Background
Methods
Information sources and search strategy
Eligibility criteria and selection of studies
Data extraction and risk of bias assessment
Data synthesis and analysis
- The overall breast cancer care: the whole healthcare process from diagnosis to follow-up
- The overall treatment process: primary and adjuvant therapy (if applicable) including surgery, CT, ET, and RT. Follow-up procedures not included.
- Systemic therapy: comprising both CT and ET
- Pre-treatment procedures/diagnosis: staging and HER2 status assessment before the treatment process
- Surgical procedures: breast-conserving surgery (BCS), mastectomy (MA), sentinel lymph node biopsy (SLNB), axillary lymphonodectomy (ALND), or other surgery recommendations, either assessed separately or as a group.
- Therapies (assessed independently): CT and associated therapies (e.g. antiemetics); ET; Targeted anti-HER2 therapy; or RT
- Supportive measures during therapies: defined as any therapy aimed to prevent side effects for specific treatments
- Follow-up/monitoring: consultations or procedures after receiving treatment with monitoring purposes
- Primary prevention strategies: interventions to promote early diagnosis of breast cancer in asymptomatic patients.
Results
Study selection
Study characteristics
Characteristics | n | % | References |
---|---|---|---|
Country | |||
The Netherlands | 13 | 31.7 | |
Italy | 8 | 19.5 | |
Germany1 | 6 | 14.6 | |
France1 | 6 | 14.6 | |
UK | 4 | 9.8 | |
Denmark | 2 | 4.9 | |
Croatia | 1 | 2.4 | [37] |
Belgium | 1 | 2.4 | [74] |
Study design | |||
Retrospective cohort1 | 19 | 46.3 | |
Cross-sectional | 13 | 31.7 | |
Non-controlled before-after | 5 | 12.2 | |
Prospective cohort1 | 2 | 4.9 | |
Case study1 | 1 | 2.4 | |
Other (qualitative) | 1 | 2.4 | [56] |
Publication yeara | |||
1999–2008 | 12 | 21.1 | |
2009–2011 | 13 | 22.8 | |
2012–2014 | 11 | 19.3 | |
2015–2017 | 16 | 28.1 | |
2018–2019 | 5 | 8.8 | |
Guideline scopeb | |||
Treatment1 | 31 | 75.6 | |
Follow-up | 4 | 9.8 | |
Preventive measures | 4 | 9.8 | |
Diagnosis | 4 | 9.8 | |
Risk of biasc | |||
Low | 25 | 62.5 | |
Moderate | 14 | 35.0 | |
High | 1 | 2.5 | [64] |
Risk of bias
Adherence to breast cancer CGs recommendations for healthcare processes
Study1 | Guideline | Overall care* or overall treatment | ST | Pre-treatment/diagnosis | Surgical procedures | CT | ET | RT | Anti HER2 | Supportive measures | Follow -up |
---|---|---|---|---|---|---|---|---|---|---|---|
Andreano 2017 [57] | ESMO 2015 | 69%* | 76% | 81% | 97% | – | – | RT after BCS 84% | – | – | 84% |
Balasubramanian 2003 [71] | North Trent breast cancer group guidelines for treatment and referral (1998) | 82% | – | – | 90% | – | 74% | – | – | – | |
Barni 2011 [58] | Italian Association of Medical Oncology (AIOM) | 64%*–71% | 93% | BCS 74%; ALND 68%; SLNB 57% | 100% | 90% | 92% | – | 0% | ||
Boskovic 2017 [74] | Bone health guidelines | – | – | – | – | – | – | – | 32–75% | – | |
BRENDA I Ebner 2015 [67] | German National Step 3 (S3) (younger vs older) | 67% vs 47% | – | 86.3% vs 88.3% | 88% vs 68% | 91% vs 87% | 95% vs 83% | – | – | – | |
BRENDA I Ebner 2015a [20] | German National Step 3 | 61% | – | – | 91% | 74% | 75% | 83% | – | – | – |
BRENDA I Hancke 2010 [21] | German National Step 3 | – | – | BCS: 87%; MT: 52% | Recommended: 56%; not recommended: 95% | Recommended: 88%; not recommended: 92% | Recommended: 86%; not recommended: 88% | – | – | – | |
BRENDA I Schwentner 2012a [12] | German National Step 3 | 33% vs 57% overall: 54% | – | – | BCS: 86% | 74% | – | 84% | – | – | – |
BRENDA I Schwentner 2012b [22] | German National Step 3 | BBC 15% | – | – | – | – | – | – | – | – | – |
BRENDA I Schwentner 2013 [68] | German National Step 3 | – | TNBC: 44%; non-TNBC: 70% | – | TNBC 86%; non-TNBC 87% | TNBC 53%; non-TNBC 87% | – | TNBC: 90%; non-TNBC 92% | – | – | – |
BRENDA I Van Ewijk 2015 [23] | German National Step 3 | – | 59% | – | 87.6% | 78% | 91% | 91% | – | – | – |
BRENDA I Varga 2010 [24] | German National Step 3 | – | 54% | – | 87% | 80% | 81% | 87% | – | – | – |
BRENDA I Wöckel 2010 [25] | German National Step 3 2004 | 52% | – | – | BCS: 85% MT: 85% | 71% | 85% | 84% | – | – | – |
BRENDA I Wöckel 2014 [26] | German National Step 3 | – | – | – | – | – | – | 87% | – | – | – |
BRENDA I Wökel 2010a [13] | German National Step 3 | 48% | – | – | – | – | – | – | – | – | – |
BRENDA I Wollschlager 2017 [27] | German National Step 3 | – | Charlson 0: 68% Charlson 1–2: 66% Charlson ≥ 3: 58% | – | – | – | – | – | – | – | – |
BRENDA I Wolters 2015 [28] | German National Step 3 | 53% | – | – | – | – | – | – | – | – | |
BRENDA II Stuber 2017 [31] | German National Step 3 | – | – | – | – | – | 92% | – | – | – | – |
BRENDA II Leinert 2019 [29] | German National Step 3 | – | – | – | – | High risk: 90%; low risk: 100% | – | – | – | – | – |
BRENDA II Schwentner 2016 [30] | German National Step 3 | – | – | – | – | 85% | – | – | – | – | |
Bucchi 2009 [66] | 1995, 1998, 2001 Gallen International Conferences guidelines | 53% | – | – | – | – | – | – | – | – | |
de Munck 2011 [40] | NABON (National Breast Cancer Organization of The Netherlands) | – | – | – | – | – | – | 94% | – | – | |
de Roos 2005 [41] | CCN guidelines | 69% | – | – | – | – | – | – | – | – | – |
DURTO 2003 [38] | St Gallen International Consensus Panel | – | – | – | – | – | 96% | – | |||
Heins 2017 [43] | Dutch National Cancer Treatment guidelines for breast cancer | – | – | – | – | 90–99% | 90–95% | – | – | – | – |
Holm-Rasmussen 2017 [72] | Danish Breast Cancer Group guideline | – | – | – | SLNB 76% | – | – | – | – | – | – |
Jacke 2015 [59] | S1-guidelines (1996–1997) vs S3-guidelines (2003–2004) | 15% vs 34% | – | – | ALND 81% vs 81% | 75% vs 93% | 70% vs 84% | BCS + RT: 29% vs 53% | – | – | – |
Jensen 2018 [73] | Danish Breast Cancer Group guidelines | – | – | 99% | 95% | 97% | 96% | 80–97% | – | – | – |
Kuijer 2017 [44] | Dutch AST guidelines: 2005–2008, 2008–2012 and 2012–2014 | – | – | – | – | 78% | 88% | – | – | – | – |
Lebeau 2011 [63] | French National CPGs | 12–29% | – | – | 65% | 73% | 88% | 48% | – | – | – |
Liebrich 2011 [64] | 2006 AGO-S3 German Cancer Society | – | – | – | – | – | – | – | 77% | – | – |
Mille 2000 [69] | Centre Regional Leon Bernard (CRLB) guideline (1993 vs 1995) | – | – | – | – | – | – | – | – | – | First–year 16% vs 74% |
Mylvaganam 2018 [54] | British best practice guidelines for implant-based breast reconstruction 2015 | – | – | – | 17–50% | – | – | – | – | 19–100% | – |
Natoli 2014 [55] | National and International Oncology societies | – | – | – | – | – | – | – | – | – | 10% |
OncoDoc2 | Cancer Est CPGs | 91% | – | – | – | – | – | – | – | – | – |
Ottevanger 2004 [60] | CCCE National guideline (1988 vs 1996) | – | – | – | BCS 39% vs 35%; MT: 56% vs 54% | 91% vs 88% | – | 75% vs 93% | – | – | – |
Poncet 2009 [51] | French National guidelines and regional CGs | – | – | – | – | – | – | – | National 31%–Regional 83% | – | – |
Ray-Coquard 1997 [35] | Guideline in 1993 (1993 vs 1995) | 19% vs 54%* | – | 75% vs 86% | 96% vs 92% | 71% vs 85% | 72% vs 94% | 83% vs 93% | – | – | 31% vs 80% |
Ray-Coquard 2012 [70] | French and international guidelines to manage CT-induced anaemia | – | – | – | – | 95% | – | – | – | – | – |
Roila 2003 [39] | St Gallen International Consensus Panel | – | – | – | – | 60% | 81% | – | – | – | – |
Sacerdote 2013 [61] | Piedmont guidelines (2002 vs 2004) | – | – | – | BCS 86% vs 93% | 66% vs 64% | 94% vs 94% | 88% vs. 88% | – | – | – |
Schaapveld 2004 [46] | Regional treatment CCCN Guidelines | – | – | – | – | 89% | – | – | – | – | – |
Schaapveld 2005 [45] | CCCN Guidelines | – | – | – | BCS: 95%; MRM: 90.6% | – | – | – | – | – | – |
Schrodi 2015 [62] | German National Step 3 (1999 vs 2010) | – | – | – | BCS 72%; SLNB: 0.2% vs 51% | – | – | – | – | – | – |
van de Water 2012 [48] | Dutch AST guidelines: 2005–2008, 2008–2012 and 2012–2014 | < 65 years: 62% ≥ 75 years: 56% | – | – | – | – | – | – | – | – | – |
Van Ryckeghem 2019 [37] | European Organisation for Research and Treatment of Cancer guidelines (EORTC 2010) | – | – | – | – | – | – | – | – | 75% | – |
Vercauteren 2010 [65] | Dutch national CGs for breast cancer screening and diagnosis, American College of Radiology CGs | – | – | Adding US: 94%; not additional: 83% | – | – | – | – | – | – | – |
Visser 2016 [49] | HERA (Herceptin adjuvant study) | – | – | – | – | – | – | – | – | 63% | – |
Weggelaar 2011 [50] | CCN guidelines | – | 77% | – | – | 90% | 76% | 91% | – | – | – |
Wimmer 2019 [36] | German National Step 3 (2017) | – | – | – | – | – | – | 97% | – | – |
Overall breast cancer care
Overall treatment process
Adherence to breast cancer CGs—procedures or therapies (assessed separately)
Pre-treatment procedures
Surgical procedures
Chemotherapy
Endocrine therapy
Targeted anti-HER2 therapy
Radiotherapy
Supportive measures during therapies
Follow-up
Primary prevention strategies
Barriers for healthcare providers’ adherence to breast cancer CGs
Factor | Main findings |
---|---|
Internal factor | |
Practitioners' perceptions and preferences | ∙ Clinicians were poorly informed about preventive therapy or perceived lack of benefit of preventive therapy and experienced difficulties interpreting guidelines [56] ∙ The considerable variation in BCS rates is more consistent with variations in surgeon preferences than the patient’s choice [45] ∙ Intentional and conscious healthcare providers’ decisions [34] |
External factor—patient-related factors | |
Patient’s age | ∙ Treatment adherence was significantly lower for surgery, RT, and systemic therapy in women aged 80 years and older, and all modalities were applied much less frequently, except for endocrine therapy which was more frequently applied in the oldest [50] ∙ Non-compliance with clinical decisions for treatment was associated with older patient age [63] ∙ Deviations from the initial therapy decision were more frequent in older patients (≥ 75 years) than in younger ones [30] ∙ Adherence to treatment guidelines was affected by age at diagnosis [48] ∙ The effect of non-adherence was stronger in the oldest [20] ∙ Non-adherence on RT and CT increased with age [21] ∙ Adherence was markedly lower for elderly patients; either ALND or RT was omitted [45] ∙ Guideline adherence was significantly lower in TNBC, most pronounced in the > 65 years subgroup [68] ∙ Tumour board decision against ET was associated with the younger age of patients [31] ∙ The use of SLNB was significantly higher in younger patients (< 40 years) [72] |
Comorbidities | ∙ Non-guideline-adherent treatment was associated with comorbidities [20], Charlson index [27] “particular cases” [32] ∙ Most common reasons to withhold trastuzumab were cardiovascular disease [40] ∙ Variation was in part but not entirely attributable to comorbidities [64] ∙ Tumour board recommendation against CT was significantly more frequent in patients with cognitive impairment [29] |
Tumour stage/tumour characteristics | ∙ Non-guideline-adherent treatment was associated with higher tumour stages [20] ∙ Non-compliance on RT was associated with lymph node involvement or peritumoral vascular invasion. Within the overall treatment sequence, it was associated with positive lymph nodes, and grade III versus grade I [63] ∙ Non-compliance was associated with a micro-invasive tumour in re-excision decisions, and with HR + and Her2+ in adjuvant decisions [33, 34] ∙ Compliance with SLNB with BCS was significantly higher in patients with tumour size ≥ 50 mm, Van Nuys classification group III, palpable lesion, and upper lateral quadrant of the breast location [72] |
Gene expression profile | ∙ The use of gene expression profiles (GEP) was independently associated with an increased risk of receiving CT in clinical low-risk patients and with a lower risk of CT administration in high-risk patients [47]. Adherence to the GEP result was higher in high-risk patients with a discordant GEP result compared to low-risk patients with a discordant GEP result [47] |
Quality of life (QoL) | |
Previous treatment | ∙ Women who received RT had excessive follow-up consultations compared to did not receive it [42] ∙ Non-adherence was associated with the absence of prior axillary surgery in adjuvant decisions [33] ∙ In high-risk febrile neutropenia category, adherence to primary prophylaxis with granulocyte colony-stimulating factors (PPG) was more common among patients receiving dose-dense therapy than those receiving the classical chemotherapy [37] |
Socioeconomic status | ∙ Low socioeconomic status (SES) patients were more likely to be undertreated with CT than high SES patients, however no association with ET. For ethnicity, no association with CT or ET was observed [44] |
External factor—structural and Organisation factors | |
Geographic region and academic status | ∙ Non-compliant decisions were mainly “choices of multidisciplinary staff meetings” [34] ∙ More adherence in research centres, in Northern Italy [38], and in one region of care versus another [63] ∙ The use of SLNB in patients who underwent BCS was significantly higher in low-volume departments. While for women who underwent a mastectomy, SLNB was higher in high-volume departments [72] |