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Predicting adjuvant endocrine therapy initiation and adherence among older women with early-stage breast cancer

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Abstract

Purpose

The CALGB 9343 trial demonstrated that women age 70 or older with early-stage, estrogen receptor positive (ER +) breast cancer (BC) may safely forgo radiation therapy (RT) and be treated with breast conserving surgery followed by adjuvant endocrine therapy (AET) alone. However, most patients in this population still undergo RT in part because AET adherence is low. We sought to develop a predictive model for AET initiation and adherence in order to improve decision-making with respect to RT omission.

Methods

Women ages 70 and older with early-stage, ER + BC were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Comorbidities, socioeconomic measures, prescription medications, and demographics were collected as potential predictors. Bivariate analysis was performed to identify factors associated with AET initiation and adherence. Stepwise selection of significant predictors was used to develop logistic regression classifiers for initiation and adherence. Model performance was evaluated using the c-statistic and other measures.

Results

11,037 patients met inclusion criteria. Within the cohort, 8703 (78.9%) patients initiated AET and 6685 (60.6%) were adherent to AET over 1 year. Bivariate predictors of AET initiation were similar to predictors of adherence. The best AET initiation and adherence classifiers were poorly predictive with c-statistics of 0.65 and 0.60, respectively.

Conclusions

The best models in the present study were poorly predictive, demonstrating that the reasons for initiation and adherence to AET are complex and individual to the patient, and therefore difficult to predict. Initiation and adherence to AET are important factors in decision-making regarding whether or not to forgo adjuvant RT. In order to better formulate treatment plans for this population, future work should focus on improving individual prediction of AET initiation and adherence.

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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 National Cancer Institute; 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. This work was supported by the National Institutes of Health under Award number 5T32CA163177-09.

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Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA

    Max O. Meneveau & Shayna L. Showalter

  2. University of Virginia School of Nursing, Charlottesville, VA, USA

    Jessica Keim-Malpass

  3. Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA

    T. Fabian Camacho & Roger T. Anderson

  4. Cancer Control and Population Health, Emily Couric Cancer Center, Charlottesville, VA, USA

    Roger T. Anderson

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  1. Max O. Meneveau
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  4. Roger T. Anderson
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  5. Shayna L. Showalter
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by JK-M, TFC, RTA, MOM, and SLS. The first draft of the manuscript was written by MOM, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Shayna L. Showalter.

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Meneveau, M.O., Keim-Malpass, J., Camacho, T.F. et al. Predicting adjuvant endocrine therapy initiation and adherence among older women with early-stage breast cancer. Breast Cancer Res Treat 184, 805–816 (2020). https://doi.org/10.1007/s10549-020-05908-8

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