title: Which patient- and physician-related factors are associated with guideline adherent initiation of adjuvant endocrine therapy? Results of the prospective multi-centre cohort study BRENDA II.
abstract: BACKGROUND
  We analysed factors that might influence patients' and physicians' decisions against the initiation of guideline adherent adjuvant endocrine therapy (ET).
  
  
  METHODS
  In a prospective multi-centre study, including four certified breast cancer centres in Germany, patients with primary breast cancer were included from 2009 to 2012. Patients completed a questionnaire prior to surgery, adjuvant therapy, and 6 months after adjuvant therapy. This questionnaire assessed health-related quality of life (QoL), psychiatric co-morbidity, demographic characteristics, and the intensity of fear for ET. Guideline adherence was classified based on an algorithm derived from international guidelines. The tumour board's (TB) decisions against or for ET was documented. The TB was blinded regarding the guideline results.
  
  
  RESULTS
  In 666 patients, adjuvant ET was indicated according to the guideline recommendations. The TB decided in 92.3 % (n = 615) of those that adjuvant ET was indicated. TB's decision against ET was associated with the younger age of patients (OR = 0.5; 95 % CI 0.3-0.9) and poor QoL (OR = 1.7; 95 % CI 1.0-2.8). In 93 patients, ET was not indicated according to the guidelines, and the TB decided in 84 of those not to prescribe ET. The TB decided in 93.4 % of the cases according to the guidelines. Of the patients, where the TB prescribed ET, 5 % (n = 31) decided against ET. This decision was associated with fear of ET (OR = 2.2; 95 % CI 1.0-5.2) and higher age (OR 9; 95 % CI 1.0-48.1). Psychiatric co-morbidity (OR = 1.8; 95 % CI 0.7-4.2), poor QoL (OR = 0.4; 95 % CI 0.2-1.2), and education (OR = 1.2; 95 % CI 0.5-2.6) were not associated with the decision.
  
  
  CONCLUSIONS
  Guideline adherent implementation of adjuvant ET is high. Physicians' decision against ET is mainly associated with patients' younger age and poor quality of life, whereas patients' decision, once the TB decided to initiate ET and if ET is indicated by guidelines, is associated with higher age and fear of ET.
authors.affiliation: Department of Gynecology and Obstetrics, University Würzburg, Joseph-Schneider Str. 4, 97080, Würzburg, Germany. stueber_t@ukw.de.
authors.forename: Tanja
authors.initials: T
authors.lastname: Stüber
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, University Würzburg, Joseph-Schneider Str. 4, 97080, Würzburg, Germany.
authors.forename: Joachim
authors.initials: J
authors.lastname: Diessner
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.|University Cancer Centre, Mainz, Germany.
authors.forename: Susanne
authors.initials: S
authors.lastname: Singer
authors.affiliation: Department of Gynecology and Obstetrics, University Ulm, Prittwitzstraße 43, 89075, Ulm, Germany.
authors.forename: Lukas
authors.initials: L
authors.lastname: Schwentner
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000188:drug therapy*; D017024:Chemotherapy, Adjuvant / Q000523:psychology*; D003657:Decision Making; D005260:Female; D005858:Germany; D019983:Guideline Adherence; D006801:Humans; D010817:Physician-Patient Relations; D011446:Prospective Studies; D011788:Quality of Life; D013315:Stress, Psychological; D011795:Surveys and Questionnaires
keywords: Breast cancer; Endocrine therapy; Guideline