Impact of disease management programs on women with breast cancer in Germany

"Interventions to increase adherence to oral therapies in breast cancer patients: A systematic review based on the behavior change technique taxonomy"

OBJECTIVE

High rates of non-adherence to oral medications in breast cancer (BC) patients have been reported. Here we provide an up-to-date systematic review of the interventions aimed at increasing adherence to oral medication in BC patients, with a particular focus on the content of the interventions.

METHODS

PubMed, Scopus, Embase and Ovid databases and reference lists of relevant studies were searched through October 2022. Studies which (1) described an intervention aimed at increasing adherence to oral anticancer medication, (2) included (or planned to include) at least one sub-group of BC patients, (3) were written in English, and (4) with full-text available were included. The contents of the interventions were coded using the Behavior Change Technique Taxonomy. Quality assessment was conducted using Downs and Black scale.

RESULTS

Thirty-six studies met the inclusion criteria and involved a total sample of 28,528 BC patients. Interventions were mainly delivered with eHealth devices (n = 21) and most of them used mobile app. Other studies used in-person modalities (e.g., CBT, relaxation technique) or written materials (e.g., psycho-educational booklet). The behavior change techniques most frequently implemented were "problem solving," "social support," "information about health consequences," and "prompts/cues". Quality assessment revealed that the higher risk of bias refers to the selection process.

CONCLUSIONS

The use of reminders, monitoring patients' medication-taking behaviors and giving feedback were the most frequently implemented techniques in those interventions that resulted significant. If these preliminary observations were to be confirmed by future comparative studies, they should be taken into account when developing new interventions.

A Systematic Review and Meta-Analysis of Interventions to Promote Adjuvant Endocrine Therapy Adherence Among Breast Cancer Survivors

PURPOSE

Adjuvant endocrine therapy (AET) adherence among breast cancer survivors is often suboptimal, leading to higher cancer recurrence and mortality. Intervention studies to promote AET adherence have burgeoned, more than doubling in number since this literature was last reviewed. The current aim is to provide an up-to-date systematic review and meta-analysis of interventions to enhance AET adherence and to identify strengths and limitations of existing interventions to inform future research and clinical care.

METHODS

Systematic searches were conducted in three electronic databases. Studies were included in the systematic review if they examined an intervention for promoting AET adherence among breast cancer survivors. Studies were further included in the meta-analyses if they examined a measure of AET adherence (defined as compliance or persistence beyond initiation) and reported (or provided upon request) sufficient information to calculate an effect size.

RESULTS

Of 5,045 unique records, 33 unique studies representing 375,951 women met inclusion criteria for the systematic review. Interventions that educated patients about how to manage side effects generally failed to improve AET adherence, whereas policy changes that lowered AET costs consistently improved adherence. Medication reminders, communication, and psychological/coping strategies showed varied efficacy. Of the 33 studies that met the inclusion criteria for the systematic review, 25 studies representing 367,873 women met inclusion criteria for the meta-analysis. The meta-analysis showed statistically significant effects of the adherence interventions overall relative to study-specified control conditions (number of studies [k] = 25; odds ratio, 1.412; 95% CI, 1.183 to 1.682; P = .0001). Subgroup analyses showed that there were no statistically significant differences in effect sizes by study design (randomized controlled trial v other), publication year, directionality of the intervention (unidirectional v bidirectional contact), or intervention type.

CONCLUSION

To our knowledge, this is the first known meta-analysis to demonstrate a significant effect for interventions to promote AET adherence. The systematic review revealed that lowering medication costs and a subgroup of psychosocial and reminder interventions showed the most promise, informing future research, policy, and clinical directions.

Disparities in accessibility to evidence-based breast cancer care facilities by rural and urban areas in Bavaria, Germany

BACKGROUND

Breast cancer (BC), which is most common in elderly women, requires a multidisciplinary and continuous approach to care. With demographic changes, the number of patients with chronic diseases such as BC will increase. This trend will especially hit rural areas, where the majority of the elderly live, in terms of comprehensive health care.

METHODS

Accessibility to several cancer facilities in Bavaria, Germany, was analyzed with a geographic information system. Facilities were identified from the national BC guideline and from 31 participants in a proof-of-concept study from the Breast Cancer Care for Patients With Metastatic Disease registry. The timeframe for accessibility was defined as 30 or 60 minutes for all population points. The collection of address information was performed with different sources (eg, a physician registry). Routine data from the German Census 2011 and the population-based Cancer Registry of Bavaria were linked at the district level.

RESULTS

Females from urban areas (n = 2,938,991 [ie, total of females living in urban areas]) had a higher chance for predefined accessibility to the majority of analyzed facilities in comparison with females from rural areas (n = 3,385,813 [ie, total number of females living in rural areas]) with an odds ratio (OR) of 9.0 for cancer information counselling, an OR of 17.2 for a university hospital, and an OR of 7.2 for a psycho-oncologist. For (inpatient) rehabilitation centers (OR, 0.2) and genetic counselling (OR, 0.3), women from urban areas had lower odds of accessibility within 30 or 60 minutes.

CONCLUSIONS

Disparities in accessibility between rural and urban areas exist in Bavaria. The identification of underserved areas can help to inform policymakers about disparities in comprehensive health care. Future strategies are needed to deliver high-quality health care to all inhabitants, regardless of residence.

Factors Associated with Refusal or Discontinuation of Treatment in Patients with Bladder Cancer: A Cohort Population-Based Study in Taiwan

Cancer treatment causes adverse effects that lead to refusal or discontinuation of treatment. The purposes of this study were to identify 1) the factors associated with and 2) the reasons for refusing and discontinuing treatment in patients with bladder cancer (BC). We conducted a retrospective cohort study in patients diagnosed with BC in Taiwan from 1 January 2014 to 30 June 2019 using a linked cancer registry database. Of the 1247 BC patients in the study cohort, 2.1% reported refusing treatment. Patients with less education and those diagnosed at cancer stage II-IV were more likely to refuse treatment. The major reason for refusing treatment was "patient or the family considered patient's poor physical condition (chronic disease or unstable systemic disease), difficulty in enduring any condition likely to cause physical discomfort from disease treatment". A total of 4.3% of BC patients reported discontinuing treatment. Patients not living in the northern region of Taiwan and those diagnosed at cancer stage II-IV were more likely to terminate treatment before completion. The major reason given for discontinuing treatment was inconvenient transportation. Sufficient social resources and supportive care can help BC patients cope with the physical and psychological burden of treatment.

Correlation of Clinicopathological Characteristics of Breast Carcinoma and Depression

The prevalence of depression among women with breast cancer (BC) is extremely variable in research studies. The aim of this study was to determine the prevalence of depressive disorder in women suffering from BC as well as to examine its relationship with clinical–pathological and immunophenotypic characteristics of BC. The study included 194 patients with BC who were diagnosed with the disease between 2009 and 2015 in the Clinical Center Kragujevac, Serbia. Pathohistological and immunohistochemical analyses was used on the material obtained after the surgical removal of breast tumors, determining all significant clinical and morphological parameters. The level of depression among the examinees confirmed that the differences in the level of depression between the histological grades were statistically significant. According to the univariate binary logistic regression, the depression of a patient correlates with the category of molecular tumor subtype/Luminal A (p < 0.0005), PR expression (p = 0.050) and lymphatic invasion (p = 0.025). Multivariate binary logistic regression showed that the onset of depression associated with the present molecular subtype of the tumor of a worse prognostic character (p = 0.019). Depression is a common disorder in women with breast cancer. The level of depression is correlates with some of the clinicоmorphological and immunophenotypic characteristics of BC.

A systematic review of interventions to improve adherence to endocrine therapy

PURPOSE

Adherence to endocrine therapy for hormone positive breast cancer is a significant problem, especially in minority populations. Further, endocrine therapy reduces recurrence and thus mortality. However, little data are available on interventions to improve adherence. The authors conducted a systematic review to examine the impact of interventions, strategies, or approaches aimed to improve endocrine therapy adherence among women with breast cancer. A secondary aim was to determine if interventions had any cultural modifications.

METHODS

Two of the authors examined articles published between 2006 and 2017 from a wide variety of databases using Covidence systematic review platform.

RESULTS

In total, 16 eligible studies met criteria for review including 4 randomized controlled trials, 4 retrospective studies, and 8 with various observational designs. Eligible studies used a broad range of definitions for adherence and measured adherence by self-report, medical records, claims data, and combinations of these. All used 80% medication possession ratio as a standard for adherence. Patient information/education was the most frequent intervention strategy but did not demonstrate a significant effect except in one study. Significant results were noted when education was combined with communication strategies.

CONCLUSIONS

Researchers need a standard definition for adherence and a reliable measure that is feasible to use in a variety of studies. While education may be a necessary component of an intervention, when used alone, it is not a sufficient approach to change behavior.

A systematic review of interventions to improve adherence to endocrine therapy

PURPOSE

Adherence to endocrine therapy for hormone positive breast cancer is a significant problem, especially in minority populations. Further, endocrine therapy reduces recurrence and thus mortality. However, little data are available on interventions to improve adherence. The authors conducted a systematic review to examine the impact of interventions, strategies, or approaches aimed to improve endocrine therapy adherence among women with breast cancer. A secondary aim was to determine if interventions had any cultural modifications.

METHODS

Two of the authors examined articles published between 2006 and 2017 from a wide variety of databases using Covidence systematic review platform.

RESULTS

In total, 16 eligible studies met criteria for review including 4 randomized controlled trials, 4 retrospective studies, and 8 with various observational designs. Eligible studies used a broad range of definitions for adherence and measured adherence by self-report, medical records, claims data, and combinations of these. All used 80% medication possession ratio as a standard for adherence. Patient information/education was the most frequent intervention strategy but did not demonstrate a significant effect except in one study. Significant results were noted when education was combined with communication strategies.

CONCLUSIONS

Researchers need a standard definition for adherence and a reliable measure that is feasible to use in a variety of studies. While education may be a necessary component of an intervention, when used alone, it is not a sufficient approach to change behavior.

Adherence to antiepileptic drugs in children and adolescents: A retrospective study in primary care settings in Germany

OBJECTIVE

The goal of this study was to analyze adherence to antiepileptic drugs (AED) in children and adolescents treated in pediatric practices in Germany.

METHODS

The present study included patients aged between 2 and 17years who were diagnosed with epilepsy (ICD-10: G40) and had received at least two prescriptions of AED between January 2006 and December 2015 in 243 pediatric practices in Germany. The medication possession ratio (MPR) was used to estimate adherence, and patients with a MPR greater than 80% were considered adherent. The impact of patient and drug characteristics on adherence was analyzed using a multivariate logistic regression model.

RESULTS

A total of 5214 patients were included. Mean age was 10.9years (SD=4.9years). The overall MPR was 88.8% (SD=34.1%), and 68.9% of patients were considered adherent. Children aged 5years or younger were more adherent to AED than those aged between 14 and 17years (OR=1.22, 95% CI: 1.07-1.39). Individuals living in western Germany were also found to be more adherent than those living in eastern Germany (OR=1.71, 95% CI: 1.55-1.88). Asthma as a comorbidity (OR=1.59, 95% CI: 1.29-1.96) was positively and attention-deficit hyperactivity disorder (OR=0.81, 95% CI: 0.71-0.93) negatively associated with treatment adherence. Finally, no significant association was found between adherence and the type of AED.

CONCLUSIONS

Two-thirds of children and adolescents suffering from epilepsy in Germany were adherent to AED. Age, place of residence, and comorbidities were significantly associated with adherence.

Risk of Nonfatal Stroke in Type 2 Diabetes Mellitus Patients: A Retrospective Comparison Between Disease Management Programs and Standard Care

OBJECTIVE

The present retrospective study examines the influence of disease management programs on nonfatal stroke in type 2 diabetes mellitus (T2DM) patients in Germany.

METHODS

The evaluation is based on retrospective patient data from the Disease Analyzer (IMS Health). The analysis included 169 414 T2DM patients aged 40 years and older with an initial prescription of antihyperglycemic therapy between January 2004 and December 2014. A total of 86 713 patients participated in a disease management program (DMP) for T2DM and 82 701 patients received standard care. The main outcome measure of this study was nonfatal stroke. Kaplan-Meier curves of DMP and SC patients were compared using log rank test. The Cox proportional hazards model was used to provide an adjusted estimate of the DMP effect.

RESULTS

It is apparent from the baseline characteristics that the general health of patients receiving standard care was poorer than that of patients participating in a DMP. The baseline HbA1c value was 7.6% in the DMP group and 7.8% in the SC group. Furthermore, the SC group had a higher proportion of preexisting conditions, such as coronary heart disease (CHD), peripheral arterial occlusive disease (pAOD), and renal insufficiency. The proportion of patients who received insulin in first year therapy was higher in the SC group. Time to event analysis showed that DMP was associated with a delayed occurrence of stroke, because stroke occurred an average of 350 days later in DMP patients than in patients receiving SC (DMP: 1.216 days, RV: 866 days). The Cox model with covariable adjustment confirmed the significant association of DMPs with nonfatal stroke in patients with type 2 diabetes mellitus (HR 0.71; 95% CI: 0.69-0.74).

CONCLUSION

The present study indicates that DMPs are positively associated with stroke. The possible reasons for this must be verified in further studies.

Correlation between hormone receptor status and depressive symptoms in patients with metastatic breast cancer

Individual differences in depressive symptoms correlate with morbidity and outcomes in breast cancer patients. We evaluated the effect of hormone receptor (HR) status on depressive symptoms in 176 women with metastatic breast cancer at diagnosis. To assess depression, the women completed Self-Rating Depression Scale (SDS) questionnaires at baseline examination (T1), after 4 chemotherapy cycles (T2) and after 6 months (T3). At baseline examination, 45/176 (25.6%) patients were found to be at high or medium risk for depression (SDS score ≥0.6). Among these, depression was both prevalent in HR-positive patients and in HR-negative patients (64.4% versus 51.4%, P = 0.001). In multivariate model, HR positivity and higher depression risk were associated with poorer overall survival (25.0 months versus 32.0 months, P < 0.05). Patients at high/medium risk of depression were treated with the antidepressant agent fluoxetine (N = 23) or no drug (N = 22). SDS scores in patients treated with fluoxetine were lower after 4 chemotherapy cycles and after 6 months than in the control group (mean scores: T2, 0.61 versus 0.67, P = 0.001; T3, 0.56 versus 0.65, P < 0.001). No difference on SDS scores was found between patients with positive or negative HR status during fluoxetine treatment. These findings suggest hormone receptor status is associated with depressive symptoms in patients with metastatic breast cancer. Fluoxetine relieves depressive symptoms in these patients, regardless of hormone receptor status.

Incidence of depression and anxiety among women newly diagnosed with breast or genital organ cancer in Germany

BACKGROUND

To analyze the incidence of depression and anxiety among women newly diagnosed with breast or genital organ cancer (BC or GOC) in Germany.

METHODS

A total of 29 366 women initially diagnosed with BC or GOC between 2005 and 2014 were available for analysis. The main outcome measure was the incidence of depression and anxiety among women newly diagnosed with BC or GOC within 5 years after the first cancer diagnosis in German gynecologist practices. Demographic and clinical data included age, type of cancer, and presence of metastases at diagnosis. The incidence rate of depression and anxiety per 100 person-years was calculated. We performed a multivariate regression model to analyze the association between depression and the variables of interest.

RESULTS

In total, 7994 women were diagnosed with depression/anxiety (81.3% had BC and 18.7% had GOC). The incidence of depression and anxiety was 8.8 per 100 person-years in women with BC. In individuals with GOC, the incidence of depression/anxiety was 5.9 per 100 person-years. Breast cancer was associated with a 1.41-fold increase in the risk of developing depression or anxiety as compared with GOC. Patients with metastases also had a higher risk of being depressed and anxious than others (odds ratio = 1.40). Finally, women in the age groups of 41 to 50, 51 to 60, and 61 to 70 years were at a higher risk of depression/anxiety than women in the age group of 71 to 80 years (odds ratios equal to 1.50, 1.38, and 1.22).

CONCLUSIONS

Women diagnosed with BC were at a higher risk of developing depression or anxiety than women with GOC.

Impact of Disease Management Programs on HbA1c Values in Type 2 Diabetes Patients in Germany

BACKGROUND

The aim was to analyze the impact of disease management programs on HbA1c values in type 2 diabetes mellitus (T2DM) patients in Germany.

METHODS

This study included 9017 patients followed in disease management programs (DMPs) who started an antihyperglycemic treatment upon inclusion in a DMP. Standard care (SC) patients were included after individual matching (1:1) to DMP cases based on age, gender, physician (diabetologist versus nondiabetologist care), HbA1c values at baseline, and index year. The main outcome was the share of patients with HbA1c <7.5% or 6.5% after at least 6 months and less than 12 months of therapy in DMP and SC groups. Multivariate logistic regression models were fitted with HbA1c level as a dependent variable and the potential predictor (DMP versus SC).

RESULTS

The mean age was 64.3 years and 54.7% of the patients were men. The mean HbA1c level at baseline was equal to 8.7%. In diabetologist practices, 64.7% of DMP patients and 55.1% of SC patients had HbA1c levels <7.5%, while 23.4% of DMP patients and 16.9% of SC patients had HbA1c levels <6.5% ( P values < .001). By comparison, in general practices, 72.4% of DMP patients and 65.7% of SC patients had HbA1c levels <7.5%, while 29.0% of DMP patients and 25.4% of SC patients had HbA1c levels <6.5% ( P values < .001). DMPs increased the likelihood of HbA1c levels lower than 7.5% or 6.5% after 6 months of therapy in both diabetologist and general care practices.

CONCLUSION

The present study indicates that the enrollment of T2DM patients in DMPs has a positive impact on HbA1c values in Germany.

Impact of metformin on metastases in patients with breast cancer and type 2 diabetes

AIM

To analyze the impact of glucose-lowering drugs on metastases in women living in Germany who have been diagnosed with breast cancer (BC) and type 2 diabetes mellitus (T2DM).

METHODS

Women initially diagnosed with BC (2004-2013) were identified in the IMS Disease Analyzer database. Patients with a documentation of metastases at index date or during the following six months were excluded. We selected T2DM women between 40 and 90years of age who received glucose-lowering therapy (metformin, sulfonylureas, incretins, insulins, other medications). The primary outcome was the diagnosis of metastases recorded in the database between the index date and the end of follow-up. A multivariate Cox regression model was used to predict BC metastases on the basis of patient characteristics and glucose-lowering medication.

RESULTS

A total of 4,953 women with BC and diabetes were included in the study. The mean age was 71.4years and 4.7% of patients had private health insurance coverage. Mean HbA1C was 7.1% and mean BMI was 30.6kg/m(2). After 5years follow-up, 9.2% of patients with metformin and 12.3% of patients without exhibited metastases (log-rank p-value=0.011), whereas 6.2% of patients with incretins and 11.0% of patients without incretins exhibited metastases (both log-rank p-values <0.001). Metformin (HR=0.73, 95% CI: 0.58-0.92) and incretins (HR=0.62, 95% CI: 0.45-0.84) both significantly decreased the risk of metastases. None of the other variables were significantly associated with diagnosis of metastases.

CONCLUSION

The use of metformin and incretins in women with T2DM and BC may reduce the risk of metastases.

Age-related differences in persistence in women with breast cancer treated with tamoxifen or aromatase inhibitors in Germany

AIMS

To study age-related persistence in postmenopausal women with endocrine-responsive breast cancer treated with tamoxifen (TAM) and aromatase inhibitors (AI).

METHODS

Data on 29,245 patients diagnosed with metastatic or non-metastatic breast cancer (BC) and initially treated with TAM or AI between 2004 and 2013 were included. The primary outcome measure was the age-dependent rate of discontinuation of endocrine treatment within 5years after initiation. Discontinuation of therapy was defined as a period of at least 90days without treatment. A multivariate Cox regression model was created to determine the influence of age on the risk of discontinuation. Health insurance type (private/statutory), type of care (gynecological/general), region (West/East Germany), concomitant diagnoses (depression, osteoporosis, and diabetes), and Charlson Comorbidity Score were included as covariates.

RESULTS

The mean ages of the women in the <70 and ≥70 groups were 55.9 (SD: 9.7) and 77.4 (SD: 5.4) years, respectively. Within 5years after treatment initiation, 88.8% of women <70 of age and 82% of women ≥70 years of age had terminated treatment (p-value<0.001). Patients aged ≥70 exhibited a lower risk of treatment discontinuation than patients aged <70 (HR=0.75, 95% CI: 0.66-0.85). Furthermore, gynecological practices, disease management programs, and high Charlson scores increased persistence.

CONCLUSIONS

Overall, the present study indicates that persistence rates are low in both women with BC aged <70 and those aged ≥70 years. We also found that younger women with BC are at a higher risk of treatment discontinuation than older women.

Age-related differences in persistence with bisphosphonates in women with metastatic breast cancer

Aims

To investigate age-related persistence with bisphosphonates (BIS) in women with breast cancer (BC) and bone metastases.

Methods

We included a dataset of 1541 patients diagnosed with BC and bone metastases and initially treated with BIS between 1994 and 2013. The primary outcome measure was the age-related rate of BIS discontinuation within 12 months after treatment initiation. Therapy discontinuation was defined as a period of at least 90 days without treatment. A multivariate Cox regression model was created to determine the influence of age on the risk of discontinuation. Health insurance coverage (private/statutory), type of care (gynecological/general), region (West/East Germany), depression, chemotherapy, hormone therapy, pain medication, antidepressants, and the number of co-medications were included as covariates.

Results

The mean ages in the group of women <70 and that of women ≥70 years of age were 55.7 (SD: 9.8) and 76.7 (SD: 5.1) years respectively. Within 12 months after treatment initiation, 44.3% of women <70 and 34.8% of women ≥70 had terminated treatment (p-value<0.001). Patients aged ≥70 were at a lower risk of treatment discontinuation than patients <70 (HR=0.78, 95% CI: 0.67–0.91). Furthermore, treatment in gynecological practices, chemotherapy, hormone therapy, pain medication, and number of co-medications decreased the risk of discontinuation. By contrast, residing in West Germany and private health insurance coverage increased discontinuation risk.

Conclusions

Women with metastatic BC aged ≥70 are at a lower risk of BIS treatment discontinuation than younger women.

Treatment of depression in cancer and non-cancer patients in German neuropsychiatric practices

AIMS

The aim of this study is to analyze the use of antidepressants in German patients with and without cancer.

METHODS

This study included patients with cancer diagnosed with depression in German neuropsychiatric practices between 2004 and 2013. Each patient was matched for age, gender, health insurance, physician, and index year with a depressed, cancer-free control. The share of patients and controls receiving medical therapy within 1 year after depression diagnosis and the proportion of subjects treated with tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, or benzodiazepines were analyzed.

RESULTS

A total of 604 depressed cancer patients and 604 depressed controls were included. There are 27.6% of patients that had breast cancer, 13.3% malignant neoplasms of the lymphoid or hematopoietic tissue, 12.5% brain tumors, 8.3% prostate cancer, and 10.0% cancer of the digestive organs. After 1 year of follow up, 66.5% of patients and 72.8% of controls had received antidepressant drugs (p = 0.017). Tricyclic antidepressants was given less frequently to patients than to controls (31.2% vs 38.2%, p-value = 0.011). By contrast, 7.0% of patients with cancer and 4.2% of controls received benzodiazepines (p-value = 0.033).

CONCLUSIONS

The use of antidepressants in Germany is less common in patients with cancer and depression than in people with depression only. Copyright © 2016 John Wiley & Sons, Ltd.