Prescribing of endocrine therapy after breast cancer diagnosis

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Prescribing of endocrine therapy after breast cancer diagnosis Gabrielle Emanuel, Katherine E Henson, John Broggio, Jackie Charman, Kieran Horgan, David Dodwell, Sarah

1 Prescribing of endocrine therapy after breast cancer diagnosis Gabrielle Emanuel, Katherine E Henson, John Broggio, Jackie Charman, Kieran Horgan, David Dodwell, Sarah C Darby National Cancer Registration and Analysis Service, Public Health England ENCR Scientific Meeting and General Assembly Copenhagen, Denmark, September 2018

2 Endocrine therapy (ET) in breast cancer Standard treatment for patients with oestrogen receptor positive (ER+ve) breast cancer Guidelines recommend prescribing for five years Aromatase inhibitors recommended for post-menopausal women Prescribing in primary care: Initiated in a hospital setting Repeat prescriptions issued in primary care Access to prescriptions data for the whole of England has been limited Aim: Test the application of the prescriptions data by evaluating the level of ET prescribing in women with breast cancer in England. 2

3 Prescriptions data April-July million individuals 332 million prescriptions Cancer registry data million patients Women with malignant breast cancer in England 1 st January 1995 and 31 st July 2015 No other cancers Alive during the reference period (April-July 2015) 369,280 patients Women with malignant breast cancer with a prescription for ET 137,792 patients (37%) 3

4 Drugs included Endocrine therapy drugs included: Anastrozole Letrozole Exemestane Tamoxifen Citrate Fulvestrant Aromatase inhibitors Toremifene Citrate Aminoglutethimide Goserelin Acetate Megestrol Acetate Medroxyprogesterone Acetate 4

5 Methods Endocrine therapy prescribing was analysed by: ER status: ER positive (ER+ve); ER negative (ER-ve); ER borderline; ER unknown Time since diagnosis Age: Calculated as of April 2015 (due to missing data) Co-prescribed drugs For early stage breast cancer patients diagnosed after July 2010 Co-prescribed defined as therapies prescribed within the same four months (April-July 2015). 5

6 The cohort 369,280 women with breast cancer diagnosed during the years % were prescribed ET during the reference period of April-July 2015: 69% ER+ve 42% ER borderline 23% ER unknown 5% ER-ve o 25% ER-ve and progesterone receptor positive o Data quality issue in the cancer registry o Data quality issue in the prescriptions data The highest proportion of prescriptions was for tamoxifen (34%) and aromatase inhibitors (64%). 6

7 ET prescriptions by ER status and time since diagnosis 100% Percentage of patients prescribed endocrine therapy 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% <5 years 5-9 years years 15+ years Time since diagnosis (years) E ars ER +ve ER borderline ER -ve ER unknown 7

8 ET prescriptions by time since diagnosis ER+ve patients 100% Percentage of patients prescribed endocrine therapy 90% 80% 70% 60% 50% 40% 30% 20% 10% 59% 90% 88% 87% 85% 71% 42% 27% 16% 12% 10% 8% 7% 7% 8% 8% 11% 13% 16% 24% 0% Time since diagnosis (years) 8

9 Tamoxifen prescriptions by age ER+ve patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentage of patients prescribed endocrine therapy 90+ Age on 1st April 2015 (years)

10 Aromatase inhibitor prescriptions by age ER+ve patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentage of patients prescribed endocrine therapy 90+ Age on 1st April 2015 (years)

11 Co-prescribed drugs - In early stage ER+ve women diagnosed between 2010 and 2015 Co-prescribed with aromatase inhibitors Oral bisphosphonates 22% of patients Co-prescribed with ET Analgesics (opioid and non-opioid) 27% of patients Statins 24% of patients Aspirin 9% of patients Oral hypoglycaemics 7% of patients Anticoagulents 4% of patients 11

12 Conclusions 1) Guidelines recommend ET be prescribed for five years and in accordance to a woman s menopausal status. 90% received ET prescriptions during the second year after diagnosis. Prescribing dropped more than five years after diagnosis. The majority of younger women (under 55) received tamoxifen. The majority of older women (55+) received aromatase inhibitors. Oral bisphosphonates and analgesics were co-prescribed as a result of side effects associated with cancer treatment. 12

13 Conclusions 2) Before the linkage, ET prescribing in women with breast cancer in England could not be reliably captured for the entire population. Prescribing was as expected from clinical practice. This study provides confidence in the use of the prescriptions data for epidemiological purposes. Prescriptions data can be used to study long-term cancer therapies which are not hospital based. 13

14 Acknowledgements This work uses data provided by patients and collected by the NHS as part of their care and support. Key contributors Dr Katherine Henson John Broggio Jackie Charman Dr. Kieran Horgan Prof. David Dodwell Prof. Sarah C Darby Special Thanks NHS Business Services Authority Public Health England 14

Medicines Management Group

Medicines Management Group SHARED CARE PROTOCOL for FULVESTRANT (FASLODEX ) INJECTION Scope Fulvestrant may be considered for shared care arrangements for the treatment of metastatic breast cancer for disease relapse. Unique Identifier