Lack of Knowledge of Hormone Receptor Status and Use of Endocrine Therapy in Invasive Breast Cancer

Validity of self-reported breast cancer characteristics in a nationwide cohort of women with a family history of breast cancer

BACKGROUND

Women may have incomplete understanding of a breast cancer diagnosis, leading to inaccurate reporting in epidemiological studies. However, it is not feasible to obtain consent for medical records from all women participating in a study. Therefore, it is important to determine how well self-reported breast cancer characteristics correspond with what is found in medical records, but few studies have evaluated agreement of self-reported breast cancer characteristics with abstracted medical records.

METHODS

We calculated the positive predictive value (PPV) of self-reports compared to medical records and explored whether participant characteristics may have influenced reporting accuracy. We analyzed data from 2518 reported breast cancer cases from the Sister Study, a large nationwide cohort of women with a family history of breast cancer.

RESULTS

Medical records or pathology reports were obtained for 2066 of 2518 (82%) women who reported incident breast cancer. Breast cancer was confirmed for over 99% (n = 2054) of women with medical records. Confirmation rates were high for invasive, ductal, hormone receptor positive, and HER2 negative breast cancers, with little variation by race/ethnicity or age. Self-reported in situ breast cancer had a lower PPV (64.2%), with medical records showing invasive breast cancer instead, especially for older and Hispanic women. Hormone receptor (ER and PR) negative and HER2 positive self-reports had lower PPVs (83.0%, 71.6%, and 66.1% respectively). Hispanic women and women ages 65 or older at diagnosis were less able to accurately report breast cancer stage, excluding stage I.

CONCLUSIONS

Accuracy of reporting overall breast cancer and common subtypes is high. Despite having a family history of breast cancer and voluntarily enrolling in a study evaluating breast cancer risk factors, participants may have greater difficulty distinguishing between in situ and invasive breast cancer and may less accurately report other less common subtypes. Discrepancies may reflect women's poor understanding of information conveyed by health care providers or lack of consistent terminology used to describe subtypes.

What do women with breast cancer expect from their treatment? Correlates of negative treatment expectations about endocrine therapy

OBJECTIVES

Patients' negative treatment expectations can lead to nocebo-related side effects and non-initiation of treatment. This study aims to identify correlates of treatment expectations in patients with breast cancer before the start of endocrine therapy.

METHODS

Expectations were assessed in a cross-sectional sample of 166 patients with breast cancer after receiving treatment information. Side effect expectations (one item) and treatment necessity-concern balance (Beliefs about Medicines Questionnaire) were assessed. Correlates were analyzed using regression analyses. The structure of treatment expectations was investigated using a network analysis.

RESULTS

About 25% of patients expressed negative expectations. Higher side effect expectations were associated with lower treatment efficacy expectations (ß = -0.20, p = 0.01), higher medication overuse beliefs (ß = 0.17, p = 0.01), and a negative treatment appraisal before study treatment information (ß = -0.17, p = 0.02). A negative necessity-concern balance was associated with lower treatment efficacy expectations (ß = 0.36, p < 0.001), lower adherence intention (ß = 0.21, p < 0.001), and no knowledge of tumor's receptor status (ß = 0.21, p < 0.001); furthermore, it was associated with higher medication harmfulness beliefs (ß = -0.16, p = 0.02), negative treatment pre-appraisal (ß = 0.15, p = 0.01), higher somatosensory amplification (ß = -0.14, p = 0.02), and higher education (ß = -0.12, p = 0.02). The most important network node was the concern that endocrine therapy disrupts life.

CONCLUSION

Negative treatment expectations before treatment start are mainly associated with psychological variables. These results are relevant for patient education in clinical settings. To improve expectations, clinicians might emphasize treatment efficacy and discuss general and specific medication concerns. Improving treatment knowledge could also be beneficial. Copyright © 2016 John Wiley & Sons, Ltd.

Adherence to adjuvant endocrine therapy for breast cancer: importance in women with low income

There are wide disparities in breast cancer-specific survival by patient sociodemographic characteristics. Women of lower income, for instance, have higher relapse and death rates from breast cancer. One possible contributing factor for this disparity is low use of adjuvant endocrine therapy-an extremely efficacious therapy in women with early stage, hormone receptor positive breast cancer, the most common subtype of breast cancer. Alone, adjuvant endocrine therapy decreases breast cancer recurrence by 50% and death by 30%. Data suggest that low use of adjuvant endocrine therapy is a potentially important and modifiable risk factor for poor outcome in low-income breast cancer patients.

Informing women with breast cancer about endocrine therapy: effects on knowledge and adherence

OBJECTIVE

Adherence to adjuvant endocrine therapy in women with breast cancer is low, and patients are not informed sufficiently. This study analyzes the effects of a structured treatment information on patients' satisfaction, knowledge, and adherence.

METHODS

An interventional single cohort study of postoperative women with estrogen-receptor-positive breast cancer was conducted to study the effects of enhanced information about endocrine therapy given additionally to clinical routine information. Knowledge and satisfaction with additional information given 1-3 weeks after surgery were assessed before and after informing patients; adherence and knowledge were measured 3 months after start of treatment.

RESULTS

A total of 137 patients were analyzed before and after provision of enhanced treatment information as well as 3 months after start of endocrine therapy. Enhanced information increased satisfaction with information and knowledge. The percentage of patients who knew their estrogen receptor status increased from 50% to 93%. At 3 months follow-up, 60% still had correct knowledge. Patients who learned their receptor status were older, and those who forgot had lower cognitive abilities and lower educational level. Patients with higher satisfaction, better learning, and comprehension directly after enhanced information showed better adherence at 3 months follow-up.

CONCLUSION

Patients, especially older ones, can benefit from enhanced treatment information given additionally to routine care. Enhanced information about mode of action and potential side effects of endocrine therapy when included into clinical routine might foster patient autonomy and prevent early disruptions in adherence.

Agreement of self-reported hormone receptor status with cancer registry data in young breast cancer patients

BACKGROUND

Though breast cancer subtype is a key determinant of treatment choice and prognosis, few studies have assessed breast cancer patients' knowledge of estrogen and progesterone receptor (ER/PR) status.

METHODS

Women diagnosed with invasive breast cancer at age 18-64 years in 2007 were recruited from the Pennsylvania Cancer Registry, and mailed a questionnaire that asked respondents to identify their ER/PR status. There were 2191 respondents included in the analysis. Agreement between self-report and cancer registry ER/PR status was assessed using kappa statistic. Logistic regression was used to assess the association of demographic, socioeconomic, and tumor factors with inaccurate self-report of ER/PR status.

RESULTS

Fifty-nine percent of respondents reported ER/PR positive status, 15% reported ER/PR negative status, 17% responded 'don't know', and 9% did not respond. Overall, there was 69% agreement between self-report and cancer registry data, and fair agreement as measured by kappa (0.36). After excluding women who did not know or did not report their ER/PR status, there was 93% agreement, and substantial agreement as measured by kappa (0.76). Women who were older, non-white, less educated, lower income, and had ER/PR negative disease were significantly more likely to inaccurately report their ER/PR status.

CONCLUSIONS

Though a significant proportion of women do not know their hormone receptor status, women who reported their ER/PR status were accurate. Our results suggest room for improvement in patient knowledge of tumor subtypes, but also that self-reported ER/PR status may be a useful surrogate when medical record or cancer registry data is unavailable.

Understanding discontinuation of oral adjuvant endocrine therapy by women with hormone receptor-positive invasive breast cancer nearly 4 years from diagnosis

OBJECTIVE

The aim of this study was to investigate the extent of discontinuation of oral adjuvant endocrine therapy (OAET) in women nearly 4 years from the diagnosis of their first episode of invasive breast cancer and the reasons for such discontinuation.

METHODS

We used a large, prospective cohort study of women who had been diagnosed with their first episode of invasive breast cancer between 2004 and 2006, recruited through a state-based cancer registry. All participants completed an enrollment questionnaire (EQ) within 12 months of diagnosis and annual follow-up questionnaires (FQs) thereafter. The data in this report were obtained from the EQ and the first three FQs.

RESULTS

A total of 1,370 women with hormone receptor-positive disease completed the EQ. At the completion of the third FQ nearly 4 years from diagnosis, 1,193 women remained in the study. Use of OAET peaked by 2 years postdiagnosis. At nearly 4 years from diagnosis, 18% of the 1,193 women remaining in the study were not taking OAET. Of these women, just more than half had ceased therapy mainly owing to a range of adverse effects, predominantly estrogen deficiency symptoms, but the remainder (8% of women remaining in the study) had never used OAET.

CONCLUSIONS

Our study confirms that early discontinuation of OAET due to estrogen deficiency symptoms remains an important issue despite calls for strategies to address this problem. The number of women potentially suitable for OAET but not receiving it was almost as great as the number of those who have discontinued therapy.

Non-initiation of adjuvant hormonal therapy in women with hormone receptor-positive breast cancer: The Breast Cancer Quality of Care Study (BQUAL)

Adjuvant hormonal therapy for non-metastatic hormone receptor (HR)-positive breast cancer decreases risk of breast cancer recurrence and increases survival. However, some women do not initiate this life-saving treatment. We used a prospective cohort design to investigate factors related to non-initiation of hormonal therapy among women with newly diagnosed, non-metastatic HR-positive breast cancer recruited from three U.S. sites. Serial interviews were conducted at baseline and during treatment to examine sociodemographic factors, tumor characteristics, and treatment decision-making factors. Multivariate modeling assessed associations between variables of interest and hormonal therapy initiation. Of 1,050 breast cancer patients recruited, 725 (69%) had HR-positive breast cancer, of whom 87 (12.0%) based on self-report and 122 (16.8%) based on medical record/pharmacy fill rates did not initiate hormonal therapy. In a multivariable analysis, non-initiation of hormonal therapy, defined by medical record/pharmacy, was associated with having greater negative beliefs about efficacy of treatment (OR 1.42, 95% CI 1.18-1.70). Non-initiation was less likely in those who found the quality of patient/physician communication to be higher (OR 0.96, 95% CI 0.93-0.99), the hormonal therapy treatment decision an easy one to make (OR 0.45, 95% CI 0.23-0.90) or neither easy nor difficult (OR 0.34, 95% CI 0.20-0.58); and had more positive beliefs about hormonal therapy efficacy (OR 0.40, 95% CI 0.34-0.62). Factors influencing non-initiation of adjuvant hormonal therapy are complex and influenced by patient beliefs regarding treatment efficacy and side effects. Educational interventions to women about the benefits of hormonal therapy may decrease negative beliefs and increase hormone therapy initiation.

Breast cancer survivors' beliefs about the causes of breast cancer

OBJECTIVE

To explore the beliefs held by breast cancer (BC) survivors about the factors that contribute to the development of their BC.  

METHODS

The BUPA Health Foundation Health and Well-being after Breast Cancer Study is a prospective cohort study of 1684 women recruited within 12 months of their first diagnosis with invasive BC. Participants completed an enrollment questionnaire (EQ), first follow-up questionnaire (FQ1) and a second follow-up questionnaire (FQ2), 12 months and 24 months post-EQ, respectively. In the FQ2, women were asked whether they believed anything contributed to the development of their BC and whether they had made lifestyle changes since the FQ1. Well-being was assessed at the FQ2 using the psychological general well-being index (PGWB).  

RESULTS

In total, 1496/1684 women completed the FQ2 and 43.5% reported belief in a factor that may have contributed to their developing BC. These women were more likely to be younger (p<0.0001) and educated beyond high school (p<0.0001). Stress (58.1%) was the most common reason given, followed by previous use of hormone therapy (17.0%) and a family history of any cancer (9.8%). Women who believed stress contributed to their BC had lower PGWB scores than other study participants (70.9 ± 16.1, n = 361 versus 77.3 ± 14.9, n = 1071, mean difference = 6.4, 95% CI: 4.6-8.2 p<0.0001) and were more likely to have made lifestyle changes since their BC diagnosis.  

CONCLUSIONS

Many women with BC believe that stress has contributed to their condition. Women who held this belief were more likely to adopt strategies to reduce stress than those who did not.

Sexual function after breast cancer

INTRODUCTION

Breast cancer (BC) remains the most common non-skin cancer in women and an increasing number are living as BC survivors.

AIM

The aim of this article is to evaluate the impact of the first diagnosis of invasive BC and its treatment, menopausal symptoms, and body image on sexual function.

METHODS

The BUPA Foundation Health and Wellbeing after Breast Cancer Study is a prospective cohort study of 1,684 women recruited within 12 months of their first diagnosis with invasive BC. Each participant completed an enrollment questionnaire (EQ) and first follow-up questionnaire (FQ1) 12 months post-EQ.

MAIN OUTCOME MEASURE

Sexual function was evaluated by the Menopause-Specific Quality of Life Questionnaire embedded within the FQ1.

RESULTS

Of the 1,011 women in the analyses, 70% experienced sexual function problems and 77% reported vasomotor symptoms. Women experiencing sexual function problems were postmenopausal (P = 0.02), experienced vasomotor symptoms (P < 0.01), and used aromatase inhibitors (P = 0.03). Women with vasomotor symptoms were twice as likely to experience sexual function problems (odds ratio [OR] 1.93, 95% confidence interval [CI] 141, 2.63; P < 0.001). This association was more extreme for women on aromatase inhibitors (OR 3.49, 95% CI 1.72, 7.09; P = 0.001) but did not persist in women not using endocrine therapies (OR 1.41, 95% CI 0.84, 2.36; P = 0.19). Women on aromatase inhibitors were more likely to report sexual function problems (OR 1.50, 95% CI 1.0, 2.2, P = 0.04) and women with body image issues were 2.5 times more likely to report sexual function problems (OR 2.5 95% CI 1.6, 3.7, P < 0.001). Women using tamoxifen were not more likely to experience sexual function problems (OR 1.1, 95% CI 0.8, 1.5, P = 0.6); however, women with body image issues were twice as likely to experience sexual function problems (OR 2.1, 95% CI 1.5, 3.0, P < 0.001).

CONCLUSION

Seventy percent of partnered BC survivors less than 70 experienced sexual function problems. Sexual problems are related to the use of aromatase inhibitors which can exacerbate menopausal symptoms.

Psychological well-being in a cohort of women with invasive breast cancer nearly 2 years after diagnosis

PURPOSE

The aim of this study was to document the psychological well-being of a group of women with invasive breast cancer (BC) on an average of nearly 2 years after their diagnosis.

METHODS

Participants were women in the Medical Benefits Fund Australia Limited Foundation Health and Wellbeing after Breast Cancer Study, a cohort study of 1,684 women recruited within 12 months of their diagnosis with invasive BC, who completed their first annual follow-up questionnaire. Psychological well-being was measured using the Psychological General Well Being Index questionnaire (PGWB) in women with BC.

RESULTS

The PGWB questionnaire was completed by 1,589 women on an average of 92 weeks after their BC diagnosis, of whom 46 had evidence of active disease. PGWB total scores for all age groups of the BC cohort were lower than community-based norms (p < 0.001 for age groups > or =70, 60-<70, 50-60; p = 0.002 for age group 40-<50 and p = 0.05 for age group <40). PGWB total scores for the BC cohort were positively associated with age (p < 0.001) and living with others (p < 0.01) and inversely associated with active disease (p < 0.001) and education beyond secondary school (p = 0.03). For the domain of anxiety, there was no statistically significant association with living with others but an inverse association with education beyond school.

CONCLUSION

A higher level of education may be associated with increased anxiety and lower well-being. Social support is particularly important for women with BC who are known to live alone.