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Factors influencing adherence to adjuvant endocrine therapy in breast cancer-treated women: using real-world data to inform a switch from acute to chronic disease management

Breast Cancer Research and Treatment volume 183, pages 189–199 (2020)Cite this article

Abstract

Purpose

Adjuvant endocrine therapy (AET) for ≥ 5 years is generally recommended for women with hormone receptor-positive breast cancer to reduce cancer recurrence/mortality; however, adherence can be suboptimal. We tested determinants of AET adherence using patient characteristics, treatment pathways, AET initiation timing, and multiple healthcare facility use. An underlying objective was to explore how oncological pathways mirror chronic disease management to monitor adherence and target improvement interventions using administrative datasets.

Methods

Using patient-linked administrative health data from the Italian Lombardy Region, we identified 33.291 surviving patients starting AET in 2010–2016, with two (22.939 patients) or five years (8400 patients) follow-up, using a ≥ 80% prescription refill approach to measure adherence and logistic regression to test determinants of adherence.

Results

AET crude adherence falls significantly during follow-up, from 94% at 1 Year to 58% at 5 Years. At 5 Years, patients who were older (>70), prescribed tamoxifen-only (OR 0.69; 95% CI 0.57–0.83; p = 0.0001) vs. aromatase inhibitors-only or therapy switches, treated for depression (OR 0.68; 95% CI 0.60–0.78; p < 0.0001), with surgery performed in high-volume hospitals (OR 0.85; 95% CI 0.75–0.97; p = 0.0116) showed lower adherence. Loyalty, or continued care in the surgical hospital (OR 1.73; 95% CI 1.51–2.00; p < 0.0001), undergoing chemotherapy before AET (OR 2.65; 95% CI 2.02–3.48; p < 0.0001), and earlier AET initiation, positively influenced adherence.

Conclusions

Chronic disease monitoring using administrative data can help oncologists focus efforts to ensure AET adherence. Results suggest addressing mental health, age, disease severity patient perceptions, timely AET initiation and therapy switches, and encouraging continued follow-up in the same hospital or better care coordination with outside follow-up specialists.

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Fig. 1

Abbreviations

AET:

Adjuvant endocrine therapy

AIs:

Aromatase inhibitors

BDA:

Banca Dati Assistito

DRG:

Diagnosis-related groups

HR+:

Hormone receptor-positive

ICD9:

International classification of diseases, ninth revision

LR:

Lombardy region

PDC:

Proportion of days covered

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Acknowledgements

Authors are grateful to the Fondazione Giancarlo Quarta Onlus for an unconditional grant to Cergas – SDA Bocconi to conduct the research. Moreover, the authors thank the Lombardy Regional Health Care Authority and Dr. Luca Merlino for making the data available for study as well as ARIA SpA for collaboration on the analysis.

Funding

Fondazione Giancarlo Quarta Onlus provided an unconditional grant to Cergas – SDA Bocconi (Grant Number is unavailable).

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Affiliations

  1. Centre for Research on Health and Social Care Management (Cergas), SDA Bocconi School of Management, Milan, Italy

    Marianna Cavazza, Helen Banks & Francesco Longo

  2. ARIA SpA (Azienda Regionale per L’Innovazione e gli Acquisti), Milan, Italy

    Michele Ercolanoni & Gjiliola Cukaj

  3. SC Oncologia Medica, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

    Giulia Bianchi & Giuseppe Capri

Authors
  1. Marianna Cavazza
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  2. Helen Banks
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  3. Michele Ercolanoni
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  4. Gjiliola Cukaj
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  5. Giulia Bianchi
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Contributions

GB, GC, MC, and FL contributed to the study conception and design. Material preparation, data collection, and analysis were performed by HB, MC, ME, and GC. The first draft of the manuscript was written by Helen Banks and Marianna Cavazza and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Marianna Cavazza.

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Cavazza, M., Banks, H., Ercolanoni, M. et al. Factors influencing adherence to adjuvant endocrine therapy in breast cancer-treated women: using real-world data to inform a switch from acute to chronic disease management. Breast Cancer Res Treat 183, 189–199 (2020). https://doi.org/10.1007/s10549-020-05748-6

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Keywords

  • Breast cancer
  • Adherence
  • Adjuvant endocrine therapy
  • Adjuvant hormonal therapy
  • Big data
  • Healthcare utilization