 2016). In this study and supporting literature suggested that the concern of fertility issues in both ends significantly reduces the chances of ovarian failure. 

The aim of the research is to reduce the premature ovarian failure with help of adjuvant therapy which will suppress the activity of the ovary. These papers showed that the adjuvant therapy along with chemotherapy is more effective in younger women who had breast cancer or survived breast cancer compared to older women with limited ovarian reserve.

Relevance to Nursing and Barriers to Practice

The issues of the breast cancer are experienced by the considerate number of the Australian woman and can be resolved by the implementation of chemotherapy in a medical field (Turner et al., 2015). However, the chemotherapy induces the premature loss of ovary and can be preserved by administration of adjuvant therapy prior to the chemotherapy. Nurses play the massive role in successful adjuvant therapy, therefore, the implementation is important for evidence-based practices (Crown, et al., 2016). The nurses are the direct caregiver and important part of the multidisciplinary team since they check the toxicity before the therapy, assessment of chemotherapy, patient’s history and decision making and effective communication with the patient and family members of the patient (Harris, Ismaila, McShane & Hayes,2016).The structured documentation of the information, detailed diet after the adjuvant and monitoring of vital signs of the patient evaluated by the nurse and, informed consent from the patient respecting the values of the patient also taken in to consideration by the nurse (Cameron et al., 2016).

The prime barrier of the practice of the adjuvant therapy is the non-adherence to the adjuvant therapy.  Due to the high cost of adjuvant therapy, patients do not adhere to the practices. In many health care centres, lack of accurate infrastructures, advanced technology and lack of sound knowledge of the practitioner act as a major barrier of the practice (Willson et al., 2017). Women who are the higher risk were more non-adherent to the therapy due to the negative experience of previous chemotherapy. The current researches suggested that women who tend to experience the menopausal symptoms. Due to the lack of sound knowledge, most of the 

individual treated by a general practitioner, not by the specialist (Jun, Kovner, & Stimpfel, 2016). Therefore, the adherence to adjuvant therapy decreases. Regardless of the high quality of researches, The personal beliefs and cultures have are the massive hindrance to clinical practice. Due to persistent believes the huge number of individuals do not adhere to the therapy and find the clinical approaches offensive.

References

Burstein, H. J., Lacchetti, C., & Griggs, J. J. (2016). Adjuvant Endocrine Therapy for Women With Hormone Receptor–Positive Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update on Ovarian Suppression Summary. Journal of oncology practice, 12(4), 390-393. https://ascopubs.org/doi/full/10.1200/jop.2016.01123.

Cameron, D., Piccart-Gebhart, M. J., Gelber, R. D., Procter, M., Goldhirsch, A., de Azambuja, E., ... & Baselga, J. (2017). 11 years' follow-up of trastuzumab after adjuvant chemotherapy in HER2-positive early breast cancer: final analysis of the HERceptin Adjuvant (HERA) trial. The Lancet, 389(10075), 1195-1205.  doi:  10.1016/S0140-6736(16)32616-2

Crown, J., Walshe, J., Fennelly, D., Long, J. C., Cairney, S., McDonnell, D., ... & Gullo, G.

(2017). 206PIncidence of permanent alopecia following adjuvant chemotherapy in women with early stage breast cancer. Annals of Oncology, 28(suppl_5). https://doi.org/10.1093/annonc/mdx362.056

Dabrosin, C. (2015) . An overview of pregnancy and fertility issues in breast cancer patients. Annals of medicine, 47(8), 673-678. https://dx.doi.org/10.3109/07853890.2015.1096953

Dieci, M. V., Ghiotto, C., Barbieri, C., Griguolo, G., Saccardi, C., Gangemi, M., ... & Tasca, G. (2018). Patterns of Fertility Preservation and Pregnancy Outcome After Breast Cancer at a Large Comprehensive Cancer Center. Journal of Women's Health. doi: 10.1089/jwh.2018.6986

Francis, P. A., Regan, M. M., Fleming, G. F., Láng, I., Ciruelos, E., Bellet, M., ... & Martino, S. (2015). Adjuvant ovarian suppression in premenopausal breast cancer. New England Journal of Medicine, 372(5), 436-446.  doi:  10.1056/NEJMoa1412379

Harris, L. N., Ismaila, N., McShane, L. M., & Hayes, D. F. (2016). Use of biomarkers to guide decisions on adjuvant systemic therapy for women with early-stage invasive breast cancer: American Society of Clinical Oncology clinical practice guideline summary. Journal of oncology practice, 12(4), 384-389. https://ascopubs.org/doi/pdfdirect/10.1200/JOP.2016.010868

Jun, J., Kovner, C. T., & Stimpfel, A. W. (2016). Barriers and facilitators of nurses’ use of clinical practice guidelines: an integrative review. International Journal of Nursing Studies, 60, 54-68. https://doi.org/10.1016/j.ijnurstu.2016.03.006

Krop, I., Ismaila, N., & Stearns, V. (2017). Use of biomarkers to guide decisions on adjuvant

systemic therapy for women with early-stage invasive breast cancer: American Society of Clinical Oncology clinical practice focused update guideline summary. Journal of oncology practice, 13(11), 763-766. https://ascopubs.org/doi/full/10.1200/jop.2015.005215

Sparano, J. A., Gray, R. J., Makower, D. F., Pritchard, K. I., Albain, K. S., Hayes, D. F., ... & Lively, T. (2018). Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. New England Journal of Medicine.doi : 10.1056/NEJMoa1804710.

Turner, N. C., Ro, J., André, F., Loi, S., Verma, S., Iwata, H., ... & Giorgetti, C. (2015). Palbociclib in hormone-receptor–positive advanced breast cancer. New England Journal of Medicine, 373(3), 209-219. https://doi.org/10.1016/j.leaqua.2015.08.006

Willson, M. L., Vernooij, R. W., Gagliardi, A. R., Armstrong, M., Bernhardsson, S., Brouwers, M., ... & Jones, S. (2017). Questionnaires used to assess barriers of clinical guideline use among physicians are not comprehensive, reliable, or valid: a scoping review. Journal of clinical epidemiology, 86, 25-38. https://doi.org/10.1016/j.jclinepi.2016.12.012.