Evaluation of the Quality of Adjuvant Endocrine Therapy Delivery for Breast Cancer Care in the United States.
OBJECTIVE
Randomized trials in breast cancer have demonstrated the clinical benefits of adjuvant endocrine therapy (AET) in preventing recurrence and death. The examination of concordance with AET guidelines at a national level as a measure of quality of care is important.


OBJECTIVE
To investigate temporal trends and factors related to receipt of AET for breast cancer.


METHODS
This retrospective cohort study included 981 729 women with breast cancer in the National Cancer Database from January 1, 2004, to December 31, 2013. Women with stages I to III breast cancer who received all or part of their treatment at the reporting institution were included in the analysis.


METHODS
Temporal changes in AET receipt (estimating the annual percentage change) and AET practice patterns (using logistic regression) and the effect of AET guideline concordance on survival of women with hormone receptor-positive (HR+) breast cancer (using the multivariable Cox proportional hazards model).


RESULTS
Of the 981 729 eligible patients (mean [SD] age, 60.8 [13.3] years), 818 435 had HR+ and 163 294 had HR-negative (HR-) cancer. Among the patients with HR+ cancer, receipt of AET increased over time, from 69.8% in 2004 to 82.4% in 2013. Among patients with HR- cancer, receipt decreased from 5.2% in 2004 to 3.4% in 2013. Hospital-level adherence (≥80% of patients with HR+ cancer received AET) increased from 40.2% in 2004 to 69.2% in 2013. Receipt of AET varied significantly by age (lower in patients ≥80 years), race (lower in African American and Hispanic participants), geographic location (lower in West South Central, Mountain, and Pacific census regions), and receptor status (lower in patients with estrogen receptor-negative and progesterone receptor-positive cancer). Surgery and radiotherapy were the factors most significantly associated with appropriate AET receipt (only 45.0% in patients who received lumpectomy without radiotherapy). Receipt of AET was associated with a 29% relative risk reduction in mortality. Based on this effectiveness estimate, if all patients with HR+ cancer received AET, approximately 14 630 lives would have been saved over 10 years.


CONCLUSIONS
From 2004 to 2013, underuse and misuse of AET have decreased for patients with breast cancer, but optimal use has not been achieved, and significant variation in care remains. The involvement of surgery and radiotherapy were among the most significant factors associated with optimal use, which underscores the benefits of team-based care to support guideline-concordant therapy.
Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
Bobby
B
Daly
Center for Clinical Cancer Genetics, Department of Medicine, University of Chicago, Chicago, Illinois.
Olufunmilayo I
OI
Olopade
Department of Public Health Sciences, University of Chicago, Chicago, Illinois.
Ningqi
N
Hou
Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois.
Katharine
K
Yao
Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois.
David J
DJ
Winchester
Department of Public Health Sciences, University of Chicago, Chicago, Illinois.
Dezheng
D
Huo
D001741:Black or African American / Q000706:statistics & numerical data; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D018931:Antineoplastic Agents, Hormonal / Q000627:therapeutic use*; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000378:metabolism / Q000473:pathology; D017024:Chemotherapy, Adjuvant / Q000592:standards; D015331:Cohort Studies; D016208:Databases, Factual; D005006:Ethnicity / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008408:Mastectomy; D015412:Mastectomy, Segmental; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D017410:Practice Guidelines as Topic; D016016:Proportional Hazards Models; D011787:Quality of Health Care; D018714:Radiotherapy, Adjuvant; D011960:Receptors, Estrogen / Q000378:metabolism; D011980:Receptors, Progesterone / Q000378:metabolism; D012189:Retrospective Studies; D014481:United States
D018931:Antineoplastic Agents, Hormonal; D011960:Receptors, Estrogen; D011980:Receptors, Progesterone