Adoption of adjuvant bisphosphonates for early breast cancer into standard clinical practice: Challenges and lessons learnt from comparison of the UK and Australian experience

Abstract

International guidelines recommend adjuvant bisphosphonates (BPs) for post-menopausal women with early breast cancer to reduce recurrence and mortality. However, globally, wide variation exists in their adoption. In the UK, adjuvant BPs were a recommendation in the breast cancer Clinical Reference Group service specification and were included as a priority for implementation by the national oncologists group UK Breast Cancer Group in November 2015, promoting national uptake, guidance and funding arrangements. In 2018, adjuvant BPs were recommended by the UKs National Institute for Health and Care Excellence. In Australia, adjuvant BPs are still 'off-label' and do not receive national reimbursement or endorsement. To date there has been no research into the prescribing habits of these agents in Australia. With the aim to gather data on adjuvant BPs prescribing practices, online surveys were developed and disseminated to breast oncologists in both countries between December 2018 and June 2019. Almost all of the UK oncologists prescribed adjuvant BPs, demonstrating that education, endorsement from professional bodies, presence of national guidelines and funding decisions have been critical to implementation. In contrast, only 48% of the Australian responders prescribed adjuvant BPs, while 83% reported that they would prescribe them if funding was available. Lack of local protocol guidance was also seen as a major barrier. This study was intended to assess the pathway taken for adjuvant BP implementation in the UK and how it might inform changes in Australian practice and also guide other countries with similar issues with the ultimate aim of improving the care of women with early breast cancer globally.

Keywords: Adjuvant; Bisphosphonates; Breast cancer; Post-menopausal; Survival.

Fig. 1

Awareness of BMAs published guidelines amongst UK and Australian clinicians (multiple choice question).

Fig. 2

Historical data for the use of adjuvant BMAs in EBC in the UK and Australia.

Fig. 3

Hospital usage by doses of the zoledronic acid used in adjuvant BC in England (2017–2020).

Fig. 4

Barriers to BMAs prescribing for Australian clinicians (multiple choice question).

Fig. 5

Patient selection for adjuvant BMAs in the UK and Australia (multiple choice question).

Fig. 6

BMD assessments prior to initiation of BMAs for prevention of disease recurrence.