Breast Cancer Research and Treatment

, Volume 164, Issue 1, pp 119–131 | Cite as

Adherence to guidelines and breast cancer patients survival: a population-based cohort study analyzed with a causal inference approach

  • Anita AndreanoEmail author
  • Paola Rebora
  • Maria Grazia Valsecchi
  • Antonio Giampiero Russo



There is a lack of real-world studies evaluating the impact on survival of an evidence-based pathway of care in breast cancer. The aim of this work is to investigate the effect of adherence to guidelines on long-term survival for a cohort of Italian breast cancer patients.


The cohort included incident female breast cancer cases (2007–12), from the registry of the Milan province (Italy), not metastatic at diagnosis and receiving primary surgery. We selected sets of indicators, according to patient and tumor characteristics. We then defined the pathway of care as adherent to guidelines if it fulfilled at least 80% of the indicators. Indicators were measured using different administrative health databases linked on a unique key. A causal inference approach was used, drawing a directed acyclic graph and fitting an inverse probability weighted marginal structural model, accounting for patient’s demographic, socioeconomic and tumor characteristics.


The analysis included 6333 patients, 69% of them were classified as having an adherent care. Mean age was 61 years (standard deviation, 13.6 years) and half of the patients were in Stage I (50%) at diagnosis. Median follow-up time was 5.6 years. Overall, 5-year survival was 90% (95% CI, 89–91%). The estimated risk of death was 30% lower for patients with adherent than nonadherent care (hazard ratio [HR], 0.66; 95% CI, 0.55–0.77).


Our study confirms, in real-world care, the impact on survival of receiving a care pathway adherent to guidelines in non-metastatic breast cancer patients.


Breast cancer care Adherence to guidelines Survival Causal inference Administrative health databases Process indicators 



Confidence interval


Directed acyclic graph


Hazard ratio


Inverse probability weighted


Randomized controlled trial



Supported by grant RF-2011-02348959 from the Italian Ministry of Health.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standards

All analyses were performed in compliance with the Italian law on health data protection.

Supplementary material

10549_2017_4210_MOESM1_ESM.docx (198 kb)
Supplementary material 1 (DOCX 197 kb)
10549_2017_4210_MOESM2_ESM.docx (22 kb)
Supplementary material 2 (DOCX 21 kb)
10549_2017_4210_MOESM3_ESM.docx (19 kb)
Supplementary material 3 (DOCX 19 kb)


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Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Center of Biostatistics for Clinical Epidemiology, School of Medicine and SurgeryUniversity of Milan BicoccaMonzaItaly
  2. 2.Epidemiology UnitAgency for Health Protection of the Province of MilanMilanItaly

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