Supportive Care in Cancer

, Volume 24, Issue 6, pp 2759–2766 | Cite as

Exploring patient- and physician-related factors preventing breast cancer patients from guideline-adherent adjuvant chemotherapy—results from the prospective multi-center study BRENDA II

  • Lukas SchwentnerEmail author
  • Reyn Van Ewijk
  • Thorsten Kühn
  • Felix Flock
  • Riccardo Felberbaum
  • Maria Blettner
  • Rolf Kreienberg
  • Wolfgang Janni
  • Achim Wöckel
  • Susanne Singer
Original Article



This study examined which patient- and physician-related factors influence guideline violations in adjuvant chemotherapy.

Patients and methods

In a prospective multi-center cohort study, patients with primary breast cancer were sampled consecutively over a period of four years (2009–2012). Patients completed a questionnaire prior to surgery and prior to adjuvant therapy. This questionnaire assessed health-related quality of life (QoL) using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, psychiatric co-morbidity with the Patient Health Questionnaire (PHQ), demographic characteristics (age, education), and the intensity of fear for chemotherapy.

After surgery, a multi-professional team discussed recommendation for adjuvant chemotherapy, and this decision was documented in a database together with the indication for chemotherapy according to the German S3 guideline. This multi-professional team was blinded to that algorithm-based decision. Six months later, it was documented whether the patient had received adjuvant chemotherapy or not.


Altogether, 857 patients were included in the study. In 391 of these patients, the tumor board (TB) decided to recommend chemotherapy. The most important reasons for not recommending chemotherapy were somatic co-morbidity not allowing adjuvant chemotherapy and age >75 years.

Of these 391 patients, 73 (19 %) patients eventually did not receive chemotherapy. Deviations from the initial therapy decision were more frequent in older patients (≥75 years) with poor QoL. If the QoL was good, higher age was not related to deviation. There was some evidence that patients with higher education less frequently received chemotherapy (CT). Furthermore, if patients were very afraid of chemotherapy, deviations from the initial therapy decision were more likely. Co-morbidity and fear of CT were not related to the likelihood of deviating from the initial therapy decision.


Nineteen percent of patients eventually did not receive chemotherapy, despite guideline and TB recommendations. In these patients, this mainly occurred in association with poor QoL in elderly patients >75 years old. In the group with a chemotherapy recommendation, patients’ fear of chemotherapy is another factor preventing patients from undergoing adjuvant chemotherapy.


Breast cancer Compliance Chemotherapy Co-morbidity Guideline 


Compliance with ethical standards

This study and the BRENDA project have been approved by the ethics committee of the University of Ulm.

Conflict of interest

The authors declare that they have no competing interests.

Funding source

This work was supported by the German Federal Ministry of Education and Research (BMBF-Grant-01ZP0505).


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Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Lukas Schwentner
    • 1
    Email author
  • Reyn Van Ewijk
    • 2
    • 7
  • Thorsten Kühn
    • 3
  • Felix Flock
    • 4
  • Riccardo Felberbaum
    • 5
  • Maria Blettner
    • 2
  • Rolf Kreienberg
    • 1
  • Wolfgang Janni
    • 1
  • Achim Wöckel
    • 6
  • Susanne Singer
    • 2
  1. 1.Department of Gynecology and ObstetricsUniversity UlmUlmGermany
  2. 2.Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI)–University Medical Centre MainzMainzGermany
  3. 3.Department of Gynecology and ObstetricsHospital EsslingenEsslingenGermany
  4. 4.Department of Gynecology and ObstetricsHospital MemmingenMemmingenGermany
  5. 5.Department of Gynecology and ObstetricsHospital KemptenKemptenGermany
  6. 6.Department of Gynecology and ObstetricsUniversity WürzburgWürzburgGermany
  7. 7.Department of EconomicsJohannes Gutenberg University MainzMainzGermany

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