Which patient- and physician-related factors are associated with guideline adherent initiation of adjuvant endocrine therapy? Results of the prospective multi-centre cohort study BRENDA II.

Abstract

We analysed factors that might influence patients' and physicians' decisions against the initiation of guideline adherent adjuvant endocrine therapy (ET). In a prospective multi-centre study, including four certified breast cancer centres in Germany, patients with primary breast cancer were included from 2009 to 2012. Patients completed a questionnaire prior to surgery, adjuvant therapy, and 6months after adjuvant therapy. This questionnaire assessed health-related quality of life (QoL), psychiatric co-morbidity, demographic characteristics, and the intensity of fear for ET. Guideline adherence was classified based on an algorithm derived from international guidelines. The tumour board's (TB) decisions against or for ET was documented. The TB was blinded regarding the guideline results. In 666 patients, adjuvant ET was indicated according to the guideline recommendations. The TB decided in 92.3% (n=615) of those that adjuvant ET was indicated. TB's decision against ET was associated with the younger age of patients (OR=0.5; 95% CI 0.3-0.9) and poor QoL (OR=1.7; 95% CI 1.0-2.8). In 93 patients, ET was not indicated according to the guidelines, and the TB decided in 84 of those not to prescribe ET. The TB decided in 93.4% of the cases according to the guidelines. Of the patients, where the TB prescribed ET, 5% (n=31) decided against ET. This decision was associated with fear of ET (OR=2.2; 95% CI 1.0-5.2) and higher age (OR 9; 95% CI 1.0-48.1). Psychiatric co-morbidity (OR=1.8; 95% CI 0.7-4.2), poor QoL (OR=0.4; 95% CI 0.2-1.2), and education (OR=1.2; 95% CI 0.5-2.6) were not associated with the decision. Guideline adherent implementation of adjuvant ET is high. Physicians' decision against ET is mainly associated with patients' younger age and poor quality of life, whereas patients' decision, once the TB decided to initiate ET and if ET is indicated by guidelines, is associated with higher age and fear of ET.