The use of adjuvant endocrine breast cancer therapy in the oldest old.

In order to report specifically on the use of adjuvant endocrine therapy (ET) in the oldest old breast cancer (BC) patients, we compared treatment patterns including drug compliance and persistence in a cohort of patients who were ≥ 80 years at diagnosis (n = 79) with those of "younger elderly" patients who were 60-79 years old (n = 358). The geriatric cohort more commonly declined the recommended ET (non-compliance: 13.0% vs. 4.5%, p = 0.011). Of the patients who initiated ET, only a minority of the older patients completed the planned therapy duration of five years (39.6% vs. 71.3%, p < 0.001). However, when applying strict criteria for non-persistence, this was found in comparable frequency (17.0% vs. 12.0%, p = 0.370). In older patients, medication was more often discontinued by the physician due to serious medical reasons independent of BC (17.0% vs. 4.7%, p = 0.003). Older women were treated by a general practitioner more often and not by an oncologist (54.4% vs. 23.9%, p < 0.001). Studies on compliance/persistence on cancer therapy in the oldest old demand a detailed follow-up of the patients and the consideration of principles of geriatric medicine. Efforts should be made to make sure that all physicians, but above all general practitioners, who are predominantly involved in the treatment of elderly BC patients, are provided with current knowledge and skills, as to ensure optimal patient management.

Compliance and persistence of endocrine adjuvant breast cancer therapy.

This study evaluates compliance and persistence in adjuvant endocrine breast cancer (BC) therapy by clearly analyzing reasons of therapy cessation by differentiating clinical meaningful situations. In order to illuminate the complex field of personal motivation to therapy, a single institution study with a more individual-based approach might better be suited to provide a detailed case documentation than the more epidemiologic approach of large database studies. An unselected cohort of 698 patients (≤ 80 years) diagnosed with hormonal receptor-positive BC from 1997 to 2008 at the University Hospital Basel, Switzerland, was analyzed. The term "non-persistence" was exclusively used for patients where the discontinuation of endocrine therapy (ET) could have been modified by more intensive care and improved counseling (e.g., in women who lost faith/motivation to therapy or those who suffered from therapy-related side effects). These cases must be differentiated from cases where therapy cessation was inevitable (e.g., due to recurrent disease or severe intercurrent illness). Out of the 685 patients to whom ET was recommended, 42 patients (6.1%) refused and never began treatment (non-compliance). Women younger than 50 were more likely to be non-compliant (P < 0.001). 12.9% of the patients who started therapy were non-persistent to therapy. Patients who were treated by general practitioners tended to be non-persistent more often compared to those treated by oncologists (17.7% vs. 11.3%; P = 0.07). The aim of a non-persistence rate between 10 and 15% is realistic when patients are treated by specialized oncologists. Interventions are needed to support patients, particularly the younger ones, to comply with therapy. Efforts should be made to make sure that all physicians, above all general practitioners, who are involved in BC treatment, are provided with current knowledge as to guarantee an optimal patient management.

Impact of body mass index on compliance and persistence to adjuvant breast cancer therapy.

Several authors found that the prognosis of overweight and obese breast cancer (BC) patients was lower than that of normal weight patients. We present the first study which evaluates the impact of body mass index (BMI) on compliance (i.e. to start a recommended therapy) and persistence to adjuvant BC therapy. An unselected cohort of 766 patients (≤75 years) diagnosed from 1997 to 2009 was analyzed in relevance to the four adjuvant therapy modalities: (A) radiation, (B) chemotherapy, (C) therapy with trastuzumab, and (D) endocrine therapy. With respect to compliance, multivariate analyses calculated Odds ratios (ORs) >1 for increased BMI in all four therapy modalities, i.e. increased BMI had a positive influence on compliance. The results were significant for radiotherapy (OR,2.37;95%CI,1.45-3.88;p < 0.001) and endocrine therapy (OR,1.92;95%CI,1.21-3.04;p = 0.002) and showed a trend in chemotherapy (OR,1.42;95%CI,0.97-2.08;p = 0.063). Analyzing persistence, increasing BMI had ORs <1 for chemotherapy and therapy with trastuzumab, both not reaching statistical significance. For endocrine therapy, increasing BMI was a significant predictor for persistence (OR,1.35;95%CI,1.08-1.80;p = 0.042). Failure of compliance and persistence to adjuvant therapy does not pose a contributing factor for the observed unfavorable prognosis in overweight/obese BC patients. In most therapy modes, patients with increasing BMI demonstrated a higher motivation and perseverance to the recommended treatment.

Eligibility, compliance and persistence of sequential therapy with aromatase inhibitors following 2-3 years of tamoxifen in endocrine adjuvant breast cancer therapy.

OBJECTIVE: This study evaluated the eligibility, compliance and persistence of sequential therapy, i.e. a switch to an aromatase inhibitor (AI) following 2-3 years of tamoxifen, in adjuvant endocrine breast cancer (BC) treatment. METHODS: Data concerning 388 BC patients (age ≤70 years) who started endocrine adjuvant therapy between 1998 and 2008 were analyzed. RESULTS: From the 263 patients who started therapy with tamoxifen, 167 (63.5%) were eligible for a sequential therapy. Fifty-nine patients (35.3%) were offered a switch by their physicians; women who had their follow-up at oncological units received the offer more often when compared to those treated by general practitioners (p < 0.001). Out of these 59 patients, 50 followed the proposal (compliance 84.7%). Of those who agreed to a sequential therapy, 2 (4%) were non-persistent to endocrine therapy; in 9 cases (18.0%), a re-switch to tamoxifen was done due to AI-related adverse side effects. CONCLUSIONS: Only a minority of the patients who started an endocrine adjuvant BC therapy was eligible for sequential therapy. Patients who underwent a switch had a high rate of persistence. Efforts should be made to make sure that all physicians, above all general practitioners, who are involved in the treatment of BC patients, are provided with current therapy guidelines.

Menopausal state in breast cancer: how reliable is the data?

UNLABELLED: Despite the high importance of the menopausal state for the management of breast cancer, above all, when planning antihormonal adjuvant therapy, the menopausal state cannot be defined at the time of diagnosis ina significant proportion of women. The scope of uncertainties regarding the recording of the menopausal state in a cohort of patients with breast cancer is evaluated. INTRODUCTION: Menopause is a cornerstone both in breast cancer (BC) pathophysiology and in clinical management. The scope of uncertainties regarding the recording of the menopausal state in a cohort of patients with BC is evaluated in this study. PATIENTS AND METHODS: The data of a Swiss prospective relational BC database that covered a 20-year period (1990-2009; n=1457) was analyzed. For the definition of menopause, the guidelines of the National Comprehensive Cancer Network were used. RESULTS: The menopausal state was unclear in 150 patients (10.2%). Of these, 122 (81.3%) had undergone a hysterectomy before menopause; in 28 women (18.7%), an endocrine therapy obscured the patient's actual endocrine status. When taking only the subgroup of women in which menopause usually occurs (45-55 years) into consideration, the menopausal state was unclear in 91 cases of 337 women (27.0%). From the entire cohort, the date of last menstruation remained obscure in 450 patients (30.9%). CONCLUSION: Despite the high importance of the menopausal state for the management of BC, above all, when planning antihormonal adjuvant therapy, the menopausal state was unable to be defined at the time of BC diagnosis in a significant proportion of women. The dilemma that menopause cannot be assessed in some BC cases is increasingly being recognized. Close cooperation between oncologists and endocrinologists is desirable to establish an optimal, individually tailored therapy for women with an unclear menopausal state due to hormonal therapies, hysterectomy, or chemotherapy.

Suicide in breast cancer patients: an individual-centered approach provides insight beyond epidemiology.

BACKGROUND: Epidemiologic studies have identified increased suicide rates among breast cancer (BC) patients. The population-based approach, however, has considerable methodic shortcomings. None of the studies have been carried out in a prospective manner and none reported suicide rates from a country in which physician-assisted suicide (PAS) is legal. PATIENTS AND METHODS: All cases recorded by a prospective Swiss BC database during a 17-year period (1990-2006; n = 1165) were analyzed. Using an individual-centered approach, the cases of women who committed suicide are reported according to the psychological autopsy method. RESULTS: In six patients (0.5%; 5.1/1.000 patients), suicidal death was identified. In four patients, suicide was committed during late stages of metastatic BC. In two cases, comorbid conditions were associated with suicide. Three women chose PAS. CONCLUSION: The individual-centered approach is a well-suited innovative concept to increase the knowledge regarding the relationship between cancer and suicide. We found a two to seven times higher suicide rate than those reported in epidemiologic studies. The population-based approach can barely elucidate the immense variety of one of the most personal decisions: the act of intentionally ending one's own life. These studies suffer from systematic failure of analysis since they did not a) consider the potential confounding role of comorbid medical and/or psychiatric conditions, and b) report in which disease stage suicide was committed, since the decisive disease-related event whether and when metastatic disease occurred was not recorded. Furthermore, epidemiologic data stems from countries in which PAS is prohibited and therefore not included in official statistics. This grey area of medicine accounts for a greater scope of underreporting than had previously been assumed.

Drug switch because of treatment-related adverse side effects in endocrine adjuvant breast cancer therapy: how often and how often does it work?

Therapy-related adverse side effects are a main reason for non-persistence to adjuvant endocrine breast cancer therapy. This study reports frequency of drug-related adverse side effects that were so severe that a modification of the therapy was necessary. We evaluated how many patients discontinued adjuvant endocrine therapy because of these side effects (non-persistence). Last, we analyzed how often a drug switch was undertaken for this reason and how often this measure led to the patient successfully continuing their endocrine therapy. Data concerning all postmenopausal breast cancer patients (≤ 80 years), who initiated endocrine adjuvant therapy between 1998 and 2008 in a Swiss breast center (n = 400), were analyzed. Out of these 400 women, 37 (9.3%) were defined as being non-persistent to the therapy; out of these, 24 (64.9%) because of therapy-related side effects. About 78 patients (19.5%) suffered from severe therapy-related side effects that made a modification of therapy necessary. Out of these 78 cases, 14 patients (17.9%) stopped the therapy without attempting a drug switch (non-persistence). In 64 patients (82.1%; 16% of all women who started endocrine therapy), a drug switch was undertaken. Out of these 64 cases, in 52 cases (81.3%) endocrine therapy was completed after therapy modification. Patients who reported one major adverse effect were more likely to continue the endocrine therapy after a drug switch (P = 0.048) compared with those who suffered from at least two different side effects. In 10 of the 64 cases (15.6%), modification of the therapy was not successful and the patients stopped the treatment prematurely (non-persistence) because of ongoing side effects. In cases when therapy-related side effects occur, a drug switch is a promising step to further improve persistence and, by doing so, the outcome of breast cancer patients.

Success and failure of primary medical, nonoperative management in breast cancer.

BACKGROUND: Nonoperative but systemic therapy as first-line management is offered to some patients with breast cancer (BC) who have assumed limited life expectancy, such as older women or those who have distant metastases at initial presentation. We evaluated rates of and predicting factors for success and failure of this therapy approach. METHODS: Seventy-five patients who were initially treated only systemically, and cases in which local control while avoiding surgery was the intended long-term therapy goal were analyzed. Additionally, two stage-dependent subgroups were distinguished (A: stage I-III, n = 31; B: stage IV, n = 44). Failure of therapy was defined as when secondary surgery had to be performed due to locoregional progression or in case of no surgery when severe locoregional clinical signs/symptoms were observed during the further course. RESULTS: Patients in group A were older than those in group B (81 vs. 67.5 years; P < 0.001) and showed an increased survival (5-year rates: 40.2% vs. 24.3%). In 24 patients of the entire cohort (32%), secondary surgery had to be performed; surgery was performed more often in group A (58.1% vs. 13.6%). In the cases in which no surgery was performed (n = 51), 11 women (21.6%) suffered from severe locoregional symptoms in the palliative situation (A: n = 1; B: n = 10). Although the presence of stage IV was a significant factor for therapy success (odds ratio (OR), 2.59; 95% confidence interval (CI), 0.95-7.05; P = 0.039), skin involvement was associated with failure of therapy (OR, 3.57; 95% CI, 1.16-11.11; P = 0.031). CONCLUSIONS: Nonoperative treatment may be offered to selected patients with BC who have assumed limited life expectancy. These women must be openly informed that this approach is not successful in nearly half of the cases.