This paper is in the following e-collection/theme issue:

Viewpoints and Perspectives (6) Chemotherapy and Side Effects Management (58) Clinical Cancer Research (81) Health Services Research in Oncology (35) ENT (Ear, Nose, Throat) (28) Medication Adherence (80)

Published on in Vol 10 (2024)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/57199, first published .
Impact of Patient Personality on Adherence to Oral Anticancer Medications: An Opportunity?

Impact of Patient Personality on Adherence to Oral Anticancer Medications: An Opportunity?

Impact of Patient Personality on Adherence to Oral Anticancer Medications: An Opportunity?

Authors of this article:

Mahtab Jafari1 Author Orcid Image ;   Alex Shahverdian1 Author Orcid Image ;   Gelareh Sadigh2 Author Orcid Image ;   Richard A Van Etten3 Author Orcid Image
Article Authors Cited by Tweetations Metrics

    Viewpoint

    1Department of Pharmaceutical Scienes, University of California, Irvine, Irvine, CA, United States

    2Department of Radiological Sciences, University of California, Irvine, Orange, CA, United States

    3Department of Medicine, University of California, Irvine, Orange, CA, United States

    Corresponding Author:

    Mahtab Jafari, PharmD

    Department of Pharmaceutical Scienes

    University of California, Irvine

    856 Health Sciences Quad 5400

    Room 4020

    Irvine, CA, 92697-3958

    United States

    Phone: 1 949 8240145

    Email: mjafari@uci.edu


    Adherence to prescribed oral anticancer therapy is an important determinant of patient outcomes, including progression-free and overall survival. While many factors (eg, medication side effects and out-of-pocket costs, problems with insurance authorization, and timely medication refills) can affect adherence, one that is relatively unexplored is the impact of a patient’s attitude and personality. Patient personality influences medication adherence and persistence in nonmalignant chronic conditions such as cardiovascular disease and diabetes. In breast cancer and chronic myeloid leukemia, studies suggest that personality also affects adherence to oral chemotherapy which can be targeted to improve adherence. In this viewpoint, we highlight the opportunity of incorporating patient personality as interventions to oral cancer therapy adherence and discuss current barriers to implementation.

    JMIR Cancer 2024;10:e57199

    doi:10.2196/57199

    Keywords

    cancer; medication adherence; medication persistence; Five-Factor Model; Type D personality; oncology; cancer medications; oral anticancer therapy; chemotherapy 


    With acceleration in development of oral anticancer medications in recent years, a substantial number of patients with cancer are responsible for managing their medication. While oral anticancer medications have many advantages over parenteral chemotherapy, including eliminating the need for venous access devices, many patients struggle with adhering to their prescribed regimens. Whereas medication adherence rates among patients with chronic diseases on oral treatment are estimated at approximately 50%, adherence rates for oral anticancer medications are substantially lower, with studies reporting adherence rates as low as 30% to 46% in patients with cancer [1-3]. Similarly, persistence to oral anticancer medications, defined as continuing treatment for the prescribed duration of therapy, is also suboptimal; for example, at 12 and 24 months, treatment persistence in patients with gastrointestinal stroma tumors and chronic myeloid leukemia was reported to be 41% and 56%, respectively [4]. These are concerning statistics given that poor adherence to prescribed cancer therapy can lead to serious consequences such as disease progression, reduced treatment efficacy, increased symptom burden, an increased risk for recurrent cancer, and decreased overall survival [5-7].

    Many patient-related factors can contribute to nonadherence and nonpersistence to prescribed therapies, including health literacy [8], social determinants of health including food insecurity and housing instability [9], out-of-pocket medication costs [10,11], patient age [12,13], number of prescribed medications [14], and medication side effects [15-17]. However, the impact of patient personality and psychosocial characteristics has remained relatively underexplored [18-22]. In this viewpoint, we review literature on the impact of personality on medication adherence and argue that developing patient education that is tailored toward each individual patient’s personality may improve anticancer medication adherence.


    The psychological literature frequently assesses personality using the Five Factor Model (FFM) [23]. Also known as the universal model, the FFM is one of the most empirically supported personality models to date and consists of 5 personality categories (Table 1): openness, conscientiousness, extraversion, agreeableness, and neuroticism. An alternative model recognizes 4 personality types (types A, B, C, and D) [24]. The original categories of type A (competitive, ambitious) and type B (patient, creative) were first defined and studied in patients with cardiovascular disease [25], and were subsequently expanded to include types C (analytical, introverted) and D (anxious, negative). In particular, the type D personality is a trait associated with negative emotions such as worrying, and a lack of social interaction out of fear of disapproval (Textbox 1) [26-28]. The relationship between the FFM and ABCD personality models has not been fully defined, but type D subjects display FFM traits ranging from neurotic introversion with relatively low conscientiousness to stable extraversion with relatively high conscientiousness [29]. The Eysenck personality theory recognizes personality traits across 3 dimensions, extraversion/introversion, neuroticism/stability, and psychoticism/superego [30], and is commonly assessed using the Eysenck Personality Questionnaire-Revised Short Scale [31].

    Table 1. The Five Factor personalities and associated adjectives (adapted from [23]).
    PersonalityAdjectives
    OpennessArtistic, curious, imaginative, insightful, original, and wide interests
    ConscientiousnessEfficient, organized, planful, reliable, responsible, and thorough
    ExtraversionActive, assertive, energetic, enthusiastic, outgoing, and talkative
    AgreeablenessAppreciative, forgiving, generous, kind, sympathetic, and trusting
    NeuroticismAnxious, self-pitying, tense, touchy, unstable, and worrying
    Textbox 1. Characteristics of type D personality [26].

    Type D traits

    • Tendency to experience negative emotions.
    • Propensity to suppress the expression of emotions and behaviors in social contacts.
    • Feeling of unhappiness, worry, irritability, and low self-esteem.
    • Distance in social relations, introversion.

    Association between patient personality assessed by the Five Factor Model and medication adherence has been studied in patients with cardiovascular disease [32]. In a recent study, patient personality was measured using the Japanese Ten-Item Personality Inventory for evaluation of the Big Five personality traits. A 12-item adherence scale measured medication compliance, health care provider collaboration, willingness to access medication information, and acceptance of needing to take medication. Having higher conscientiousness was significantly associated with greater medication compliance, patient-provider–shared decision-making, and willingness to access information about medications [32]. Conscientiousness has also been associated significantly with health-related quality of life, self-efficacy, and satisfaction with life in patients with cardiovascular disease [33]. The type D personality trait, a measure of low social interaction and negative affectivity, is frequently observed in patients with cardiovascular disease [34,35]. Type D individuals have significantly poorer medication adherence patterns in patients with myocardial infarction [36], heart failure [35,37], and acute coronary syndrome [38]. This is in addition to the type D personality being a significant predictor of mortality in patients suffering from coronary heart disease [34].

    Another common disease where medication adherence and personality have been studied is diabetes. Low adherence is a known issue in diabetic patients, leading to increased adverse outcomes such as higher hemoglobin A1c (HbA1c) levels and peripheral neuropathy [39]. More recently, studies have investigated the role the Five Factor personalities have in diabetes [40,41]. In one study, diabetics determined to possess the neuroticism trait based on the Eysenck Personality Questionnaire-Revised Short Scale were significantly less likely to be adherent to medication in bivariate analyses. The authors hypothesized an indirect relationship between adherence and neuroticism mediated through neuroticism’s association with a lack of social support and self-efficacy [40]. Another study also showed a significant negative relationship between neuroticism and adherence along with self-care behaviors [41], but found a significant positive relationship between agreeableness and adherence. Finally, conscientiousness has also been demonstrated to be significantly positively correlated to taking medications as prescribed in type 2 diabetics [42]. These trends are not exclusive to type 2 diabetes, as adolescents with type 1 diabetes who possessed the conscientiousness trait were significantly more adherent to insulin administration while those with the neuroticism trait showed a significantly negative correlation [43]. Like cardiovascular disease, type D personality has also been linked to poor medication adherence in type 2 diabetics [44,45] and to be associated with increased HbA1c [45].


    As in other chronic nonmalignant diseases, nonadherence and nonpersistence to oral anticancer medication can be associated with multiple patient-related factors, some of which may be specific to the type or stage of cancer diagnosis or the duration of the prescribed therapy. The mental impact that accompanies a diagnosis of cancer may trigger or exacerbate behaviors that tend to be associated with the specific personality type of a patient [46-48]. For example, it is possible that some patients with aspects of the type D personality may express negative social and affective traits when confronted with cancer. Relative to other chronic diseases like hypertension and diabetes, cancer therapy is unique in that patients are dealing with an imminent life-threatening condition with medications where the drug choices may be limited, and the side effects are substantial. Indeed, many studies in cancer patients identify medication side effects to be a major factor contributing to poor adherence and persistence [3,49-51]. It follows that a patient’s attitude and personality might have a major effect on coping with such symptoms. However, literature examining personality traits and adherence in patients with cancer is limited. A study that examined the link between the Five Factor Model and adherence to outpatient cancer therapies suggested that the 2 personality types of conscientiousness and agreeableness correlated with increased adherence [52], but the specific types of cancer and treatments were not explored in detail. Other studies have focused on aspects of a patient’s emotional state rather than on personality traits per se, as a functional relationship between personality type and the regulation of emotions has been documented [53-55]. For example, a review of psychosocial determinants of adherence to oral anticancer treatment found high levels of distress (anxiety and depression) to be a major factor contributing to nonadherence [56]. Medication beliefs have also been found to impact adherence to cancer medications [50,57-59].

    Two cancer types where adherence has been studied in significant detail are early-stage breast cancer and chronic myeloid leukemia [7]. Patients with either of these vastly different malignancies share 2 characteristics: minimal symptoms arising from the cancer itself and a major impact of medication nonadherence on progression-free and overall survival. Patients with early-stage hormone-receptor positive breast cancer are frequently treated with oral medications targeting estrogen and progesterone signaling (adjuvant endocrine therapy [AET]) following surgical management of the primary tumor. Nonadherence and nonpersistence to prescribed AET have been shown in numerous studies to correlate with significantly reduced overall survival [60-62], particularly in Black women [63]. Side effects of AET represent a major factor associated with nonadherence in this population [49,64,65]. Patient personality has not been studied explicitly as a factor in AET adherence, but other studies have identified anticipatory positive emotions [66] and lower depressive symptoms associated with greater social support [67] to be associated with increased adherence.

    Therapy of chronic myeloid leukemia (CML) has been revolutionized by Abelson 1 tyrosine kinase inhibitors (TKIs) such as imatinib (Gleevec). Most patients with CML achieve cytogenetic remission with TKI treatment [68,69] and enjoy age-adjusted normal life expectancy [70], but therapy must be lifelong for most patients [71]. Adherence and persistence to TKI therapy is of paramount importance to clinical outcomes of patients with CML, as missing just 1 dose a week is associated with suboptimal response [72] and treatment failure [73,74]. As a consequence, the factors associated with TKI adherence in CML have been studied extensively [75,76] and include out-of-pocket costs [77,78], long-term side effects [79,80], and dosing schedule [81]. In CML as in breast cancer, the impact of patient personality on medication adherence has been largely unexplored, but a recent study found that patients with either type A or type D personality (particularly negative affectivity) were more prone to TKI nonadherence [82].


    A patient’s personality can inform differences in the way they think, behave and feel [83]. It can help predict their compliance with follow-up appointments, adherence to medications, and the tendency to accept and implement medical advice [84,85]. Furthermore, the personality of a patient likely influences other patient-related factors including emotional state, regulation, and stability [54,55]. The specific mechanisms through which a patient’s personality type might impact their adherence to medication have not been fully defined. It is possible that personality might have a direct effect on adherence, or a given personality trait might moderate the relationship between other factors that influence adherence, for example, between stress and levels of anxiety or depression. Previous studies of the moderating effects of personality on stress responses have yielded mixed results. For example, the neuroticism personality type has been found to moderate the relationship between stress and negative affect or health behaviors [86,87] and between medication beliefs and adherence during the COVID-19 pandemic [88], while another study demonstrated a correlation between personality and health trajectory but no moderating effect of personality type on the effect of stress on health outcomes [89]. Further studies are necessary to clarify the mechanistic relationship between personality and medication adherence and to inform strategies for intervention.

    Given the current state of our knowledge, what opportunities exist to leverage a patient’s personality to improve their adherence to prescribed medication in general and in cancer specifically? One approach might be to attempt to alter or modify a patient’s personality toward one that is more favorable for medication adherence (for example, from type D to type A, or from neuroticism to conscientiousness). While there is general agreement that one’s personality can change, most adult personalities are relatively stable over time and the degree of any change is small [90,91]. Furthermore, attempts to change personality may be complicated by the challenges imposed by a cancer diagnosis. Although personality trait change has been recognized as a potentially fruitful area for health policy initiatives [92], there is a dearth of published research on this method to improve medication adherence. A better approach might be to adapt patient educational and motivational materials to an individual’s personality to ensure that the information is conveyed in a way that is most effective. Communications tailored to personality have been shown to be more effective than standard one size fits all messaging in advertising [93], education [94], and health care [95,96], but have not yet been applied to medication adherence.

    For example, patients who exhibit a neurotic personality type could be more likely to experience negative emotions like irritability and anxiety following a cancer diagnosis, negatively impacting adherence [97]. A behavioral intervention strategy that acknowledges the neurotic patient’s emotions and uses positive psychology techniques could prove helpful in this case [98]. For a patient who is extroverted or outgoing, allowing a safe and nonjudgmental space to share their opinions before educating them on their medication usage could ensure improved listening and adherence. Since extroverts thrive on being creative, they could also be empowered to take control of their own health and identify strategies that help them remember to take medications. It is important to note, however, that each of the 5 personality traits in the FFM represent a range between 2 extremes [23]. For instance, the extraversion trait represents a continuum between extreme extraversion and extreme introversion. In general, however, since most people lie at neither end of the spectrum but somewhere in between, multiple strategies for each patient’s unique disposition would likely be more effective [23].

    A more frequently applied strategy to increase medication adherence is to focus interventions on psychosocial factors, some of which may be associated with personality. Several recent studies in patients with breast cancer have used interventions focused on personal attitudes and values to increase adherence to AET [99,100]. Post hoc analysis of a randomized controlled trial found relaxation training to be more effective than cognitive behavioral therapy in improving adherence to AET [101]. A remotely delivered intervention based on personal values demonstrated feasibility and acceptability and showed promise in improving AET adherence [102]. In CML, an education program tailored to individual patients based on interviews and a designed set of distinct adherence aids improved TKI adherence in a randomized trial [103]. However, most efforts to improve TKI adherence have relied on analysis of large datasets to identify interventions and lack patient-focused approaches [104]. To address this, we (the authors) have launched a clinical trial aimed at better understanding the correlation between patient personality (the dominant trait as assessed by the FFM) and TKI adherence in patients with CML (ClinicalTrials.gov NCT06229860).

    Before these strategies can be explored further in the real-world setting, existing FFM personality assessments currently used in cancer care or literature must be evaluated. Although assessments of patient personality often appear in medical records, they are usually 1-sided remarks limited to terms such as “pleasant,” “short-tempered,” or “difficult” and portray a rather superficial and incomplete perspective, which can in turn lead to biased intuitions [105,106], suboptimal care, and poor adherence. Instead, a structured and validated approach should be adopted to provide a more reliable breakdown of personality. A recent study examined the use of the 20-item Mini International Personality Item Pool (mini-IPIP) scale in adults with cancer and reported potential validity of the tool in oncologic clinical settings [107]. Despite being a shorter version compared with other full versions of FFM personality measures, such as the NEO-Five Factor Inventory [108], the mini-IPIP has also been widely cited in studies including healthy adults and illustrated sufficient internal reliability across diverse population samples [109]. Since the mini-IPIP is a 20-item questionnaire with potential internal and external validity, the tool could be reasonably administered to cancer patients. To facilitate smooth patient-provider interactions, patients could be requested to complete these assessments during a patient intake process or before an appointment through patient portals to allow providers ample time to review their personality profiles and prepare as needed before an encounter.


    Behavioral intervention studies that seek to address each personality type should be conducted to reinforce positive health behaviors and promote adherence. Instead of using a cookie-cutter approach to patient counseling, understanding each person’s unique personality, and adopting communication strategies that encourage optimal adherence can improve oncologic patient care. However, further research is needed to evaluate the impact of personality-specific medication counseling on adherence to oral anticancer medications. This includes validation studies that confirm the reliability of personality assessments in cancer patients, as well as studies that explore the effectiveness of psychological behavioral techniques on adherence in different personalities. At the same time, there are enough data to encourage research in this direction. We strongly believe that incorporating personality into oncological care will redefine how we approach patient care as a whole, especially in this age where personalized care models like precision medicine are on the rise.

    Acknowledgments

    Supported in part by a gift from the Kay Family Foundation.

    Conflicts of Interest

    None declared.

    1. Greer JA, Amoyal N, Nisotel L, Fishbein JN, MacDonald J, Stagl J, et al. A systematic review of adherence to oral antineoplastic therapies. Oncologist. 2016;21(3):354-376. [FREE Full text] [CrossRef] [Medline]
    2. De Geest S, Sabaté E. Adherence to long-term therapies: evidence for action. Eur J Cardiovasc Nurs. 2003;2(4):323. [CrossRef] [Medline]
    3. Salgado TM, Mackler E, Severson JA, Lindsay J, Batra P, Petersen L, et al. The relationship between patient activation, confidence to self-manage side effects, and adherence to oral oncolytics: a pilot study with Michigan oncology practices. Support Care Cancer. 2017;25(6):1797-1807. [CrossRef] [Medline]
    4. Hohneker J, Shah-Mehta S, Brandt PS. Perspectives on adherence and persistence with oral medications for cancer treatment. J Oncol Pract. 2011;7(1):65-67. [FREE Full text] [CrossRef] [Medline]
    5. Ganesan P, Sagar TG, Dubashi B, Rajendranath R, Kannan K, Cyriac S, et al. Nonadherence to imatinib adversely affects event free survival in chronic phase chronic myeloid leukemia. Am J Hematol. 2011;86(6):471-474. [FREE Full text] [CrossRef] [Medline]
    6. Makubate B, Donnan PT, Dewar JA, Thompson AM, McCowan C. Cohort study of adherence to adjuvant endocrine therapy, breast cancer recurrence and mortality. Br J Cancer. 2013;108(7):1515-1524. [FREE Full text] [CrossRef] [Medline]
    7. McCue DA, Lohr LK, Pick AM. Improving adherence to oral cancer therapy in clinical practice. Pharmacotherapy. 2014;34(5):481-494. [CrossRef] [Medline]
    8. Schönfeld MS, Pfisterer-Heise S, Bergelt C. Self-reported health literacy and medication adherence in older adults: a systematic review. BMJ Open. 2021;11(12):e056307. [FREE Full text] [CrossRef] [Medline]
    9. Wilder ME, Kulie P, Jensen C, Levett P, Blanchard J, Dominguez LW, et al. The impact of social determinants of health on medication adherence: a systematic review and meta-analysis. J Gen Intern Med. 2021;36(5):1359-1370. [FREE Full text] [CrossRef] [Medline]
    10. Sadigh G, Switchenko J, Weaver KE, Elchoufi D, Meisel J, Bilen MA, et al. Correlates of financial toxicity in adult cancer patients and their informal caregivers. Support Care Cancer. 2022;30(1):217-225. [FREE Full text] [CrossRef] [Medline]
    11. Dusetzina SB, Besaw RJ, Whitmore CC, Mattingly TJ, Sinaiko AD, Keating NL, et al. Cost-related medication nonadherence and desire for medication cost information among adults aged 65 years and older in the US in 2022. JAMA Netw Open. 2023;6(5):e2314211. [FREE Full text] [CrossRef] [Medline]
    12. Weingarten MA, Cannon BS. Age as a major factor affecting adherence to medication for hypertension in a general practice population. Fam Pract. 1988;5(4):294-296. [CrossRef] [Medline]
    13. Punnapurath S, Vijayakumar P, Platty P, Krishna S, Thomas T. A study of medication compliance in geriatric patients with chronic illness. J Family Med Prim Care. 2021;10(4):1644-1648. [FREE Full text] [CrossRef] [Medline]
    14. Kim S, Kwon O, Han E, Lee C, Oh S, Joh H, et al. Impact of number of medications and age on adherence to antihypertensive medications: a nationwide population-based study. Medicine (Baltimore). 2019;98(49):e17825. [FREE Full text] [CrossRef] [Medline]
    15. Leporini C, De Sarro G, Russo E. Adherence to therapy and adverse drug reactions: is there a link? Expert Opin Drug Saf. 2014;13 Suppl 1:S41-S55. [CrossRef] [Medline]
    16. Tedla YG, Bautista LE. Drug side effect symptoms and adherence to antihypertensive medication. Am J Hypertens. 2016;29(6):772-779. [FREE Full text] [CrossRef] [Medline]
    17. Peddie N, Agnew S, Crawford M, Dixon D, MacPherson I, Fleming L. The impact of medication side effects on adherence and persistence to hormone therapy in breast cancer survivors: a qualitative systematic review and thematic synthesis. Breast. 2021;58:147-159. [FREE Full text] [CrossRef] [Medline]
    18. Zugelj U, Zupancic M, Komidar L, Kenda R, Varda NM, Gregoric A. Self-reported adherence behavior in adolescent hypertensive patients: the role of illness representations and personality. J Pediatr Psychol. 2010;35(9):1049-1060. [CrossRef] [Medline]
    19. Theofilou P, Panagiotaki H. A literature review to investigate the link between psychosocial characteristics and treatment adherence in cancer patients. Oncol Rev. 2012;6(1):e5. [FREE Full text] [CrossRef] [Medline]
    20. Shahin W, Kennedy GA, Stupans I. The impact of personal and cultural beliefs on medication adherence of patients with chronic illnesses: a systematic review. Patient Prefer Adherence. 2019;13:1019-1035. [FREE Full text] [CrossRef] [Medline]
    21. Szabo G, Fornaro M, Dome P, Varbiro S, Gonda X. A bitter pill to swallow? Impact of affective temperaments on treatment adherence: a systematic review and meta-analysis. Transl Psychiatry. 2022;12(1):360. [FREE Full text] [CrossRef] [Medline]
    22. Szabo G, Szigeti FJ, Sipos M, Varbiro S, Gonda X. Affective temperaments show stronger association with infertility treatment success compared to somatic factors, highlighting the role of personality focused interventions. Sci Rep. 2023;13(1):21956. [FREE Full text] [CrossRef] [Medline]
    23. McCrae RR, John OP. An introduction to the five-factor model and its applications. J Pers. 1992;60(2):175-215. [CrossRef] [Medline]
    24. Kanten P, Gümüstekin G, Kanten S. Exploring the role of A, B, C and D personality types on individuals work-related behaviors and health problems: a theoretical model. Int J Bus Manag Invent. 2017;6(7):29-37. [FREE Full text]
    25. Friedman M, Rosenman RH. Association of specific overt behavior pattern with blood and cardiovascular findings; blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease. J Am Med Assoc. 1959;169(12):1286-1296. [CrossRef] [Medline]
    26. Denollet J. Type D personality. A potential risk factor refined. J Psychosom Res. 2000;49(4):255-266. [CrossRef] [Medline]
    27. Denollet J. DS14: standard assessment of negative affectivity, social inhibition, and type D personality. Psychosom Med. 2005;67(1):89-97. [CrossRef] [Medline]
    28. Mols F, Denollet J. Type D personality in the general population: a systematic review of health status, mechanisms of disease, and work-related problems. Health Qual Life Outcomes. 2010;8:9. [FREE Full text] [CrossRef] [Medline]
    29. De Fruyt F, Denollet J. Type D personality: a five-factor model perspective. Psychology & Health. 2010;17(5):671-683. [CrossRef]
    30. Matthews G, Gilliland K. The personality theories of H.J. Eysenck and J.A. Gray: a comparative review. Personality and Individual Differences. 1999;26(4):583-626. [CrossRef]
    31. Eysenck SBG, Eysenck HJ, Barrett P. A revised version of the psychoticism scale. Personality and Individual Differences. 1985;6(1):21-29. [CrossRef]
    32. Adachi T, Tsunekawa Y, Tanimura D. Association between the big five personality traits and medication adherence in patients with cardiovascular disease: a cross-sectional study. PLoS One. 2022;17(12):e0278534. [FREE Full text] [CrossRef] [Medline]
    33. Tabernero C, Gutiérrez-Domingo T, Vecchione M, Cuadrado E, Castillo-Mayén R, Rubio S, et al. A longitudinal study on perceived health in cardiovascular patients: the role of conscientiousness, subjective wellbeing and cardiac self-efficacy. PLoS One. 2019;14(10):e0223862. [FREE Full text] [CrossRef] [Medline]
    34. Denollet J, Sys SU, Stroobant N, Rombouts H, Gillebert TC, Brutsaert D. Personality as independent predictor of long-term mortality in patients with coronary heart disease. Lancet. 1996;347(8999):417-421. [CrossRef] [Medline]
    35. Wu J, Song EK, Moser DK. Type D personality, self-efficacy, and medication adherence in patients with heart failure-a mediation analysis. Heart Lung. 2015;44(4):276-281. [FREE Full text] [CrossRef] [Medline]
    36. Williams L, O'Connor RC, Grubb N, O'Carroll R. Type D personality predicts poor medication adherence in myocardial infarction patients. Psychol Health. 2011;26(6):703-712. [CrossRef] [Medline]
    37. Wu J, Moser DK. Type D personality predicts poor medication adherence in patients with heart failure in the USA. Int J Behav Med. 2014;21(5):833-842. [FREE Full text] [CrossRef] [Medline]
    38. Molloy GJ, Randall G, Wikman A, Perkins-Porras L, Messerli-Bürgy N, Steptoe A. Type D personality, self-efficacy, and medication adherence following an acute coronary syndrome. Psychosom Med. 2012;74(1):100-106. [CrossRef] [Medline]
    39. Zhang ZP, Premikha M, Luo M, Venkataraman K. Diabetes distress and peripheral neuropathy are associated with medication non-adherence in individuals with type 2 diabetes in primary care. Acta Diabetol. 2021;58(3):309-317. [CrossRef] [Medline]
    40. Huang J, Ding S, Xiong S, Liu Z. Medication adherence and associated factors in patients with type 2 diabetes: a structural equation model. Front Public Health. 2021;9:730845. [FREE Full text] [CrossRef] [Medline]
    41. Hazrati-Meimaneh Z, Amini-Tehrani M, Pourabbasi A, Gharlipour Z, Rahimi F, Ranjbar-Shams P, et al. The impact of personality traits on medication adherence and self-care in patients with type 2 diabetes mellitus: the moderating role of gender and age. J Psychosom Res. 2020;136:110178. [CrossRef] [Medline]
    42. Skinner TC, Bruce DG, Davis TME, Davis WA. Personality traits, self-care behaviours and glycaemic control in type 2 diabetes: the Fremantle diabetes study phase II. Diabet Med. 2014;31(4):487-492. [CrossRef] [Medline]
    43. Wheeler K, Wagaman A, McCord D. Personality traits as predictors of adherence in adolescents with type I diabetes. J Child Adolesc Psychiatr Nurs. 2012;25(2):66-74. [CrossRef] [Medline]
    44. Li X, Zhang S, Xu H, Tang X, Zhou H, Yuan J, et al. Type D personality predicts poor medication adherence in Chinese patients with type 2 diabetes mellitus: a six-month follow-up study. PLoS One. 2016;11(2):e0146892. [FREE Full text] [CrossRef] [Medline]
    45. Li X, Gao M, Zhang S, Xu H, Zhou H, Wang X, et al. Medication adherence mediates the association between type D personality and high HbA1c level in Chinese patients with type 2 diabetes mellitus: a six-month follow-up study. J Diabetes Res. 2017;2017:7589184. [FREE Full text] [CrossRef] [Medline]
    46. Dahl AA. Link between personality and cancer. Future Oncol. 2010;6(5):691-707. [CrossRef]
    47. McFarland D, Morita J, Alici Y. Personality disorders in patients with cancer. Oncology (Williston Park). 2019;33(10):686510. [FREE Full text] [Medline]
    48. Chow PI, Shaffer KM, Lohman MC, LeBaron VT, Fortuna KL, Ritterband LM. Examining the relationship between changes in personality and depression in older adult cancer survivors. Aging Ment Health. 2020;24(8):1237-1245. [CrossRef] [Medline]
    49. Henry NL, Azzouz F, Desta Z, Li L, Nguyen AT, Lemler S, et al. Predictors of aromatase inhibitor discontinuation as a result of treatment-emergent symptoms in early-stage breast cancer. J Clin Oncol. 2012;30(9):936-942. [FREE Full text] [CrossRef] [Medline]
    50. Krikorian S, Pories S, Tataronis G, Caughey T, Chervinsky K, Lotz M, et al. Adherence to oral chemotherapy: challenges and opportunities. J Oncol Pharm Pract. 2019;25(7):1590-1598. [CrossRef] [Medline]
    51. Verbrugghe M, Verhaeghe S, Lauwaert K, Beeckman D, Van Hecke A. Determinants and associated factors influencing medication adherence and persistence to oral anticancer drugs: a systematic review. Cancer Treat Rev. 2013;39(6):610-621. [CrossRef] [Medline]
    52. Lima MP, Machado WDL, Irigaray TQ. Predictive factors of treatment adherence in cancer outpatients. Psychooncology. 2018;27(12):2823-2828. [CrossRef] [Medline]
    53. Revelle W, Scherer KR. Personality and emotion. In: Sander D, Scherer KR, editors. The Oxford Companion to Emotion and the Affective Sciences. United Kingdom. Oxford University Press; 2009:304-306.
    54. Zhu Z, Qin S, Dodd A, Conti M. Understanding the relationships between emotion regulation strategies and big five personality traits for supporting effective emotion regulation tools/interventions design. Advanced Design Research. 2023;1(1):38-49. [CrossRef]
    55. Chen YN. The relationship between personality traits, emotional stability and mental health in art vocational and technical college students during epidemic prevention and control. Psychol Res Behav Manag. 2023;16:2857-2867. [FREE Full text] [CrossRef] [Medline]
    56. Kaptein AA, Schoones JW, van der Meer PB, Matsuda A, Murray M, Heimans L, et al. Psychosocial determinants of adherence with oral anticancer treatment: 'we don't need no education'. Acta Oncol. 2021;60(1):87-95. [CrossRef] [Medline]
    57. Fink AK, Gurwitz J, Rakowski W, Guadagnoli E, Silliman RA. Patient beliefs and tamoxifen discontinuance in older women with estrogen receptor--positive breast cancer. J Clin Oncol. 2004;22(16):3309-3315. [CrossRef] [Medline]
    58. Grunfeld EA, Hunter MS, Sikka P, Mittal S. Adherence beliefs among breast cancer patients taking tamoxifen. Patient Educ Couns. 2005;59(1):97-102. [CrossRef] [Medline]
    59. Birand N, Boşnak AS, Diker Ö, Abdikarim A, Başgut B. The role of the pharmacist in improving medication beliefs and adherence in cancer patients. J Oncol Pharm Pract. 2019;25(8):1916-1926. [CrossRef] [Medline]
    60. McCowan C, Shearer J, Donnan PT, Dewar JA, Crilly M, Thompson AM, et al. Cohort study examining tamoxifen adherence and its relationship to mortality in women with breast cancer. Br J Cancer. 2008;99(11):1763-1768. [FREE Full text] [CrossRef] [Medline]
    61. Hershman DL, Shao T, Kushi LH, Buono D, Tsai WY, Fehrenbacher L, et al. Early discontinuation and non-adherence to adjuvant hormonal therapy are associated with increased mortality in women with breast cancer. Breast Cancer Res Treat. 2011;126(2):529-537. [FREE Full text] [CrossRef] [Medline]
    62. Eliassen FM, Blåfjelldal V, Helland T, Hjorth CF, Hølland K, Lode L, et al. Importance of endocrine treatment adherence and persistence in breast cancer survivorship: a systematic review. BMC Cancer. 2023;23(1):625. [FREE Full text] [CrossRef] [Medline]
    63. Dang TH, Forkan ARM, Wickramasinghe N, Jayaraman PP, Alexander M, Burbury K, et al. Investigation of intervention solutions to enhance adherence to oral anticancer medicines in adults: overview of reviews. JMIR Cancer. 2022;8(2):e34833. [FREE Full text] [CrossRef] [Medline]
    64. Demissie S, Silliman RA, Lash TL. Adjuvant tamoxifen: predictors of use, side effects, and discontinuation in older women. J Clin Oncol. 2001;19(2):322-328. [CrossRef] [Medline]
    65. Fleming L, Agnew S, Peddie N, Crawford M, Dixon D, MacPherson I. The impact of medication side effects on adherence and persistence to hormone therapy in breast cancer survivors: a quantitative systematic review. Breast. 2022;64:63-84. [FREE Full text] [CrossRef] [Medline]
    66. Hurtado-de-Mendoza A, Carrera P, Parrott WG, Gómez-Trillos S, Perera RA, Sheppard VB. Applying the theory of planned behavior to examine adjuvant endocrine therapy adherence intentions. Psychooncology. 2019;28(1):187-194. [FREE Full text] [CrossRef] [Medline]
    67. Bright EE, Stanton AL. Prospective investigation of social support, coping, and depressive symptoms: a model of adherence to endocrine therapy among women with breast cancer. J Consult Clin Psychol. 2018;86(3):242-253. [CrossRef] [Medline]
    68. Hochhaus A, Larson RA, Guilhot F, Radich JP, Branford S, Hughes TP, et al. IRIS Investigators. Long-term outcomes of imatinib treatment for chronic myeloid leukemia. N Engl J Med. 2017;376(10):917-927. [FREE Full text] [CrossRef] [Medline]
    69. Jabbour E, Kantarjian H. Chronic myeloid leukemia: 2022 update on diagnosis, therapy, and monitoring. Am J Hematol. 2022;97(9):1236-1256. [FREE Full text] [CrossRef] [Medline]
    70. Gambacorti-Passerini C, Antolini L, Mahon F, Guilhot F, Deininger M, Fava C, et al. Multicenter independent assessment of outcomes in chronic myeloid leukemia patients treated with imatinib. J Natl Cancer Inst. 2011;103(7):553-561. [CrossRef] [Medline]
    71. Atallah E, Schiffer CA. Discontinuation of tyrosine kinase inhibitors in chronic myeloid leukemia: when and for whom? Haematologica. 2020;105(12):2738-2745. [FREE Full text] [CrossRef] [Medline]
    72. Noens L, van Lierde MA, De Bock R, Verhoef G, Zachée P, Berneman Z, et al. Prevalence, determinants, and outcomes of nonadherence to imatinib therapy in patients with chronic myeloid leukemia: the ADAGIO study. Blood. 2009;113(22):5401-5411. [FREE Full text] [CrossRef] [Medline]
    73. Marin D, Bazeos A, Mahon FX, Eliasson L, Milojkovic D, Bua M, et al. Adherence is the critical factor for achieving molecular responses in patients with chronic myeloid leukemia who achieve complete cytogenetic responses on imatinib. J Clin Oncol. 2010;28(14):2381-2388. [FREE Full text] [CrossRef] [Medline]
    74. Ibrahim AR, Eliasson L, Apperley JF, Milojkovic D, Bua M, Szydlo R, et al. Poor adherence is the main reason for loss of CCyR and imatinib failure for chronic myeloid leukemia patients on long-term therapy. Blood. 2011;117(14):3733-3736. [FREE Full text] [CrossRef] [Medline]
    75. Jabbour E, Saglio G, Radich J, Kantarjian H. Adherence to BCR-ABL inhibitors: issues for CML therapy. Clin Lymphoma Myeloma Leuk. 2012;12(4):223-229. [FREE Full text] [CrossRef] [Medline]
    76. Geissler J, Sharf G, Bombaci F, Daban M, De Jong J, Gavin T, et al. Factors influencing adherence in CML and ways to improvement: results of a patient-driven survey of 2546 patients in 63 countries. J Cancer Res Clin Oncol. 2017;143(7):1167-1176. [CrossRef] [Medline]
    77. Dusetzina SB, Winn AN, Abel GA, Huskamp HA, Keating NL. Cost sharing and adherence to tyrosine kinase inhibitors for patients with chronic myeloid leukemia. J Clin Oncol. 2014;32(4):306-311. [CrossRef] [Medline]
    78. Winn AN, Keating NL, Dusetzina SB. Factors associated with tyrosine kinase inhibitor initiation and adherence among medicare beneficiaries with chronic myeloid leukemia. J Clin Oncol. 2016;34(36):4323-4328. [FREE Full text] [CrossRef] [Medline]
    79. Eliasson L, Clifford S, Barber N, Marin D. Exploring chronic myeloid leukemia patients' reasons for not adhering to the oral anticancer drug imatinib as prescribed. Leuk Res. 2011;35(5):626-630. [CrossRef] [Medline]
    80. Unnikrishnan R, Veeraiah S, Mani S, Rajendranath R, Rajaraman S, Vidhubala Elangovan GS, et al. Comprehensive evaluation of adherence to therapy, its associations, and its implications in patients with chronic myeloid leukemia receiving imatinib. Clin Lymphoma Myeloma Leuk. 2016;16(6):366-371.e3. [CrossRef] [Medline]
    81. Santoleri F, Ranucci E, La Barba G, Colasanto I, Scaldaferri M, Cattel F, et al. Adherence, persistence and efficacy of dasatinib and nilotinib in the treatment of patients resistant or intolerant to imatinib with chronic myeloid leukemia in chronic phase: an Italian multicenter study over two years in real life. Curr Med Res Opin. 2021;37(3):477-481. [CrossRef] [Medline]
    82. Rychter A, Miniszewska J, Góra-Tybor J. Personality traits favourable for non-adherence to treatment in patients with chronic myeloid leukaemia: role of type A and D personality. Biopsychosoc Med. 2023;17(1):1. [CrossRef] [Medline]
    83. Personality. American Psychological Association; 2022. URL: https://www.apa.org/topics/personality [accessed 2024-09-05]
    84. Axelsson M, Brink E, Lundgren J, Lötvall J. The influence of personality traits on reported adherence to medication in individuals with chronic disease: an epidemiological study in West Sweden. PLoS One. 2011;6(3):e18241. [FREE Full text] [CrossRef] [Medline]
    85. Cheli S, Lam WWT, Estapé T, Winterling J, Bahcivan O, Andritsch E, et al. Risk perception, treatment adherence, and personality during COVID-19 pandemic: an international study on cancer patients. Psychooncology. 2022;31(1):46-53. [FREE Full text] [CrossRef] [Medline]
    86. Korotkov D. Does personality moderate the relationship between stress and health behavior? Expanding the nomological network of the five-factor model. J Res Personality. 2008;42(6):1418-1426. [CrossRef]
    87. Joshanloo M. Personality traits and psychological well-being as moderators of the relationship between stressors and negative affect: a daily diary study. Curr Psychol. 2023;42(4):15647-15657. [FREE Full text] [CrossRef]
    88. Ferretti F, Goracci A, Laurenzi PF, Centola R, Crecchi I, De Luca A, et al. Neuroticism and conscientiousness moderate the effect of oral medication beliefs on adherence of people with mental illness during the pandemic. Brain Sci. 2022;12(10):1315. [FREE Full text] [CrossRef] [Medline]
    89. Mitchell LL, Zmora R, Finlay JM, Jutkowitz E, Gaugler JE. Do big five personality traits moderate the effects of stressful life events on health trajectories? Evidence from the health and retirement study. J Gerontol B Psychol Sci Soc Sci. 2021;76(1):44-55. [FREE Full text] [CrossRef] [Medline]
    90. Bleidorn W, Schwaba T, Zheng A, Hopwood CJ, Sosa SS, Roberts BW, et al. Personality stability and change: a meta-analysis of longitudinal studies. Psychol Bull. 2022;148(7-8):588-619. [CrossRef] [Medline]
    91. Jackson JJ, Wright AJ. The process and mechanisms of personality change. Nat Rev Psychol. 2024;4:305-318. [FREE Full text] [CrossRef]
    92. Bleidorn W, Hill PL, Back MD, Denissen JJA, Hennecke M, Hopwood CJ, et al. The policy relevance of personality traits. Am Psychol. 2019;74(9):1056-1067. [FREE Full text] [CrossRef] [Medline]
    93. Hirsh JB, Kang SK, Bodenhausen GV. Personalized persuasion: tailoring persuasive appeals to recipients' personality traits. Psychol Sci. 2012;23(6):578-581. [CrossRef] [Medline]
    94. Takami K, Flanagan B, Dai Y, O?gata HS. Personality-based tailored explainable recommendation for trustworthy smart learning system in the age of artificial intelligence. Smart Learn Environ. 2023;10:65. [FREE Full text] [CrossRef]
    95. Holt CL, Clark EM, Kreuter MW, Scharff DP. Does locus of control moderate the effects of tailored health education materials? Health Educ Res. 2000;15(4):393-403. [CrossRef] [Medline]
    96. Alqahtani F, Meier S, Orji R. Personality-based approach for tailoring persuasive mental health applications. User Modeling and User-Adapted Interaction. 2022;32:253-295. [FREE Full text] [CrossRef]
    97. Cook SA, Salmon P, Hayes G, Byrne A, Fisher PL. Predictors of emotional distress a year or more after diagnosis of cancer: a systematic review of the literature. Psychooncology. 2018;27(3):791-801. [FREE Full text] [CrossRef] [Medline]
    98. Ng W. Neuroticism and well-being? Let's work on the positive rather than negative aspects. J Positive Psychol. 2012;7(5):416-426. [FREE Full text] [CrossRef]
    99. Pezzolato M, Marzorati C, Lanzoni L, Monzani D, Masiero MA, Pietrobon R, et al. Interventions to increase adherence to oral therapies in breast cancer patients: a systematic review based on the behavior change technique taxonomy. Psychooncology. 2023;32(10):1481-1502. [CrossRef] [Medline]
    100. Bright EE, Finkelstein LB, Nealis MS, Genung SR, Wrigley J, Gu HCJ, et al. A systematic review and meta-analysis of interventions to promote adjuvant endocrine therapy adherence among breast cancer survivors. J Clin Oncol. 2023;41(28):4548-4561. [CrossRef] [Medline]
    101. Ream ME, Walsh EA, Jacobs JM, Taub C, Lippman M, Schaefer-Solle N, et al. Brief relaxation training is associated with long-term endocrine therapy adherence among women with breast cancer: post hoc analysis of a randomized controlled trial. Breast Cancer Res Treat. 2021;190(1):79-88. [FREE Full text] [CrossRef] [Medline]
    102. Arch JJ, Crespi CM, Levin ME, Genung SR, Nealis M, Mitchell JL, et al. Randomized controlled pilot trial of a low-touch remotely-delivered values intervention to promote adherence to adjuvant endocrine therapy among breast cancer survivors. Ann Behav Med. 2022;56(8):856-871. [FREE Full text] [CrossRef] [Medline]
    103. Kekäle M, Söderlund T, Koskenvesa P, Talvensaari K, Airaksinen M. Impact of tailored patient education on adherence of patients with chronic myeloid leukaemia to tyrosine kinase inhibitors: a randomized multicentre intervention study. J Adv Nurs. 2016;72(9):2196-2206. [CrossRef] [Medline]
    104. Heiney SP, Sorrell M, Sheng J, Adams SA, Nelson K, Nguyen LA, et al. Interventions to improve adherence to tyrosine kinase inhibitors in chronic myeloid leukemia: a systematic review. Am J Clin Oncol. 2021;44(6):291-298. [CrossRef] [Medline]
    105. Park J, Saha S, Chee B, Taylor J, Beach MC. Physician use of stigmatizing language in patient medical records. JAMA Netw Open. 2021;4(7):e2117052. [FREE Full text] [CrossRef] [Medline]
    106. Himmelstein G, Bates D, Zhou L. Examination of stigmatizing language in the electronic health record. JAMA Netw Open. 2022;5(1):e2144967. [FREE Full text] [CrossRef] [Medline]
    107. Perry LM, Hoerger M, Molix LA, Duberstein PR. A validation study of the Mini-IPIP five-factor personality scale in adults with cancer. J Pers Assess. 2020;102(2):153-163. [FREE Full text] [CrossRef] [Medline]
    108. McCrae RR, Costa PT. A contemplated revision of the NEO Five-Factor inventory. Personality and Individual Differences. 2004;36(3):587-596. [CrossRef]
    109. Donnellan MB, Oswald FL, Baird BM, Lucas RE. The mini-IPIP scales: tiny-yet-effective measures of the big five factors of personality. Psychol Assess. 2006;18(2):192-203. [CrossRef] [Medline]

    ‎
    AET: adjuvant endocrine therapy
    CML: chronic myeloid leukemia
    FFM: Five Factor Model
    HbA1c: hemoglobin A1c
    IPIP: International Personality Item Pool
    TKI: tyrosine kinase inhibitors

    Edited by T de Azevedo Cardoso; submitted 16.02.24; peer-reviewed by Y Jiang, E Fiorio; comments to author 17.04.24; revised version received 03.05.24; accepted 31.07.24; published 30.10.24.

    Copyright

    ©Mahtab Jafari, Alex Shahverdian, Gelareh Sadigh, Richard A Van Etten. Originally published in JMIR Cancer (https://cancer.jmir.org), 30.10.2024.

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