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      Are breast cancer patients with suboptimal adherence to cardiovascular treatment more likely to discontinue adjuvant endocrine therapy? Competing risk survival analysis in a nationwide cohort of postmenopausal women


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          High rates of discontinuation undermine the effectiveness of adjuvant endocrine therapy (AET) among hormone-receptive breast cancer patients. Patient prognosis also relies on the successful management of cardiovascular risk, which affects a high proportion of postmenopausal women. As with AET, adherence with cardiovascular drugs is suboptimal. We examined whether patient adherence with cardiovascular drugs was associated with the rate of AET discontinuation in a French nationwide claims database linked with hospitalisation data.


          We identified postmenopausal women starting AET between 01/01/2016 and 31/12/2020 and taking at least two drugs for the primary prevention of cardiovascular disease (antihypertensive drugs, lipid-lowering drugs and platelet aggregation inhibitors) before AET initiation. Adherence was assessed for each drug class by computing the proportion of days covered. Women were categorised as fully adherent, partially adherent or fully non-adherent with their cardiovascular drug regimen based on whether they adhered with all, part or none of their drugs. AET discontinuation was defined as a 90-day gap in AET availability. Time to AET discontinuation according to levels of cardiovascular drug adherence was estimated using cumulative incidence curves, accounting for the competing risks of death and cancer recurrence. Multivariate cause-specific Cox regressions and Fine-and-Gray regressions were used to assess the relative hazards of AET discontinuation.


          In total, 32,075 women fit the inclusion criteria. Women who were fully adherent with their cardiovascular drugs had the lowest cumulative incidence of AET discontinuation at any point over the 5-year follow-up period. At 5 years, 40.2% of fully non-adherent women had discontinued AET compared with 33.5% of partially adherent women and 28.8% of fully adherent women. Both partial adherence and full non-adherence with cardiovascular drugs were predictors of AET discontinuation in the two models (cause-specific hazard ratios 1.16 [95% CI 1.10–1.22] and 1.49 [95% CI 1.39–1.58]; subdistribution hazard ratios 1.15 [95% CI 1.10–1.21] and 1.47 [95% CI 1.38–1.57]).


          Clinicians should be aware that patients who do not adhere with their entire cardiovascular drug regimen are also more likely to discontinue AET. This stresses the importance of integrated care, as suboptimal adherence with both treatment components poses a threat to achieving ideal patient outcomes.

          Supplementary Information

          The online version contains supplementary material available at 10.1186/s12916-023-03156-3.

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          Most cited references46

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          A Proportional Hazards Model for the Subdistribution of a Competing Risk

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            Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials

            The Lancet, 365(9472), 1687-1717
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              Introduction to the Analysis of Survival Data in the Presence of Competing Risks

              Supplemental Digital Content is available in the text.

                Author and article information

                BMC Med
                BMC Med
                BMC Medicine
                BioMed Central (London )
                24 November 2023
                24 November 2023
                : 21
                : 463
                [1 ]Centre for Research in Epidemiology and Population Health (Inserm U1018), ( https://ror.org/01ed4t417) Villejuif, France
                [2 ]GRID grid.463845.8, ISNI 0000 0004 0638 6872, Paris-Saclay University, UVSQ, Inserm, CESP, ; Villejuif, France
                [3 ]Department of Gynecology and Obstetrics, Kremlin-Bicêtre Hospital, ( https://ror.org/05c9p1x46) Le Kremlin-Bicêtre, France
                [4 ]GRID grid.36823.3c, ISNI 0000 0001 2185 090X, Direction of Strategy, Studies and Statistics, , French National Health Insurance (CNAM), ; Paris, France
                © The Author(s) 2023

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                : 11 May 2023
                : 6 November 2023
                Funded by: Fondation pour la Recherche Médicale (FRM)
                Award ID: ECO202106013772
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                Research Article
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                © BioMed Central Ltd., part of Springer Nature 2023

                multimorbidity,breast cancer,adjuvant endocrine therapy,cardiovascular risk,administrative claims data,adherence


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