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Breast cancer therapy adherence
Promoting Adherence: Practical Strategies for Optimizing Outcomes With Oral Therapy in Breast Cancer

Released: July 24, 2025

Kristi K. Orbaugh
Kristi K. Orbaugh, MSN, NP, AOCNP
Kimberly Podsada
Kimberly Podsada, MSN, NP-C, CNS
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Key Takeaways
  • Early proactive management of adverse events associated with oral therapies using tailored antiemetic, antidiarrheal, and metabolic monitoring strategies is essential to maintain adherence.
  • Personalized adherence support such as treatment calendars, reminder systems, and regular follow-up tailored to patient lifestyle and technology literacy are important strategies to ensure adherence.
  • Ongoing patient education on the rationale for each therapy, addressing barriers in real time, and engaging caregivers helps ensure treatment persistence.

Oral anticancer therapies have become an essential part of the treatment landscape in breast cancer, particularly for hormone receptor (HR)–positive and HER2-positive subtypes. However, the clinical benefits of these therapies hinge on patient adherence and persistence. This subject area is packed with challenges because of treatment complexity, adverse events (AEs), psychosocial burdens, and logistical barriers. Here we discuss practical strategies and emerging evidence to support optimal use of oral therapies in patients with breast cancer, highlighting key pharmacologic classes and offering clinical insights based on our experience and available evidence.

HR-Positive Breast Cancer: Navigating Endocrine Therapy and Targeted Agents

Kristi K. Orbaugh, MSN, NP, AOCNP:
Adherence to endocrine therapy is essential for patients with HR-positive breast cancer. Tamoxifen and aromatase inhibitors are widely used to treat HR-positive breast cancer, yet commonly associated toxicities such as hot flashes, arthralgias, and fatigue can undermine patient persistence with treatment, and mitigation of these toxicities is critical to ensure successful adherence. Among the CDK4/6 inhibitors, abemaciclib, palbociclib, and ribociclib are now standard in the metastatic treatment setting with abemaciclib and ribociclib being increasingly used in high-risk early breast cancer. Abemaciclib’s continuous dosing and ribociclib’s 3-week-on/1-week-off schedule may require distinct adherence strategies, including personalized calendars, patient-specific counseling, and toxicity anticipation.

Clinically, diarrhea is a prominent AE with abemaciclib, especially within the first 8 weeks. We often initiate prophylactic loperamide and counsel patients that symptoms typically lessen with time. Similarly, neutropenia is frequent with ribociclib and palbociclib, necessitating scheduled complete blood count monitoring. Education around AE expectations and prompt symptom reporting can foster trust with patients and improve medication adherence.

With the introduction of oral selective estrogen receptor degraders like elacestrant, there are additional treatment options for patients with ESR1-mutant disease. Although nausea remains the most frequently reported treatment-related AE, receiving elacestrant with food typically mitigates this issue. In our clinical experience, we rarely need to prescribe antiemetics beyond the first few weeks of treatment with this drug.

BRCA-Mutated Breast Cancer: Supporting Adherence to PARP Inhibitors

Kimberly Podsada, MSN, NP-C, CNS:
PARP inhibitors offer significant survival advantages in both the metastatic and adjuvant settings for patients with BRCA-mutant disease with talazoparib currently indicated for metastatic disease and olaparib being indicated for early and metastatic disease. However, quality-of-life challenges such as nausea, fatigue, and anemia can compromise therapy duration and, consequently, efficacy. Adherence often decreases in patients juggling busy personal lives or those with a limited support system. We proactively initiate anti-emetics at the onset of PARP inhibitor treatment. Reinforcing the transient nature of nausea and validating the patient’s effort in staying on track with twice-daily dosing schedules greatly improve patient experience while being treated with these agents. In cases where fatigue or anemia interferes with daily life, we engage nutrition experts and check labs for other underlying conditions and, when appropriate, implement short-term dose reductions. Explaining the link between adherence and long-term outcomes often motivates continued therapy, especially in patients with high-risk early-stage disease.

HER2-Positive Breast Cancer: Overcoming Pill Burden and Gastrointestinal Toxicity With TKIs

Kimberly Podsada, MSN, NP-C, CNS:
HER2-targeted TKIs present a different set of challenges. Lapatinib is indicated for use in adults with advanced or metastatic HER2-positive disease, tucatinib is indicated for adults with advanced unresectable or metastatic HER2-positive disease, including brain metastases, and neratinib for is indicated for use in the extended adjuvant treatment of adults with early state HER2-positive breast cancer or in advanced/metastatic HER2-positive disease. Particular challenges with these agents include high pill burdens and gastrointestinal AEs such as diarrhea. To mitigate these toxicities with neratinib, we leverage findings from the phase II CONTROL study. By initiating a dose-escalation strategy and scheduled loperamide to help patients tolerate the first few treatment cycles, some patients see great benefit, especially from adjuncts like colestipol or bulk-forming agents. We have found that once patients establish a consistent bowel regimen, many can maintain HER2-targeted TKIs long term without dose reduction. In short, adherence support, proactive management of AEs, and use of reminder tools can assist patient familiarity and confidence with complicated medication regimens.

Targeted Therapy for PIK3CA, AKT1, and mTOR Pathway Alterations

Kimberly Podsada, MSN, NP-C, CNS:
The introduction of agents targeting the PI3K/AKT/mTOR pathway has greatly expanded treatment options for endocrine-resistant, HR-positive breast cancer. However, these agents come with their own hurdles—of note hyperglycemia and gastrointestinal toxicity. Hyperglycemia with some agents like alpelisib can be daunting, especially in patients with prediabetes or an elevated BMI. We routinely perform baseline metabolic screening, engage endocrinologists early in the treatment journey, and initiate metformin when appropriate. Patients are provided with glucometers and easy-to-follow glucose monitoring schedules, reinforcing the message that hyperglycemia is manageable and is not a reason to abandon therapy. Capivasertib’s diarrhea profile also requires attention. For patients on intermittent dosing schedules, we pair antidiarrheal agents with education and follow-up, ensuring early intervention before toxicity impairs persistence.

Kristi K. Orbaugh, MSN, NP, AOCNP:
In summary, the success of oral anticancer therapies for the treatment of breast cancer requires more than just a prescription for a therapeutic agent. It demands a proactive partnership and multifaceted approach among patients, their caregiver(s), and the healthcare team to ensure therapy adherence and persistence. Our role as healthcare professionals is to anticipate challenges, proactively manage AEs, and implement individualized support systems that respect patient preferences and life demands. Through thoughtful communication and practical tools, we can help our patients realize the full potential of these powerful and advancing therapies.

Your Thoughts?
How have you addressed adherence issues with your patients with breast cancer who are being treated with oral anticancer therapies? Let us know about your experiences with these patients in your practice. Download the slides from the live program and join the conversation by answering the polling question and posting a comment.

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What have you found to be the most effective approach or approaches for improving adherence to oral anticancer therapies in your patients with breast cancer?

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