Women commencing anastrozole, letrozole or tamoxifen for early breast cancer: The impact of comorbidity and demographics on initial choice
Kemp, A., Preen, D. B., Saunders, C., Boyle, F., Bulsara, M., Holman, C. J., Malacova, E., & Roughead, E. E. (2014). Women commencing anastrozole, letrozole or tamoxifen for early breast cancer: The impact of comorbidity and demographics on initial choice. PLOS ONE, 9 (1), e84835.
Background: Australian clinical guidelines recommend endocrine therapy for all women with hormone-dependent early breast cancer. Guidelines specify tamoxifen as first-line therapy for pre-menopausal women, and tamoxifen or an aromatase inhibitor (AI) for post-menopausal women depending on the risk of recurrence based on tumour characteristics including size. Therapies have different side effect profiles; therefore comorbidity may also influence choice. We examined comorbidity, and the clinical and demographic characteristics of women commencing different therapies.
Patients and Methods: We identified the first dispensing of tamoxifen, anastrozole or letrozole for women diagnosed with invasive breast cancer in the 45 and Up Study from 2004–2009 (N=1266). Unit-level pharmacy and medical service claims, hospital, Cancer Registry, and self-reported data were linked to determine menopause status at diagnosis, tumour size, age, comorbidities, and change in subsidy restrictions. Chi-square tests and generalised regression models were used to compare the characteristics of women commencing different therapies.
Results: Most pre-menopausal women commenced therapy with tamoxifen (91%). Anastrozole was the predominant therapy for post-menopausal women (57%), followed by tamoxifen (28%). Women with osteoporosis were less likely to commence anastrozole compared with tamoxifen (anastrozole RR = 0.7, 95% CI = 0.5–0.9). Women with arthritis were 1.6- times more likely to commence letrozole than anastrozole (95% CI = 1.1–2.1). Tamoxifen was more often initiated in women with tumours .1 cm, who were also $75 years. Subsidy restriction changes were associated with substantial increases in the proportion of women commencing AIs (anastrozole RR = 4.3, letrozole RR = 8.3).
Conclusions: The findings indicate interplay of comorbidity and therapy choice for women with invasive breast cancer. Most post-menopausal women commenced therapy with anastrozole; however, letrozole and tamoxifen were more often
initiated for women with comorbid arthritis and osteoporosis, respectively. Tamoxifen was also more common for women with tumours .1 cm and aged $75 years. Subsidy restrictions appear to have strongly influenced therapy choice.
breast cancer, endocrine therapy, anastrozole, letrozole, tamoxifen