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Public Health England. National Disease Registration.

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, 26-28 September 2018

Public Health England. National Disease Registration.

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.

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Endocrine therapy after breast cancer diagnosis

Public Health England. National Disease Registration. 3

Endocrine therapy after breast cancer diagnosis

Prescriptions data April-July 2015 29 million individuals 332 million prescriptions Cancer registry data 1995-2015 7 million patients Women with malignant breast cancer in England 1st January 1995 and 31st 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%)

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Drugs included

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Endocrine therapy after breast cancer diagnosis

Endocrine therapy drugs included:

• Anastrozole
• Letrozole
• Exemestane
• Tamoxifen Citrate
• Fulvestrant
• Toremifene Citrate
• Aminoglutethimide
• Goserelin Acetate
• Megestrol Acetate
• Medroxyprogesterone Acetate

Aromatase inhibitors

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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).

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Endocrine therapy after breast cancer diagnosis

Public Health England. National Disease Registration.

The cohort

• 369,280 women with breast cancer diagnosed during the years 1995-2015.
• 37% were prescribed ET during the reference period of April-July 2015:
• 69% ER+ve
• 42% ER borderline
• 23% ER unknown
• 5% ER-ve
• 25% ER-ve and progesterone receptor positive
• Data quality issue in the cancer registry
• Data quality issue in the prescriptions data
• The highest proportion of prescriptions was for tamoxifen (34%) and aromatase inhibitors (64%).

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Endocrine therapy after breast cancer diagnosis

Public Health England. National Disease Registration.

ET prescriptions by ER status and time since diagnosis

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <5 years 5-9 years 10-14 years 15+ years Percentage of patients prescribed endocrine therapy Time since diagnosis (years)

E

ears

ER unknown ER -ve ER borderline ER +ve

Public Health England. National Disease Registration.

ET prescriptions by time since diagnosis – ER+ve patients

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59% 90% 88% 87% 85% 71% 42% 27% 16% 12% 10% 8% 7% 7% 8% 8% 11% 13% 16% 24% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% ≤1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Percentage of patients prescribed endocrine therapy Time since diagnosis (years)

Public Health England. National Disease Registration.

Tamoxifen prescriptions by age – ER+ve patients

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 16-24 25-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Percentage of patients prescribed endocrine therapy Age on 1st April 2015 (years)

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Aromatase inhibitor prescriptions by age – ER+ve patients

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 16-24 25-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Percentage of patients prescribed endocrine therapy Age on 1st April 2015 (years)

Public Health England. National Disease Registration.

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

Co-prescribed drugs

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• In early stage ER+ve women diagnosed between 2010 and 2015

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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.

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Endocrine therapy after breast cancer diagnosis

Public Health England. National Disease Registration.

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.

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Endocrine therapy after breast cancer diagnosis

Public Health England. National Disease Registration.

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

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Endocrine therapy after breast cancer diagnosis