A system-level approach can improve the uptake of preventive therapy among women at risk for breast cancer.


 

The National Comprehensive Cancer Network (NCCN) guidelines recommend that women with atypical hyperplasia (AH) and lobular carcinoma in situ (LCIS) receive a strong recommendation for preventive therapy from their provider as close to the time of diagnosis as possible in order to increase the acceptance of treatment and patient adherence. “Women with premalignant breast lesions (eg, LCIS/AH) are at high risk of developing an invasive breast cancer and preventive therapy given for 5 years can reduce the risk,” says Abenaa Brewster, MD. However, previous studies indicate that the low uptake of antiestrogen preventive therapy among women at high risk of developing breast cancer remains a challenge. To help better treat this patient population, a team of researchers implemented a performance improvement program designed to increase the application of preventive therapy among women with AH/LCIS.

 

Get With the Program

Dr. Brewster and colleagues conducted a study—published in Cancer Prevention Research—in which this performance improvement program was implemented from November 2015 to February 2017 for patients with a new (<6 months) or existing (≥6 months) diagnosis of AH/LCIS. The program consisted of an audit of eligible women who were recommended and prescribed preventive therapy and the provision of clinical performance feedback to providers. The baseline uptake of preventive therapy was estimated from patients enrolled in a high-risk breast cohort.

“The use of preventive therapy lowers the chances of developing breast cancer by 75% among women at high risk of developing breast cancer due to a diagnosis of certain premalignant breast lesions,” Dr. Brewster says. “Unfortunately, across clinics in the United States, only 25% to 30% of these women are receiving preventive therapy. It is important to increase the use of preventive therapy in order to decrease the number of women who will develop invasive breast cancer.”

According to the study, baseline uptake of preventive therapy was 44%. The program registered 408 patients with a new or existing diagnosis of AH/LCIS; mean age was 57, and 71% were non-Hispanic white. Among participants, 98% received a recommendation for preventive therapy. With the program, the overall rates for prescriptions of preventive therapy for women with a new or existing diagnosis were 82% (monthly range, 40% to 100%) and 48% (monthly range, 27% to 57%), respectively. Adherence rates at 6 months among patients with a new or existing diagnosis were 76% and 48%, respectively.

“Preventive therapy was well tolerated by the majority of women who were treated with several options, including tamoxifen, raloxifene, anastrozole, and exemestane,” Dr. Brewster adds. “For the majority of women with premalignant breast lesions, the benefits of treatment outweighed the risks. Therefore, we recommend that physicians discuss the common and rare side effects of treatment with their patients, but also emphasize the benefits of treatment. The recommendation can also be given by mid-level providers, as shown in this study, and doesn’t need to come directly from a physician.”

 

Some Declined Therapy

Dr. Brewster and colleagues found, however, that some patients declined preventive therapy, with wide variations by diagnosis status (Table). Reasons for declining preventive therapy included:

  1. I do not believe my risk of breast cancer is high (6.1% existing diagnosis, 25.0% new diagnosis).
  2. Very concerned about side effects (62.3%, 25.0%).
  3. Do not want to take medication daily for 5 years (23.5%, 12.5%).
  4. My provider did not strongly recommend the medication (2.0%, 25.0%).

“While the most frequent reason cited by patients for declining preventive therapy was the potential side-effects of treatment, patients should be made aware that the majority of women will not experience side effects, and that if side-effects do occur, they can be managed by their provider,” explains Dr. Brewster.

Dr. Brewster stresses that future research is needed to evaluate whether a similar strategy will be effective at other institutions. Future research should also be focused on evaluating whether the strategy will be effective at increasing the uptake of preventive therapy among high-risk women without premalignant breast lesions but who are also eligible for preventive therapy.

References

Brewster A, Thomas P, Brown P, et al. A System-Level Approach to Improve the Uptake of Antiestrogen Preventive Therapy among Women with Atypical Hyperplasia and Lobular Cancer In Situ. Cancer Prev Res. 2018;11(5):295-302.