Adherence to Needed Adjuvant Therapy Could Decrease Recurrence Rates for Rural Patients With Early Breast Cancer

Sociodemographic and Clinical Factors Associated With Radiation Treatment Nonadherence and Survival Among Rural and Nonrural Patients With Cancer

PURPOSE

Cancer treatment nonadherence is associated with higher rates of cancer recurrence and decreased survival. Rural patients with cancer experience a 10% higher mortality rate compared with their nonrural counterparts; geographic differences in nonadherence may contribute to this increased mortality. The goal of this study was to assess for geographic disparities and determine sociodemographic and clinical factors associated with radiation therapy (RT) nonadherence and survival among rural and nonrural patients with cancer.

METHODS AND MATERIALS

We examined cancer registry, medical records, and billing claims data at a safety net academic medical center. Geographic residence was defined as rural versus nonrural by US Department of Agriculture 2013 Rural-Urban Continuum Codes. Other factors assessed were age, sex, race, marital status, insurance type, employment, area median household income, residential distance to cancer treatment center, clinical stage, cancer type, treatment modality, total radiation dose received, and radiation dose per fraction. We used Cox proportional hazards modeling to examine 7 ways of operationalizing nonadherence and selected the definition that resulted in the best model fit statistics and prediction of mortality. Overall survival rates were estimated with the Kaplan-Meier method. We then examined nonadherence as the main exposure along with additional covariates in least absolute shrinkage and selection operator penalized survival analyses and as the outcome in our multivariable generalized linear regression analyses predicting nonadherence. We considered 2-way interaction terms with the main exposure, geographic residence.

RESULTS

We identified 3,077 patients with cancer who averaged 62 years old, were 59% female, 34% Black, and 14% rural. Twenty-two percent of patients missed at least 2 fractions and missed an average of 10% of their treatment plan. Rural patients experienced a higher mortality rate than nonrural patients (53% vs 42%, P < .0001). Survival was assessed through December 31, 2021, with a mean follow-up of 4.5 years. Proportion of missed fractions as the indicator of nonadherence provided the best model fit statistics and prediction of survival. Marital status, employment status, tumor, nodes, metastases stage, cancer type, and age at diagnosis significantly affected survival, in addition to a treatment delay by geographic residence interaction effect. Specifically, patients residing in rural areas who experienced a treatment delay were more than twice as likely to die as nonrural residents who also experienced a treatment delay, and nearly twice as likely to die as rural residents who did not experience a treatment delay. The 2-year survival rate was 76% for nonrural residents who did not experience a treatment delay versus 27% for rural residents who experienced a treatment delay. Patients who were widowed, had stage 4 cancer, or lung cancer were more likely to be nonadherent. Finally, patients residing in rural areas who experienced a treatment delay were more likely to subsequently be nonadherent.

CONCLUSIONS

In a geographically and racially diverse population, RT nonadherence is a significant concern that affects survival, yet it is a modifiable risk factor. We demonstrated that rural residence was associated with both RT nonadherence and poorer overall survival. Rural patients with a treatment delay had the lowest overall survival, compared with both nonrural survivors and rural survivors without delay. Rural residents who are delayed in starting treatment are at heightened risk for poor outcomes and should receive targeted support to mitigate the observed disparities. Additional patient populations that may benefit from targeted treatment adherence support include widowed patients and those with stage 4 cancer or lung cancer.

Breast Cancer Screening Should Embrace Precision Medicine: Evidence by Reviewing Economic Evaluations in China

The cost-effectiveness of conventional population-based breast cancer screening strategies (e.g. mammography) has been found controversial, while evidence shows that genetic testing for early detection of pathogenic variants is cost-effective. We aimed to review the economic evaluations of breast cancer screening in China to provide an information summary for future research on this topic. We searched the literature to identify the economic evaluations that examined breast cancer screening and testing in China, supplemented by hand-searching the reference lists of the included studies. We finally included five studies satisfying our inclusion criteria. Four articles examined mammography while the rest investigated multigene testing. The existing breast cancer screening programmes were found to be cost-effective among urban Chinese women, but one study concluded that they might cause harm to women in rural areas. Contextual factors, such as data absence, urban-rural disparity, willingness-to-pay threshold, and model design, imposed barriers to cost-effectiveness analysis. Multigene testing was found to be cost-effective and has a promising population impact among all women with breast cancer in China. Future research should investigate the cost-effectiveness of screening and identifying breast cancer through precision medicine technologies, including genetic testing, genome sequencing, cascade testing, and the return of secondary findings.

Adherence to Oral Anticancer Medications Among Women With Breast Cancer in Africa: A Scoping Review

PURPOSE

Oral anticancer medications (OAMs) improve treatment outcomes and survival in women with breast cancer (BC). However, adherence to OAM therapy remains suboptimal. This scoping review provides evidence of adherence to OAMs among African women with BC.

METHODS

We searched four databases and gray literature, using guidance from the Joanna Briggs Institute. Thirteen studies on adherence rates, determinants, and interventions were included. NVivo 12 software was used to perform thematic analysis of the included studies. The determinants (barriers and facilitators) associated with adherence were analyzed according to the five dimensions of the WHO multidimensional adherence model.

RESULTS

Most studies (n = 11, 85%) focused on endocrine medication. Depending on the definition, measurements, and assessment period, the nonadherence rates ranged from 4.3% to 65.4% for endocrine medications, 80.9% for cytotoxic chemotherapies, and 32.7% for combined medications. The significant barriers associated with adherence include Islamic religion, concurrent comorbidities, mastectomy, anastrozole treatment, side effects, unawareness of treatment insurance coverage, and seeking treatment from traditional healers. Thorough therapeutic communication regarding treatment, neoadjuvant chemotherapy, and adequate social support significantly facilitate adherence. A randomized controlled trial of breast nursing interventions reported improved patient adherence.

CONCLUSION

The evidence mapped from studies that evaluated OAM adherence in women with BC indicates that nonadherence to OAMs is common. Applying context-specific standardized measures to assess adherence and facilitators or strategies targeting the identified barriers can optimize adherence and treatment outcomes. Effective interventions to improve adherence are limited. Therefore, further empirical and interventional studies in Africa are required to enhance the evidence.

Cost-Effectiveness of Genetic Testing for All Women Diagnosed with Breast Cancer in China

Simple Summary

Unselected multigene testing at breast cancer (BC) diagnosis has been reported to be cost-effective compared with family history (FH)/clinical-criteria-based testing in high-income countries such as the US and UK. Chinese patients are younger than Caucasian women at diagnosis, tending to have a higher gene mutation prevalence, and the family size and number of female relatives are smaller due to the one-child policy (which has been changed) in China. Therefore, offering genetic testing for BC patients could potentially prevent more cancer cases and deaths in China. However, the health economic evidence for multigene testing at BC diagnosis in China is lacking. The aim of the current study was to evaluate the cost-effectiveness of three genetic testing strategies among BC patients using a microsimulation model at the individual level in China. We found that offering unselected multigene testing to all BC patients in China is highly cost-effective compared with FH/clinical-criteria-based testing or no testing from both the societal and payer perspectives.

Abstract

Unselected multigene testing for all women with breast cancer (BC) identifies more cancer susceptibility gene (CSG) carriers who can benefit from precision prevention compared with family history (FH)/clinical-criteria-based guidelines. Very little CSG testing is undertaken in middle-income countries such as China, and its cost-effectiveness remains unaddressed. We aimed to estimate cost-effectiveness and population impact of multigene testing for all Chinese BC patients. Data from 8085 unselected BC patients recruited to a Peking University Cancer Hospital study were used for microsimulation modeling, comparing three strategies in the Chinese setting: all BC women undergo BRCA1/BRCA2/PALB2 genetic testing, only BC women fulfilling FH/clinical criteria undergo BRCA testing, and no genetic testing. Prophylactic mastectomy and salpingo-oophorectomy would be adopted where appropriate. Societal and payer perspectives with a lifetime horizon along with sensitivity analyses were presented. Incremental cost-effectiveness ratio (ICER): incremental cost per quality-adjusted life-year (QALY) gained is compared to the USD 10,260/QALY (one-times GDP per capita) willingness-to-pay threshold. BC incidence, ovarian cancer (OC) incidence, and related deaths were also estimated. FH/clinical-criteria-based BRCA testing was ruled out on the principle of extensive dominance. Compared with no genetic testing, multigene testing for all BC patients had an ICER = USD 4506/QALY (societal perspective) and USD 7266/QALY (payer perspective), well below our threshold. Probabilistic sensitivity analysis showed unselected multigene testing remained cost-effective for 94.2%/86.6% of simulations from the societal and payer perspectives. One year’s unselected multigene testing could prevent 7868 BC/OC cases and 5164 BC/OC deaths in China. Therefore, unselected multigene testing is extremely cost-effective and should be offered to all Chinese women with BC.

The association between guideline adherence, age and overall survival among women with non-metastatic breast cancer: A systematic review

INTRODUCTION

Conformity with treatment guidelines should benefit patients. Studies have reported variation in adherence to breast cancer (BC) guidelines, particularly among older women. This study investigated (i) whether adherence to treatment guideline recommendations for women with non-metastatic BC improves overall survival (OS), (ii) whether that relationship varies by age.

METHODOLOGY

MEDLINE and EMBASE were systematically searched for studies on guideline adherence and OS in women with non-metastatic BC, published after January 2000, which examined recommendations on breast surgery, chemotherapy, radiotherapy or endocrine therapy. Study results were summarised using narrative synthesis.

RESULTS

Sixteen studies met the inclusion criteria. The recommendations for each treatment covered were similar, but studies differed in their definitions of adherence. 5-year OS rates among patients having compliant treatment ranged from 91.3% to 93.2%, while rates among patients having non-compliant treatment ranged from 75.9% to 83.4%. Six studies reported an adjusted hazard ratio (aHR) for non-compliant treatment compared with compliant treatment; all concluded OS was worse among patients whose overall treatment was non-compliant (aHR range: 1.52 [1.30-1.82] to 2.57 [1.96-3.37]), but adjustment for potential confounders was limited. Worse adherence among older women was reported in 12/16 studies, but they did not provide consistent evidence on whether OS was associated with treatment adherence and age.

CONCLUSIONS

Individual studies reported that better adherence to guidelines improved OS among women with non-metastatic BC, but the evidence base has weaknesses including inconsistent definitions of adherence. More precise and consistent research designs, including the evaluation of barriers to adherence across the spectrum of healthcare practice, are required to fully understand guideline compliance, as well as the relationship between compliance and OS following a BC diagnosis.

Systematic review of real-world studies evaluating the impact of medication non-adherence to endocrine therapies on hard clinical endpoints in patients with non-metastatic breast cancer

Breast cancer, one of the most common malignancies, is associated with significant economic and health burden both at the patient and societal level. Although medication non-adherence to endocrine breast cancer therapies is common, so far only limited systematic evidence has been available on its quantitative consequences, as previous systematic reviews focused mainly on factors contributing to medication non-adherence. The objective of this review was to explore the implications of medication non-adherence to endocrine therapies on hard clinical outcomes in breast cancer based on real-world studies. A systematic literature review was conducted on PubMed; empirical evidence on hard clinical endpoints (i.e., survival, disease-free survival, metastasis and recurrence) were extracted from uni- or multivariate statistical analyses from retrospective or prospective cohort studies. Of the 2,360 identified records, 12 studies met the inclusion criteria. Two studies identified significant positive association between medication non-adherence and the risk of distant metastasis, three articles between medication non-adherence and the recurrence of breast cancer, two studies between medication non-adherence- and non-persistence and of worse disease-free survival and eight articles between medication non-adherence and mortality. There was only one study where the positive association between medication adherence and survival did not apply to all subgroups. The strong evidence on the negative health consequences of non-adherence to breast cancer treatments indicates the need for the regular monitoring of medication adherence. Furthermore, explicit inclusion of adherence enhancing interventions into health policy agenda would be warranted to improve medication adherence also at a system level.

Cost-effectiveness of breast cancer screening programme for women in rural China

In low and middle-income countries mammographic breast cancer screening is prohibitively expensive and a cheaper alternative option is to use ultrasound as the primary screening test. In 2009, China launched a breast cancer screening programme for rural women aged 35-64 years with clinical breast examination coupled with ultrasound as the primary tool. Our study aimed to analyse the cost-effectiveness of breast screening compared to no screening among Chinese rural women. We developed a Markov model to estimate the lifetime costs and effects for rural women aged 35 years from a societal perspective. Asymptomatic women in the intervention arm were screened every 3 years before age 64 years. Breast cancer in the non-screening arm can only be diagnosed on presentation of symptoms. Parameter uncertainty was explored using one-way and probabilistic sensitivity analyses. Compared to no screening, breast cancer screening cost $186.7 more and led to a loss of 0.20 quality-adjusted life years (QALYs). Breast screening was more expensive and did harm to health among rural women with an incremental cost-effectiveness ratio (ICER) of $-916/QALY. The sensitivity analysis identified utility loss from false positives as the factor that most influenced the results, but this did not affect the conclusions. In a rural setting with such low breast cancer incidence, screening for asymptomatic disease is not cost-effective with current screening tools. Priority should be given to ensure that symptomatic women have proper access to diagnosis and treatment at an early stage as this will lead to mortality reductions without the usual screening harms.