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Endocrine therapy initiation among women with stage I–III invasive, hormone receptor-positive breast cancer from 2001–2016

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

Abstract

Purpose

This retrospective cohort study examined patterns of endocrine therapy initiation over time and by demographic, tumor, and treatment characteristics.

Methods

We included 7777 women from three U.S. integrated healthcare systems diagnosed with incident stage I–III hormone receptor-positive breast cancer between 2001 and 2016. We extracted endocrine therapy from pharmacy dispensings, defining initiation as dispensings within 12 months of diagnosis. Demographic, tumor, and treatment characteristics were collected from electronic health records. Using generalized linear models with a log link and Poisson distribution, we estimated initiation of any endocrine therapy, tamoxifen, and aromatase inhibitors (AI) over time with relative risks (RR) and 95% confidence intervals (CI) adjusted for age, tumor characteristics, diagnosis year, other treatment, and study site.

Results

Among women aged 20+ (mean 62 years), 6329 (81.4%) initiated any endocrine therapy, and 1448 (18.6%) did not initiate endocrine therapy. Tamoxifen initiation declined from 67 to 15% between 2001 and 2016. AI initiation increased from 6 to 69% between 2001 and 2016 in women aged ≥ 55 years. The proportion of women who did not initiate endocrine therapy decreased from 19 to 12% between 2002 and 2014 then increased to 17% by 2016. After adjustment, women least likely to initiate endocrine therapy were older (RR = 0.81, 95% CI 0.77–0.85 for age 75+ vs. 55–64), Black (RR = 0.93, 95% CI 0.87–1.00 vs. white), and had stage I disease (RR = 0.88, 95% CI 0.85–0.91 vs. stage III).

Conclusions

Despite an increase in AI use over time, at least one in six eligible women did not initiate endocrine therapy, highlighting opportunities for improving endocrine therapy uptake in breast cancer survivors.

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Data availability

The data analyzed in the current study are not publicly available because they contain potentially identifiable information (e.g., dates of diagnoses and treatment) that cannot be shared openly without human subjects approval and data use agreements but are available from the corresponding author on reasonable request.

Abbreviations

AI:

Aromatase inhibitor

BCS:

Breast-conserving surgery

CI:

Confidence interval

ER:

Estrogen receptor

HR:

Hormone receptor

HER2:

Human epidermal growth factor receptor 2

KP:

Kaiser Permanente

NCCN:

National Comprehensive Cancer Network

PR:

Progesterone receptor

RR:

Relative risk

SEER:

Surveillance epidemiology and end results

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Funding

This work was supported by the Intramural Research Program of the Division of Cancer Epidemiology and Genetics of the US National Cancer Institute. Data collected at Kaiser Permanente Colorado was supported by contracts from the National Cancer Institute (contract numbers HHSN 261201800469P, HHSN 261201700708P, HHSN 261201600711P) and a subcontract with RTI International (contract number HHSN 26120090017C). Data collected at Kaiser Permanente Washington were supported by grants from the National Institutes of Health (Grant Nos. 1R01CA120562, P01CA154292, and R50CA211115 [to EJAB]) and contracts from the National Cancer Institute (contract numbers HHSN 261201700564P, HHSN75N91019P00076, HHSN 5N91020P00327). Data collected at Kaiser Permanente Northwest were supported by several National Cancer Institute subcontracts with RTI International (contract numbers 20-312-0212208, 17-312-0212208). Cancer incidence data used in this study were supported by the Cancer Surveillance System of the Fred Hutchinson Cancer Research Center, which is funded by Contract No. N01-CN-67009 and N01-PC-35142 from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute with additional support from the Fred Hutchinson Cancer Research Center and the State of Washington.

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Authors and Affiliations

  1. Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA

    Erin J. Aiello Bowles & Diana S. M. Buist

  2. Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA

    Cody Ramin, Lene H. S. Veiga, Clara Bodelon, Rochelle E. Curtis, Jacqueline B. Vo, Amy Berrington de Gonzalez & Gretchen L. Gierach

  3. Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA, USA

    Diana S. M. Buist & Heather Spencer Feigelson

  4. Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA

    Heather Spencer Feigelson

  5. Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA

    Sheila Weinmann

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  1. Erin J. Aiello Bowles
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Contributions

Study conceptualization: [EJAB, CR, ABG, GLG]; Data curation: [EJAB, DSMB, HSF, SW, LV, REC]; Formal analysis and methodology: [led by CR with contributions from all authors]; Funding acquisition: [DSMB, HSF, SW, ABG, GLG]; Investigation: [all authors]; Visualization: [CR]; Writing—original draft, reviewing, and editing: [led by EJAB with contributions from all authors].

Corresponding author

Correspondence to Erin J. Aiello Bowles.

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Conflict of interest

The authors have no conflicts of interest to disclose.

Ethical approval

This study received approval from the NCI Special Studies Institutional Review Board, and the Institutional Review Boards of Kaiser Permanente Washington, Kaiser Permanente Colorado, and Kaiser Permanente Northwest.

Consent to participate

This study received a waiver of written informed consent to access and analyze participant data based on the minimal risk of this electronic linkage-based research.

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Bowles, E.J.A., Ramin, C., Buist, D.S.M. et al. Endocrine therapy initiation among women with stage I–III invasive, hormone receptor-positive breast cancer from 2001–2016. Breast Cancer Res Treat 193, 203–216 (2022). https://doi.org/10.1007/s10549-022-06561-z

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  • DOI: https://doi.org/10.1007/s10549-022-06561-z

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