1
|
Waaijer MEC, Lemij AA, de Boer AZ, Bastiaannet E, van den Bos F, Derks MGM, Kroep JR, Liefers GJ, Portielje JEA, de Glas NA. The impact of geriatric characteristics and comorbidities on distant metastases and other cause mortality in older women with non-metastatic breast cancer treated with primary endocrine therapy. Breast Cancer Res Treat 2023; 201:471-478. [PMID: 37479944 PMCID: PMC10460719 DOI: 10.1007/s10549-023-07029-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 06/28/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION In recent years, primary surgical treatment of older women with non-metastatic breast cancer has decreased in favor of primary endocrine therapy (PET). PET can be considered in women with a remaining life expectancy of less than five years. The aim of this study was to (1) assess the risk of distant metastases and other cause mortality over ten years in women aged 65 and older with stage I-III breast cancer treated with PET, (2) whether this was associated with geriatric characteristics and comorbidities and to (3) describe the reasons on which the choice for PET was made. METHODS Women were included from the retrospective FOCUS cohort, which comprises all incident women diagnosed with breast cancer aged 65 or older between January 1997 and December 2004 in the Comprehensive Cancer Center Region West in the Netherlands. We selected women (N = 257) with stage I-III breast cancer and treated with PET from this cohort. Patient characteristics (including comorbidity, polypharmacy, walking, cognitive and sensory impairment), treatment and tumor characteristics were retrospectively extracted from charts. Outcomes were distant metastasis and other cause mortality. Cumulative incidences were calculated using the Cumulative Incidence for Competing Risks method (CICR); and subdistribution hazard ratios (SHR) were tested between groups based on age, geriatric characteristics and comorbidity with the Fine and Gray model. RESULTS Women treated with PET were on average 84 years old and 41% had one or more geriatric characteristics. Other cause mortality exceeded the cumulative incidence of distant metastasis over ten years (83 versus 5.6%). The risk of dying from another cause further increased in women with geriatric characteristics (SHR 2.06, p < 0.001) or two or more comorbidities (SHR 1.72, p < 0.001). Often the reason for omitting surgery was not recorded (52.9%), but if recorded surgery was omitted mainly at the patient's request (18.7%). DISCUSSION This study shows that the cumulative incidence of distant metastasis is much lower than other cause mortality in older women with breast cancer treated with PET, especially in the presence of geriatric characteristics or comorbidities. This confirms the importance of assessment of geriatric characteristics to aid counseling of older women.
Collapse
Affiliation(s)
- M E C Waaijer
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - A A Lemij
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Post zone C7-Q, P.O. Box 9600 RC, Leiden, the Netherlands
| | - A Z de Boer
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Post zone C7-Q, P.O. Box 9600 RC, Leiden, the Netherlands
| | - E Bastiaannet
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Post zone C7-Q, P.O. Box 9600 RC, Leiden, the Netherlands
| | - F van den Bos
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - M G M Derks
- Department of Medical Oncology, Leiden University Medical Center, Post zone C7-Q, P.O. Box 9600 RC, Leiden, the Netherlands
| | - J R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Post zone C7-Q, P.O. Box 9600 RC, Leiden, the Netherlands
| | - G J Liefers
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Post zone C7-Q, P.O. Box 9600 RC, Leiden, the Netherlands
| | - N A de Glas
- Department of Medical Oncology, Leiden University Medical Center, Post zone C7-Q, P.O. Box 9600 RC, Leiden, the Netherlands.
| |
Collapse
|
2
|
Record SM, Chanenchuk T, Parrish KM, Kaplan SJ, Kimmick G, Plichta JK. Prognostic Tools for Older Women with Breast Cancer: A Systematic Review. Medicina (Kaunas) 2023; 59:1576. [PMID: 37763695 PMCID: PMC10534323 DOI: 10.3390/medicina59091576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023]
Abstract
Background: Breast cancer is the most common cancer in women, and older patients comprise an increasing proportion of patients with this disease. The older breast cancer population is heterogenous with unique factors affecting clinical decision making. While many models have been developed and tested for breast cancer patients of all ages, tools specifically developed for older patients with breast cancer have not been recently reviewed. We systematically reviewed prognostic models developed and/or validated for older patients with breast cancer. Methods: We conducted a systematic search in 3 electronic databases. We identified original studies that were published prior to 8 November 2022 and presented the development and/or validation of models based mainly on clinico-pathological factors to predict response to treatment, recurrence, and/or mortality in older patients with breast cancer. The PROBAST was used to assess the ROB and applicability of each included tool. Results: We screened titles and abstracts of 7316 records. This generated 126 studies for a full text review. We identified 17 eligible articles, all of which presented tool development. The models were developed between 1996 and 2022, mostly using national registry data. The prognostic models were mainly developed in the United States (n = 7; 41%). For the derivation cohorts, the median sample size was 213 (interquartile range, 81-845). For the 17 included modes, the median number of predictive factors was 7 (4.5-10). Conclusions: There have been several studies focused on developing prognostic tools specifically for older patients with breast cancer, and the predictions made by these tools vary widely to include response to treatment, recurrence, and mortality. While external validation was rare, we found that it was typically concordant with interval validation results. Studies that were not validated or only internally validated still require external validation. However, most of the models presented in this review represent promising tools for clinical application in the care of older patients with breast cancer.
Collapse
Affiliation(s)
- Sydney M. Record
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Tori Chanenchuk
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Kendra M. Parrish
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | | | - Gretchen Kimmick
- Duke Cancer Institute, Duke University, Durham, NC 27710, USA
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - Jennifer K. Plichta
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
- Duke Cancer Institute, Duke University, Durham, NC 27710, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC 27710, USA
| |
Collapse
|
3
|
Wyld L, Reed MWR, Collins K, Ward S, Holmes G, Morgan J, Bradburn M, Walters S, Burton M, Lifford K, Edwards A, Brain K, Ring A, Herbert E, Robinson TG, Martin C, Chater T, Pemberton K, Shrestha A, Nettleship A, Richards P, Brennan A, Cheung KL, Todd A, Harder H, Audisio R, Battisti NML, Wright J, Simcock R, Murray C, Thompson AM, Gosney M, Hatton M, Armitage F, Patnick J, Green T, Revill D, Gath J, Horgan K, Holcombe C, Winter M, Naik J, Parmeshwar R. Improving outcomes for women aged 70 years or above with early breast cancer: research programme including a cluster RCT. Programme Grants Appl Res 2022. [DOI: 10.3310/xzoe2552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
In breast cancer management, age-related practice variation is widespread, with older women having lower rates of surgery and chemotherapy than younger women, based on the premise of reduced treatment tolerance and benefit. This may contribute to inferior outcomes. There are currently no age- and fitness-stratified guidelines on which to base treatment recommendations.
Aim
We aimed to optimise treatment choice and outcomes for older women (aged ≥ 70 years) with operable breast cancer.
Objectives
Our objectives were to (1) determine the age, comorbidity, frailty, disease stage and biology thresholds for endocrine therapy alone versus surgery plus adjuvant endocrine therapy, or adjuvant chemotherapy versus no chemotherapy, for older women with breast cancer; (2) optimise survival outcomes for older women by improving the quality of treatment decision-making; (3) develop and evaluate a decision support intervention to enhance shared decision-making; and (4) determine the degree and causes of treatment variation between UK breast units.
Design
A prospective cohort study was used to determine age and fitness thresholds for treatment allocation. Mixed-methods research was used to determine the information needs of older women to develop a decision support intervention. A cluster-randomised trial was used to evaluate the impact of this decision support intervention on treatment choices and outcomes. Health economic analysis was used to evaluate the cost–benefit ratio of different treatment strategies according to age and fitness criteria. A mixed-methods study was used to determine the degree and causes of variation in treatment allocation.
Main outcome measures
The main outcome measures were enhanced age- and fitness-specific decision support leading to improved quality-of-life outcomes in older women (aged ≥ 70 years) with early breast cancer.
Results
(1) Cohort study: the study recruited 3416 UK women aged ≥ 70 years (median age 77 years). Follow-up was 52 months. (a) The surgery plus adjuvant endocrine therapy versus endocrine therapy alone comparison: 2854 out of 3416 (88%) women had oestrogen-receptor-positive breast cancer, 2354 of whom received surgery plus adjuvant endocrine therapy and 500 received endocrine therapy alone. Patients treated with endocrine therapy alone were older and frailer than patients treated with surgery plus adjuvant endocrine therapy. Unmatched overall survival and breast-cancer-specific survival were higher in the surgery plus adjuvant endocrine therapy group (overall survival: hazard ratio 0.27, 95% confidence interval 0.23 to 0.33; p < 0.001; breast-cancer-specific survival: hazard ratio 0.41, 95% confidence interval 0.29 to 0.58; p < 0.001) than in the endocrine therapy alone group. In matched analysis, surgery plus adjuvant endocrine therapy was still associated with better overall survival (hazard ratio 0.72, 95% confidence interval 0.53 to 0.98; p = 0.04) than endocrine therapy alone, but not with better breast-cancer-specific survival (hazard ratio 0.74, 95% confidence interval 0.40 to 1.37; p = 0.34) or progression-free-survival (hazard ratio 1.11, 95% confidence interval 0.55 to 2.26; p = 0.78). (b) The adjuvant chemotherapy versus no chemotherapy comparison: 2811 out of 3416 (82%) women received surgery plus adjuvant endocrine therapy, of whom 1520 (54%) had high-recurrence-risk breast cancer [grade 3, node positive, oestrogen receptor negative or human epidermal growth factor receptor-2 positive, or a high Oncotype DX® (Genomic Health, Inc., Redwood City, CA, USA) score of > 25]. In this high-risk population, there were no differences according to adjuvant chemotherapy use in overall survival or breast-cancer-specific survival after propensity matching. Adjuvant chemotherapy was associated with a lower risk of metastatic recurrence than no chemotherapy in the unmatched (adjusted hazard ratio 0.36, 95% confidence interval 0.19 to 0.68; p = 0.002) and propensity-matched patients (adjusted hazard ratio 0.43, 95% confidence interval 0.20 to 0.92; p = 0.03). Adjuvant chemotherapy improved the overall survival and breast-cancer-specific survival of patients with oestrogen-receptor-negative disease. (2) Mixed-methods research to develop a decision support intervention: an iterative process was used to develop two decision support interventions (each comprising a brief decision aid, a booklet and an online tool) specifically for older women facing treatment choices (endocrine therapy alone or surgery plus adjuvant endocrine therapy, and adjuvant chemotherapy or no chemotherapy) using several evidence sources (expert opinion, literature and patient interviews). The online tool was based on models developed using registry data from 23,842 patients and validated on an external data set of 14,526 patients. Mortality rates at 2 and 5 years differed by < 1% between predicted and observed values. (3) Cluster-randomised clinical trial of decision support tools: 46 UK breast units were randomised (intervention, n = 21; usual care, n = 25), recruiting 1339 women (intervention, n = 670; usual care, n = 669). There was no significant difference in global quality of life at 6 months post baseline (difference –0.20, 95% confidence interval –2.7 to 2.3; p = 0.90). In women offered a choice of endocrine therapy alone or surgery plus adjuvant endocrine therapy, knowledge about treatments was greater in the intervention arm than the usual care arm (94% vs. 74%; p = 0.003). Treatment choice was altered, with higher rates of endocrine therapy alone than of surgery in the intervention arm. Similarly, chemotherapy rates were lower in the intervention arm (endocrine therapy alone rate: intervention sites 21% vs. usual-care sites 15%, difference 5.5%, 95% confidence interval 1.1% to 10.0%; p = 0.02; adjuvant chemotherapy rate: intervention sites 10% vs. usual-care site 15%, difference 4.5%, 95% confidence interval 0.0% to 8.0%; p = 0.013). Survival was similar in both arms. (4) Health economic analysis: a probabilistic economic model was developed using registry and cohort study data. For most health and fitness strata, surgery plus adjuvant endocrine therapy had lower costs and returned more quality-adjusted life-years than endocrine therapy alone. However, for some women aged > 90 years, surgery plus adjuvant endocrine therapy was no longer cost-effective and generated fewer quality-adjusted life-years than endocrine therapy alone. The incremental benefit of surgery plus adjuvant endocrine therapy reduced with age and comorbidities. (5) Variation in practice: analysis of rates of surgery plus adjuvant endocrine therapy or endocrine therapy alone between the 56 breast units in the cohort study demonstrated significant variation in rates of endocrine therapy alone that persisted after adjustment for age, fitness and stage. Clinician preference was an important determinant of treatment choice.
Conclusions
This study demonstrates that, for older women with oestrogen-receptor-positive breast cancer, there is a cohort of women with a life expectancy of < 4 years for whom surgery plus adjuvant endocrine therapy may offer little benefit and simply have a negative impact on quality of life. The Age Gap decision tool may help make this shared decision. Similarly, although adjuvant chemotherapy offers little benefit and has a negative impact on quality of life for the majority of older women with oestrogen-receptor-positive breast cancer, for women with oestrogen-receptor-negative breast cancer, adjuvant chemotherapy is beneficial. The negative impacts of adjuvant chemotherapy on quality of life, although significant, are transient. This implies that, for the majority of fitter women aged ≥ 70 years, standard care should be offered.
Limitations
As with any observational study, despite detailed propensity score matching, residual bias cannot be excluded. Follow-up was at median 52 months for the cohort analysis. Longer-term follow-up will be required to validate these findings owing to the slow time course of oestrogen-receptor-positive breast cancer.
Future work
The online algorithm is now available (URL: https://agegap.shef.ac.uk/; accessed May 2022). There are plans to validate the tool and incorprate quality-of-life and 10-year survival outcomes.
Trial registration
This trial is registered as ISRCTN46099296.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 6. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Karen Collins
- Faculty of Health and Wellbeing, Department of Allied Health Professions, Collegiate Cresent Campus, Sheffield Hallam University, Sheffield, UK
| | - Sue Ward
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Geoff Holmes
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jenna Morgan
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Mike Bradburn
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Stephen Walters
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Maria Burton
- Faculty of Health and Wellbeing, Department of Allied Health Professions, Collegiate Cresent Campus, Sheffield Hallam University, Sheffield, UK
| | - Kate Lifford
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Kate Brain
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Esther Herbert
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Cardiovascular Research Centre, Glenfield General Hospital, Leicester, UK
| | - Charlene Martin
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Tim Chater
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Kirsty Pemberton
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anne Shrestha
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Paul Richards
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alan Brennan
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Annaliza Todd
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Riccardo Audisio
- Sahlgrenska Universitetssjukhuset, University of Gothenburg, Göteborg, Sweden
| | | | | | | | | | | | - Margot Gosney
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | | | | | - Julietta Patnick
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tracy Green
- Yorkshire and Humber Research Network Consumer Research Panel, Sheffield, UK
| | - Deirdre Revill
- Yorkshire and Humber Research Network Consumer Research Panel, Sheffield, UK
| | - Jacqui Gath
- Yorkshire and Humber Research Network Consumer Research Panel, Sheffield, UK
| | | | - Chris Holcombe
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Matt Winter
- Breast Unit, Weston Park Hospital, Sheffield, UK
| | - Jay Naik
- Breast Unit, Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Rishi Parmeshwar
- Breast Unit, Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
| |
Collapse
|
4
|
Zhao A, Larbi M, Miller K, O'Neill S, Jayasekera J. A scoping review of interactive and personalized web-based clinical tools to support treatment decision making in breast cancer. Breast 2022; 61:43-57. [PMID: 34896693 PMCID: PMC8669108 DOI: 10.1016/j.breast.2021.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/20/2021] [Accepted: 12/04/2021] [Indexed: 01/28/2023] Open
Abstract
The increasing attention on personalized breast cancer care has resulted in an explosion of new interactive, tailored, web-based clinical decision tools for guiding treatment decisions in clinical practice. The goal of this study was to review, compare, and discuss the clinical implications of current tools, and highlight future directions for tools aiming to improve personalized breast cancer care. We searched PubMed, Embase, PsychInfo, Cochrane Database of Systematic Reviews, Web of Science, and Scopus to identify web-based decision tools addressing breast cancer treatment decisions. There was a total of 17 articles associated with 21 unique tools supporting decisions related to surgery, radiation therapy, hormonal therapy, bisphosphonates, HER2-targeted therapy, and chemotherapy. The quality of the tools was assessed using the International Patient Decision Aid Standard instrument. Overall, the tools considered clinical (e.g., age) and tumor characteristics (e.g., grade) to provide personalized outcomes (e.g., survival) associated with various treatment options. Fewer tools provided the adverse effects of the selected treatment. Only one tool was field-tested with patients, and none were tested with healthcare providers. Future studies need to assess the feasibility, usability, acceptability, as well as the effects of personalized web-based decision tools on communication and decision making from the patient and clinician perspectives.
Collapse
Affiliation(s)
- Amy Zhao
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Maya Larbi
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC, USA; Towson University, Maryland, USA
| | - Kristen Miller
- MedStar Health National Center for Human Factors in Healthcare, Washington, DC, USA
| | - Suzanne O'Neill
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Jinani Jayasekera
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC, USA.
| |
Collapse
|
5
|
Abstract
As our global population ages, we will see more cancer diagnoses in older adults. Surgery is an important treatment modality for solid tumours, forming the majority of all cancers. However, the management of older adults with cancer can be more complex compared to their younger counterparts. This narrative review will outline the current challenges facing older adults with cancer and potential solutions. The challenges facing older adults with cancer are complex and include lack of high-level clinical trials targeting older adults and selection of the right patient for surgery. This may be standard surgical treatment, minimally invasive surgery or alternative therapies (no surgery) which can be local or systemic. The next challenge is to identify the individual patient’s vulnerabilities to allow them to be maximally optimised for treatment. Prehabilitation has been shown to be of benefit in some cancer settings but uniform guidance across all surgical specialties is required. Greater awareness of geriatric conditions amongst surgical oncologists and integration of geriatric assessment into a surgical clinic are potential solutions. Enhanced recovery programmes tailored to older adults could reduce postoperative functional decline. Ultimately, the greatest challenge an older adult with cancer may face is the mindset of their treating clinicians—a shared care approach between surgical oncologists and geriatricians is required.
Collapse
Affiliation(s)
- Ruth Parks
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham NG7 2RD, UK;
| | - Kwok-Leung Cheung
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham NG7 2RD, UK;
- School of Medicine, Royal Derby Hospital Centre, Uttoxeter Road, University of Nottingham, Derby DE22 3DT, UK
- Correspondence: ; Tel.: +44-(0)-1332-724881
| |
Collapse
|
6
|
Burton M, Lifford KJ, Wyld L, Armitage F, Ring A, Nettleship A, Collins K, Morgan J, Reed MWR, Holmes GR, Bradburn M, Gath J, Green T, Revell D, Brain K, Edwards A. Process evaluation of the Bridging the Age Gap in Breast Cancer decision support intervention cluster randomised trial. Trials 2021; 22:447. [PMID: 34256828 PMCID: PMC8278730 DOI: 10.1186/s13063-021-05360-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 06/07/2021] [Indexed: 11/24/2022] Open
Abstract
Background The Bridging the Age Gap in Breast Cancer research programme sought to improve treatment decision-making for older women with breast cancer by developing and testing, in a cluster randomised trial (n = 1339 patients), two decision support interventions (DESIs). Both DESIs were used in the intervention arm and each comprised an online risk prediction model, brief decision aid and information booklet. One DESI supported the decision to have either primary endocrine therapy (PET) or surgery with adjuvant therapies and the second supported the decision to have adjuvant chemotherapy after surgery or not. Methods Sixteen sites were randomly selected to take part in the process evaluation. Multiple methods of data collection were used. Medical Research Council (MRC) guidelines for the evaluation of complex interventions were used. Results Eighty-two patients, mean age 75.5 (range 70–93), provided data for the process evaluation. Seventy-three interviews were completed with patients. Ten clinicians from six intervention sites took part in telephone interviews. Dose: Ninety-one members of staff in the intervention arm received intervention training. Reach: The online tool was accessed on 324 occasions by 27 clinicians. Reasons for non-use of the online tool were commonly that the patient had already made a decision or that there was no online access in the clinic. Of the 32 women for whom there were data available, fifteen from the intervention arm and six from the usual care arm were offered a choice of treatment. Fidelity: Clinicians used the online tool in different ways, with some using it during the consultation and others checking the online survival estimates before the consultation. Adaptation: There was evidence of adaptation when using the DESIs. A lack of infrastructure, e.g. internet access, was a barrier to the use of the online tool. The brief decision aid was rarely used. Mediators: Shared decision-making: Most patients felt able to contribute to decision-making and expressed high levels of satisfaction with the process. Participants’ responses to intervention: Six patients reported the DESIs to be very useful, one somewhat useful and two moderately useful. Conclusions Clinicians who participated were mainly supportive of the interventions and had attempted some adaptations to make the interventions applicable, but there were practical and engagement barriers that led to sub-optimal adoption in routine practice. Trial registration ISRCTN46099296. Registered on 11 August 2016—retrospectively registered Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05360-z.
Collapse
Affiliation(s)
- Maria Burton
- College of Health, Wellbeing & Life Sciences, Sheffield Hallam University, Collegiate Crescent, Sheffield, UK
| | - Kate J Lifford
- Division of Population Medicine, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Fiona Armitage
- Department of Oncology and Metabolism, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Alistair Ring
- Breast Unit, Royal Marsden NHS Foundation Trust, London, UK
| | | | - Karen Collins
- College of Health, Wellbeing & Life Sciences, Sheffield Hallam University, Collegiate Crescent, Sheffield, UK
| | - Jenna Morgan
- Department of Oncology and Metabolism, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Malcolm W R Reed
- Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, UK
| | - Geoffrey R Holmes
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- Clinical Trials Research Unit, University of Sheffield, ScHARR, 30 Regent Street, Sheffield, UK
| | - Jacqui Gath
- Yorkshire and Humberside (formerly North Trent Cancer Network) Consumer Research Panel UK, Sheffield, UK
| | - Tracy Green
- Yorkshire and Humberside (formerly North Trent Cancer Network) Consumer Research Panel UK, Sheffield, UK
| | - Deirdre Revell
- Yorkshire and Humberside (formerly North Trent Cancer Network) Consumer Research Panel UK, Sheffield, UK
| | - Kate Brain
- Division of Population Medicine, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | | |
Collapse
|
7
|
Holmes GR, Ward SE, Brennan A, Bradburn M, Morgan JL, Reed MWR, Richards P, Rafia R, Wyld L. Cost-Effectiveness Modeling of Surgery Plus Adjuvant Endocrine Therapy Versus Primary Endocrine Therapy Alone in UK Women Aged 70 and Over With Early Breast Cancer. Value Health 2021; 24:770-779. [PMID: 34119074 DOI: 10.1016/j.jval.2020.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 10/27/2020] [Accepted: 12/02/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Approximately 20% of UK women aged 70+ with early breast cancer receive primary endocrine therapy (PET) instead of surgery. PET reduces surgical morbidity but with some survival decrement. To complement and utilize a treatment dependent prognostic model, we investigated the cost-effectiveness of surgery plus adjuvant therapies versus PET for women with varying health and fitness, identifying subgroups for which each treatment is cost-effective. METHODS Survival outcomes from a statistical model, and published data on recurrence, were combined with data from a large, multicenter, prospective cohort study of over 3400 UK women aged 70+ with early breast cancer and median 52-month follow-up, to populate a probabilistic economic model. This model evaluated the cost-effectiveness of surgery plus adjuvant therapies relative to PET for 24 illustrative subgroups: Age {70, 80, 90} × Nodal status {FALSE (F), TRUE (T)} × Comorbidity score {0, 1, 2, 3+}. RESULTS For a 70-year-old with no lymph node involvement and no comorbidities (70, F, 0), surgery plus adjuvant therapies was cheaper and more effective than PET. For other subgroups, surgery plus adjuvant therapies was more effective but more expensive. Surgery plus adjuvant therapies was not cost-effective for 4 of the 24 subgroups: (90, F, 2), (90, F, 3), (90, T, 2), (90, T, 3). CONCLUSION From a UK perspective, surgery plus adjuvant therapies is clinically effective and cost-effective for most women aged 70+ with early breast cancer. Cost-effectiveness reduces with age and comorbidities, and for women over 90 with multiple comorbidities, there is little cost benefit and a negative impact on quality of life.
Collapse
Affiliation(s)
- Geoffrey R Holmes
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, England, UK.
| | - Sue E Ward
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Alan Brennan
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Michael Bradburn
- Department of Statistics, ScHARR, University of Sheffield, England, UK
| | - Jenna L Morgan
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, England, UK
| | - Malcolm W R Reed
- Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, England, UK
| | - Paul Richards
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Rachid Rafia
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Lynda Wyld
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, England, UK
| |
Collapse
|