title: Exploring patient- and physician-related factors preventing breast cancer patients from guideline-adherent adjuvant chemotherapy-results from the prospective multi-center study BRENDA II.
abstract: This study examined which patient- and physician-related factors influence guideline violations in adjuvant chemotherapy.
  
  
  
  In a prospective multi-center cohort study, patients with primary breast cancer were sampled consecutively over a period of four years (2009-2012). Patients completed a questionnaire prior to surgery and prior to adjuvant therapy. This questionnaire assessed health-related quality of life (QoL) using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, psychiatric co-morbidity with the Patient Health Questionnaire (PHQ), demographic characteristics (age, education), and the intensity of fear for chemotherapy. After surgery, a multi-professional team discussed recommendation for adjuvant chemotherapy, and this decision was documented in a database together with the indication for chemotherapy according to the German S3 guideline. This multi-professional team was blinded to that algorithm-based decision. Six months later, it was documented whether the patient had received adjuvant chemotherapy or not.
  
  
  
  Altogether, 857 patients were included in the study. In 391 of these patients, the tumor board (TB) decided to recommend chemotherapy. The most important reasons for not recommending chemotherapy were somatic co-morbidity not allowing adjuvant chemotherapy and age >75 years. Of these 391 patients, 73 (19 %) patients eventually did not receive chemotherapy. Deviations from the initial therapy decision were more frequent in older patients (≥75 years) with poor QoL. If the QoL was good, higher age was not related to deviation. There was some evidence that patients with higher education less frequently received chemotherapy (CT). Furthermore, if patients were very afraid of chemotherapy, deviations from the initial therapy decision were more likely. Co-morbidity and fear of CT were not related to the likelihood of deviating from the initial therapy decision.
  
  
  
  Nineteen percent of patients eventually did not receive chemotherapy, despite guideline and TB recommendations. In these patients, this mainly occurred in association with poor QoL in elderly patients >75 years old. In the group with a chemotherapy recommendation, patients' fear of chemotherapy is another factor preventing patients from undergoing adjuvant chemotherapy.
authors.affiliation: Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075, Ulm, Germany. lukas.schwentner@yahoo.de.
authors.forename: Lukas
authors.initials: L
authors.lastname: Schwentner
authors.affiliation: Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI)-University Medical Centre Mainz, Obere Zahlbacher Straße 69, 55131, Mainz, Germany.|Department of Economics, Johannes Gutenberg University Mainz, Jakob-Welder-Weg 4, 55128, Mainz, Germany.
authors.forename: Reyn
authors.initials: R
authors.lastname: Van Ewijk
authors.affiliation: Department of Gynecology and Obstetrics, Hospital Esslingen, Hirschlandstraße 97, 73730, Esslingen, Germany.
authors.forename: Thorsten
authors.initials: T
authors.lastname: Kühn
authors.affiliation: Department of Gynecology and Obstetrics, Hospital Memmingen, Bismarkstraße 23, 87700, Memmingen, Germany.
authors.forename: Felix
authors.initials: F
authors.lastname: Flock
authors.affiliation: Department of Gynecology and Obstetrics, Hospital Kempten, Robert-Weixler-Straße 50, 87439, Kempten, Germany.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Felberbaum
authors.affiliation: Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI)-University Medical Centre Mainz, Obere Zahlbacher Straße 69, 55131, Mainz, Germany.
authors.forename: Maria
authors.initials: M
authors.lastname: Blettner
authors.affiliation: Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075, Ulm, Germany.
authors.forename: Rolf
authors.initials: R
authors.lastname: Kreienberg
authors.affiliation: Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075, Ulm, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Janni
authors.affiliation: Department of Gynecology and Obstetrics, University Würzburg, Joseph-Schneider Str. 4, 97080, Würzburg, Germany.
authors.forename: Achim
authors.initials: A
authors.lastname: Wöckel
authors.affiliation: Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI)-University Medical Centre Mainz, Obere Zahlbacher Straße 69, 55131, Mainz, Germany.
authors.forename: Susanne
authors.initials: S
authors.lastname: Singer
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000523:psychology*; D017024:Chemotherapy, Adjuvant / Q000523:psychology*; D015897:Comorbidity; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D011446:Prospective Studies; D011788:Quality of Life / Q000523:psychology*
keywords: Breast cancer; Chemotherapy; Co-morbidity; Compliance; Guideline
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