Association between cognitive impairment and guideline adherence for application of chemotherapy in older patients with breast cancer: Results from the prospective multicenter BRENDA II study

Abstract

Background: This study examined the association between cognitive impairment and guideline adherence for application of chemotherapy in older patients with breast cancer. Patients and methods:In the prospective multicenter cohort study BRENDA II, patients aged ≥65 years with primary breast cancer were sampled over a period of 4 years (2009)(2010)(2011)(2012). A multiprofessional team (tumor board) discussed recommendation for adjuvant chemotherapy according to the German S3 guideline. Cognitive impairment was screened by the clock-drawing test (CDT) prior to adjuvant treatment. Results: Two hundred and sixty-three patients were included in the study and CDT data were available for 193 patients. Thirty-one percent of the patients had cognitive impairment with different degree of severity. In high-risk patients (n = 61) tumor board recommendation in favor of chemotherapy was 90% and in intermediate-risk patients (n = 170) 27%. Not receiving recommendation for chemotherapy in spite of guideline recommendation was more frequent in patients with cognitive impairment (67%) vs patients without cognitive impairment (46%) with P = 0.02 (OR 2.4, 95% confidence interval (CI) 1.2-4.9). Age, education, migration background and comorbidities were not associated with chemotherapy recommendation by the tumor board among cognitively impaired patients. Once the tumor board had recommended chemotherapy, application of chemotherapy was similar in both groups of patients with or without cognitive impairment. Conclusion: Almost one third of older patients with breast cancer are affected by cognitive impairment prior to adjuvant treatment. In these patients, cognitive impairment was associated with tumor board decision against chemotherapy in spite of a positive guideline recommendation. | 387 LEINERT ET aL.

Healthcare providers’ adherence to breast cancer guidelines in Europe: a systematic literature review

“…We finally included 57 references representing 41 primary studies. Three studies were reported in more than one publication: BRENDA I [12,13,[20][21][22][23][24][25][26][27][28], BRENDA II [29][30][31], and OncoDoc2 [32][33][34]. (Fig.…”

“…Six studies (6/31, 19.4%) addressed adherence as a process indicator integrated in the quality assurance programme of their institution [57][58][59][60][61][62]. In three studies (3/31, 9.7%), a "tumour board", or a multidisciplinary team of physicians, was involved in the clinical pathway of treatment decision [29,31,32,63]. The definitions of adherence were variable across studies.…”

“…• Non-guideline-adherent treatment was associated with comorbidities [20], Charlson index [27] "particular cases" [32] • Most common reasons to withhold trastuzumab were cardiovascular disease [40] • Variation was in part but not entirely attributable to comorbidities [64] • Tumour board recommendation against CT was significantly more frequent in patients with cognitive impairment [29] Tumour stage/tumour characteristics • Non-guideline-adherent treatment was associated with higher tumour stages [20] • Non-compliance on RT was associated with lymph node involvement or peritumoral vascular invasion. Within the overall treatment sequence, it was associated with positive lymph nodes, and grade III versus grade I [63] • Non-compliance was associated with a micro-invasive tumour in re-excision decisions, and with HR + and Her2+ in adjuvant decisions [33,34] • Compliance with SLNB with BCS was significantly higher in patients with tumour size ≥ 50 mm, Van Nuys classification group III, palpable lesion, and upper lateral quadrant of the breast location [72] Gene expression profile • The use of gene expression profiles (GEP) was independently associated with an increased risk of receiving CT in clinical low-risk patients and with a lower risk of CT administration in high-risk patients [47].…”

“…While for women who underwent a mastectomy, SLNB was higher in high-volume departments [72] gene expression profile [47] having triple-negative breast cancer [12,68] or being diagnosed with higher tumour stages [20,63]. Non-adherence was also associated with comorbidities [20,27,29,32,40,64] [e.g. in patients with cardiovascular diseases, it was more frequent to withhold trastuzumab [40], or in patients with cognitive impairment it was more frequent the delay starting chemotherapy [29]].…”

“…Non-adherence was also associated with comorbidities [20,27,29,32,40,64] [e.g. in patients with cardiovascular diseases, it was more frequent to withhold trastuzumab [40], or in patients with cognitive impairment it was more frequent the delay starting chemotherapy [29]]. Other patient-related factors included the quality of life (QoL) and low socioeconomic status (SES) [31].…”