A Teaching Model for Aromatase Inhibitors After Tamoxifen
- First Online:
- Cite this article as:
- Trotter, T., Webster, M., Railton, C. et al. J Canc Educ (2010) 25: 493. doi:10.1007/s13187-010-0095-9
- 39 Views
Breast cancer is the most common cancer diagnosed in women. The present study evaluated the family physicians' (FPs) understanding of adjuvant hormonal therapies for an early breast cancer. FPs were invited to attend teaching workshops on this topic, which utilized a pretest, didactic and interactive teaching, and posttest format. FPs (n = 23) showed an improvement (p < 0.001) in pretest to posttest score. It is clear that, with a targeted teaching, FPs can quickly become more knowledgeable on the topic of hormonal therapies in breast cancer, with the potential of applying this information in their own practice.
KeywordsTamoxifenPhysicianAromatase inhibitorsTeaching modelLetrozole
Tamoxifen has been considered the gold standard in adjuvant endocrine therapy in an early breast cancer for over 20 years. Over the past 6 years, results from several large randomized trials have shown that, in postmenopausal women, the third generation aromatase inhibitors (AIs; letrozole, anastrozole, and exemestane) improve the disease-free survival (DFS) by 3–4% as compared to tamoxifen when used in the adjuvant treatment of breast cancer [1–6]. Following funding approval, the Southern Alberta Breast Tumor Group implemented a program to counsel the initial cohort of women who had recently completed 5 years of adjuvant tamoxifen and needed to be immediately informed of the recent data showing improvements in DFS with extended hormonal therapy using the AI letrozole . From the Alberta Cancer Board pharmacy database, it was determined that there were 153 women who met the eligibility criteria for this new treatment. As the majority of these patients had been discharged back to the care of their community physician some years ago, a special program was implemented to call back these women for discussion of letrozole after tamoxifen. Of the women seen in consultation, 67 elected to proceed with 3 years of adjuvant letrozole after completing 5 years of adjuvant tamoxifen. On multivariate analysis, age was the only variable that was found to be statistically significantly different between the groups of women who continued with further adjuvant treatment for breast cancer as compared to those who did not .
Due to resource constraints, the breast group was not able to conduct extra clinics on an ongoing basis to counsel the continuing cohort of women on tamoxifen who needed to be seen for a discussion regarding aromatase inhibitors after tamoxifen.
A meta-analysis by Davis et al.  found that interactive and mixed sessions in continuing medical education (CME) could lead to changes in professional practice and health-care outcomes (standardized effect size, 0.67; 95% confidence interval, 0.01–1.45). A Cochrane review on the effects of CME and workshops on professional practice and health-care outcomes  followed up the meta-analysis reported by Davis et al. and commented that interactive workshops can result in moderately large changes in professional practice, while didactic sessions alone are unlikely to change practice.
It was felt that an active approach involving family physicians could lead to breast cancer patients being seen by their community practitioners for the discussion of AIs after tamoxifen. The present study evaluated a teaching module for family physicians which aimed to improve their understanding of adjuvant hormonal therapies for early breast cancer and would allow them to confidently discuss this issue with their own patients. It was hypothesized that the family physicians that underwent this targeted teaching would have an equal or better acceptance by their patients of the switch from tamoxifen to an AI, as compared to that found during the initial call back cohort seen at the Tom Baker Cancer Centre, where 44% of eligible patients continued with extended hormonal therapy after 5 years of tamoxifen.
The study was approved by the University of Calgary Conjoint Health Research Ethics Board and approved for MainPro M-1 study credit by the College of Family Physicians of Alberta.
Chart review identified 115 women in the next cohort of patients to be seen for a switch to AI or continued hormonal therapy with letrozole. The patients eligible for the study were postmenopausal women with a diagnosis of intermediate to high risk node-negative, or node-positive breast cancer who had been taking adjuvant tamoxifen for the past 2 or 5 years and lived within the Calgary Health Region or affiliated community cancer center areas.
The family physicians of the 115 patients were contacted by mail and invited to attend a teaching workshop on hormonal therapies in breast cancer. A nontargeted group of 116 rural family physicians was also invited to participate. There were a total of ten workshops over a 1-month period that the physicians could choose from.
The participants completed a short demographic questionnaire at the beginning of each session. The workshops started with a 10–15-min pretest, followed by 40 min of didactic presentation, then 30 min of interactive review of six sample case studies, and finishing with a 10–15-min posttest (repeat of pretest). The workshop participants completed a feedback survey at the end of the workshop.
Face and content validity of the test and education workshop material was determined by circulation of the materials to the breast group medical oncologists at the Tom Baker Cancer Centre with an invitation for review and editing. There is no gold standard to compare this specific program to, so it is difficult to comment on criterion validity. However, the approach in this project, with a pretest, teaching intervention, and posttest, has been used by many other researchers and shown to lead to measurable changes in practice [10–12].
At the end of each workshop, those physicians who had one or more known breast cancer patients in their practice ready for the switch from tamoxifen to AI were given a form with the patient names indicated. The physician was asked to return the form after consulting the patient.
Descriptive statistics including means with standard deviation were used to evaluate pretest to posttest scores, and two-tailed independent and paired-samples t tests were used to compare differences.
From 231 invitation letters mailed out, 36 physicians responded with the intent of participating (15.6%), and 24 actually attended a workshop (10.4%). One of the participants had to leave prior to the posttest, and therefore, information on this person was not included in the analysis. Participant numbers ranged from one to six per workshop. Of participants, 52.2% were from an urban/town practice, and 56.5% had more than ten breast cancer patients in their practice. Of participants, 78.3% were female, and 73.9% of the participants had been in practice for more than 10 years.
Paired-samples t test for family physicians' pre-/posttest scores (n = 23)
Pretest score (%)
Posttest score (%)
Sum of correct–incorrect
Independent samples t test showed that there was no difference in score based on physician's location of practice, number of breast cancer patients in a physician's practice, or number of years in practice. Although females had higher scores than males, with more correct than incorrect responses, this finding did not reach statistical significance on both the pre- and posttest scores.
There were 11 physicians who attended the teaching workshops who were identified as having a patient in their practice ready for a switch from tamoxifen to AI. In the group of 11, there were 19 patients to be seen. However, two of the general practitioners (GPs) had closed their practice, and one had retired, with four patients therefore not being seen for counseling in the community. Two patients had left their GPs' practice. Four patients were seen and declined AI. One was not recommended to switch due to comorbidities. One patient accepted the switch, and one patient was considering AI after discussion but was going to decide after speaking to her surgeon. One patient had been contacted by the GP's office to attend for AI consultation but had not attended at the time of last enquiry. Follow-up on five patients was incomplete as no information was returned despite phone calls to the attending GP's offices.
The objectives of the present study were to determine whether family physicians would express an interest in attending a workshop on adjuvant hormonal therapies in breast cancer, and then demonstrate an increased understanding of these treatments that would allow them to discuss these with their own patients. There was a statistically significant increase in understanding of hormonal therapies in breast cancer at the conclusion of the workshop. However, due to a number of factors, there were too few patients seen in the community to allow for a statistical comparison of uptake of AI after tamoxifen in the community as compared to patients seen in specialist consultation.
The rate of participation in this study was low and would therefore indicate that the approach used in this study is not likely to be considered useful in other jurisdictions.
A significant challenge for family physicians is keeping current on a wide array of topics. Therefore, presenting information that is timely and relevant, and making it easy to find for the practicing physician is paramount to delivering a good patient care. For the majority of physicians in this study, there was only one patient in their practice who was eligible for the discussion of AI after tamoxifen at the time the workshops were held. Based on such limited frequency, the practitioner would likely feel less inclined to participate in a teaching session on adjuvant hormonal therapies in breast cancer and feel it is more appropriate to have the patient seen by their oncologist for this discussion.
Alternate approaches to teaching family physicians about adjuvant hormonal therapies in breast cancer could include a multitopic program encompassing women's health issues such as hormone replacement therapy, osteoporosis management, and adjuvant hormonal therapies in breast cancer, or utilizing an archived internet format for the teaching module.
While there are a number of research studies demonstrating the benefits of AIs as compared to tamoxifen in improving DFS, it is a challenge to make all eligible breast cancer patients aware of this information. The approach used in this study led to too few physicians participating in the teachings sessions to have a meaningful impact on the continuing cohort of women who need to be seen for the discussion of AI after tamoxifen. It is clear that, due to the infrequent nature of this discussion in a general practice, a family physician would require an easily accessible and regularly updated paper or online resource to assist them in discussing this topic with their own patients. Until such resources are in place, the women who are eligible for the switch from tamoxifen to AI will continue to be seen by their oncologist.