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Variation in guideline-concordant care for elderly patients with metastatic breast cancer in the United States

  • Epidemiology
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Breast Cancer Research and Treatment Aims and scope Submit manuscript

Abstract

Purpose

Prior studies have identified shortcomings in the quality of care for early-stage breast cancer. Guidelines recommend systemic therapy for metastatic breast cancer (MBC), but few studies have examined guideline concordance for these patients.

Methods

We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify patients aged ≥ 66 diagnosed in 2010–2011 with de novo MBC who were continuously enrolled in fee-for-service Medicare. We described initial care (within 6 months of diagnosis) for hormone receptor (HR)-positive/human epidermal receptor-2 (HER2)-negative, HER2-positive, and triple-negative (TN) tumors. We identified factors independently associated with receiving no initial systemic therapy, and compared hospice and hospital utilization for treated versus untreated patients.

Results

Among 446 patients, 65% were HR-positive, 21% were HER2-positive, and 14% were TN. Most patients (76.9%) received initial systemic treatment. Among treated HR-positive patients, 15% received chemotherapy as initial treatment; among treated HER2-positive patients, 34% did not receive HER2-targeted initial therapy. Factors independently associated with receiving no initial systemic therapy included older age (ORage continuous/year = 1.08, 95% CI 1.04–1.11), being not married (ORnot married vs. married = 2.87, 95% CI 1.42–5.81), and subtype (ORTN vs. HR+ = 4.95, 95% CI 2.53–9.71). Of patients who did not receive initial systemic therapy, 41.1% did not receive hospice services.

Conclusions

In this population-based MBC cohort, almost one quarter did not receive initial systemic therapy and a substantial proportion of treated patients did not receive guideline-concordant first-line therapy. Further research should explore underuse of chemotherapy and HER2-targeted therapies, investigate whether patterns of care are consistent with patient preferences, and identify opportunities to optimize hospice utilization for patients not receiving treatment.

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Acknowledgements

This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database. The collection of the California cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section103885; the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program under contract N01-PC-35136 awarded to the Northern California Cancer Center, contract N01-PC-35139 awarded to the University of Southern California, and contract N02-PC-15105 awarded to the Public Health Institute; and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under agreement #U55/CCR921930-02 awarded to the Public Health Institute. The ideas and opinions expressed herein are those of the author(s) and endorsement by the State of California, Department of Public Health the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors is not intended nor should be inferred.

Funding

The study was supported by Fundacao para a Ciencia e Tecnologia (HMSP-ICS/0004/2011, Career Development Award) (to I Vaz-Luis) and Dana-Farber Cancer Institute Friends Grant (to I Vaz-Luis).

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Authors and Affiliations

  1. Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA

    Philip D. Poorvu, Ines Vaz-Luis, Rachel A. Freedman, Nancy U. Lin, Eric P. Winer & Michael J. Hassett

  2. Department of Medical Oncology, INSERM U981, Institut Gustave Roussy, Villejuif, France

    Ines Vaz-Luis

  3. Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA

    William T. Barry

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  1. Philip D. Poorvu
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  2. Ines Vaz-Luis
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  3. Rachel A. Freedman
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  4. Nancy U. Lin
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  6. Eric P. Winer
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  7. Michael J. Hassett
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Correspondence to Michael J. Hassett.

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Poorvu, P.D., Vaz-Luis, I., Freedman, R.A. et al. Variation in guideline-concordant care for elderly patients with metastatic breast cancer in the United States. Breast Cancer Res Treat 168, 727–737 (2018). https://doi.org/10.1007/s10549-018-4659-4

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