Early discontinuation and nonadherence to adjuvant hormonal therapy in a cohort of 8,769 early-stage breast cancer patients

Abstract

Purpose: While studies have found that adjuvant hormonal therapy for hormone-sensitive breast cancer (BC) dramatically reduces recurrence and mortality, adherence to medications is suboptimal. We investigated the rates and predictors of early discontinuation and nonadherence to hormonal therapy in patients enrolled in Kaiser Permanente of Northern California health system.

Patients and methods: We identified women diagnosed with hormone-sensitive stage I-III BC from 1996 to 2007 and used automated pharmacy records to identify hormonal therapy prescriptions and dates of refill. We used Cox proportional hazards regression models to analyze factors associated with early discontinuation and nonadherence (medication possession ratio < 80%) of hormonal therapy.

Results: We identified 8,769 patients with BC who met our eligibility criteria and who filled at least one prescription for tamoxifen (43%), aromatase inhibitors (26%), or both (30%) within 1 year of diagnosis. Younger or older age, lumpectomy (v mastectomy), and comorbidities were associated with earlier discontinuation, while Asian race, being married, earlier year at diagnosis, receipt of chemotherapy or radiotherapy, and longer prescription refill interval were associated with completion of 4.5 years of therapy. Of those who continued therapy, similar factors were associated with full adherence. Women age younger than 40 years had the highest risk of discontinuation (hazard ratio, 1.51; 95% CI, 1.23 to 1.85). By 4.5 years, 32% discontinued therapy, and of those who continued, 72% were fully adherent.

Conclusion: Only 49% of patients with BC took adjuvant hormonal therapy for the full duration at the optimal schedule. Younger women are at high risk of nonadherence. Interventions to improve adherence and continuation of hormonal therapy are needed, especially for younger women.

Fig 1.

Annual proportions of adherent, nonadherent, and discontinued patients on adjuvant hormonal therapy, of those patients with stage I-III breast cancer who were taking hormonal therapy at the start of the year, Kaiser Permanente of Northern California (KPNC), 1996 to 2006. AI, aromatase inhibitor.

Fig 2.

(A) Kaplan-Meier curve for continuation of hormonal therapy among 8,769 patients with stage I-III hormone receptor–positive breast cancer who initiated treatment at Kaiser Permanente of Northern California (KPNC), 1996 to 2006. (B) Kaplan-Meier curve for hormonal therapy adherence among 5,979 patients with stage I-III hormone receptor–positive breast cancer who continued adjuvant treatment at KPNC, 1996 to 2006. (*) 13% of patients never adhered.

Fig 3.

Patient age as a predictor of discontinuation and nonadherence to endocrine therapy among 8,769 women diagnosed with stage I-III hormone receptor–positive breast cancer who initiated adjuvant hormonal therapy at Kaiser Permanente of Northern California (KPNC), 1996 to 2006. (*) P < .05.

Fig A1.

Disposition of patients. KPNC, Kaiser Permanente of Northern California.