Patient Compliance Is Critical for Equivalent Clinical Outcomes for Breast Cancer Treated by Breast-Conservation Therapy

Abstract

ObjectiveTo determine the compliance with a standard breast-conservation therapy (BCT) program in a predominantly indigent, minority population of patients with early breast cancer (stage I and II) served by a rural state institution in the South; to compare the clinical outcomes of this group with those reported in clinical trials; and to examine the socioeconomic factors that may have contributed to the rate of compliance. Summary Background DataDisease-free survival and overall survival in early breast cancer treated by BCT versus modified radical mastectomy are reported to be equivalent in prospective randomized trials. However, patients enrolled in clinical trials may not be representative of patients living in the various diverse communities that make up the United States. The authors' hypothesis is that patients enrolled in clinical trials at the national level may not be representative of indigent patients in the rural South and that clinical trial results may not be directly applicable. MethodsA retrospective review of 55 women with early-stage breast cancer treated from 1990 to 1995 was performed. Clinical data, compliance with treatment and clinical follow-up, and recurrence rates were examined. Statistical analysis performed include the Fisher exact test, Kaplan-Meier survival analysis, and log-rank test. ResultsFull compliance (defined as completion of the entire course of radiation therapy and clinical follow-up) with the BCT program was observed in only 36% of patients. Fifteen of the 35 noncompliant patients did not complete radiation therapy. A significantly higher local failure rate was observed: 8 of these 15 patients (53%) have had local failure. In contrast, patients who were either in full compliance with the BCT program or were deficient only in that they missed part of their clinical follow-up had local failure rates of 5% (1/20) and 10% (2/20), respectively. Age, race, stage of cancer, economic status (measured by availability of medical insurance), distance of patient's residence from the hospital, and education level were evaluated as potential predictors of compliance. None predicted patient compliance, although a trend toward higher compliance was noted in patients with a higher education level, as determined by literacy testing. ConclusionsCompliance with the BCT protocol at the authors' institution was worse than reported in clinical trials, and noncompliance translated into a significant increase in the local failure rate. Factors examined suggest that literacy may play a role in predicting compliance. Although BCT should be discussed with all breast cancer patients, the judicious application of clinical trial data to an institution's local population is warranted.

Adherence to Recommended Treatments for Early Invasive Breast Cancer: Decisions of Women Attending Surgeons in the Breast Cancer Audit of Australia and New Zealand

“…Non-adherence to treatment recommendations have been shown to correlate with lower cancer survivals in previous studies cancers (Li et al, 2000;Herbert-Croteau et al, 2004;McCowan et al, 2008;Wockel et al, 2010 a, b ; Hershman et al, 2011). While the statistical power available to demonstrate similar associations in the present study was very low due to small numbers, point estimates were suggestive of higher case fatalities when treatments were declined.…”

“…Remoteness is well-known to reduce opportunities to gain recommended treatments (Li et al, 2000;BCNA, 2011). This was also demonstrated in the present study where women treated in more remote areas were more likely to decline a treatment recommendation.…”

“…Adherence to recommended treatments has been linked to higher disease-free and overall survival for breast and other cancers (Li et al, 2000;Herbert-Croteau et al, 2004;McCowan et al, 2008;Wockel et al, 2010a,b;Hershman et al, 2011). Non-adherence can be a result of many clinical factors including treatment compromises to accommodate patient frailty or co-morbidity, clinician preference, poor service access or high user cost Lebeau et al, 2011).…”

“…Patient adherence to recommended breast cancer treatments varies widely with treatment setting, but commonly poorer adherence has been associated with older age, low income status, some ethnic sub-groups, and lower educational status (Hebert-Croteau et al, 1999;Li et al, 2000;Truong et al, 2004;Schaapveld et al, 2005;Gilligan et al, 2007;Hershman et al, 2011;Lebeau et al, 2011;Weggelaar et al, 2011). Often adherence has been lower for adjuvant chemotherapies and radiotherapy than surgical interventions (Wockel et al, 2010a).…”

Racial differences in treatment and survival from early‐stage breast carcinoma

“…In addition, previous research indicates that patient factors related to socioeconomic status (SES), such as child/family care concerns, literacy/education levels, and lack of transportation, may contribute to noncompliance among patients in the treatment of breast carcinoma and other diseases. [31][32][33][34][35] Noncompliance may contribute to the significantly poorer survival among African-American women who receive equivalent treatment.…”