Early discontinuation of endocrine therapy for breast cancer: Who is at risk in clinical practice?

Purpose: Despite evidence supporting at least five years of endocrine therapy for early breast cancer, many women discontinue therapy early. We investigated the impact of initial therapy type and specific comorbidities on discontinuation of endocrine therapy in clinical practice. Methods We identified women in a population-based cohort with a diagnosis of early breast cancer and an incident dispensing of anastrozole, letrozole or tamoxifen from 2003-2008 (N = 1531). Pharmacy and health service data were used to determine therapy duration, treatment for pre-existing and post-initiation comorbidities (anxiety, depression, hot flashes, musculoskeletal pain, osteoporosis, vaginal atrophy), demographic and other clinical characteristics. Time to discontinuation of initial, and any, endocrine therapy was calculated. Cox regression determined the association of different characteristics on early discontinuation. Results Initial endocrine therapy continued for a median of 2.2 years and any endocrine therapy for 4.8 years. Cumulative probability of discontinuing any therapy was 17% after one year and 58% by five years. Initial tamoxifen, pre-existing musculoskeletal pain and newly-treated anxiety predicted shorter initial therapy but not discontinuation of any therapy. Early discontinuation of any therapy was associated with newly-treated hot flashes (HR = 2.1, 95%CI = 1.3-3.3), not undergoing chemotherapy (HR = 1.4, 95%CI = 1.1-1.8) and not undergoing mastectomy (HR = 1.5, 95%CI = 1.2-1.8). Conclusions Less than half of women completed five years of endocrine therapy. Women at greatest risk of stopping any therapy early were those with newly-treated hot flashes, no initial chemotherapy, or no initial mastectomy. This suboptimal use means that the reductions in recurrence demonstrated in clinical trials may not be realised in practice

Financial literacy education: Toward reasonable, just, and sustainable practices

Improving financial literacy is a global concern. Many countries have established initiatives and strategies to help citizens acquire the financial skills and capabilities that are deemed necessary to ensure effective management of personal finances over a lifetime (OECD 2012, 2013). However, most definitions of financial literacy imply that once financial skills and knowledge are acquired, an individual will be motivated to make effective financial decisions that lead to financial well-being, but such alignment does not follow as a matter of course because it does not consider the life experiences of marginalised and vulnerable populations. For example, Indigenous people were displaced and dispossessed from their lands during colonization, and this dispossession continues to have an impact on the economic participation of many Indigenous people who are living on low-incomes and/or in poverty. Distinguished Professor Moreton-Robinson (2015) argues that “Indigenous people have never been recognized as property-owning subjects in our own right as Indigenous peoples, and this continues in current law and policy” (p 94). Owning property and passing property ownership on through inheritance is how intergenerational wealth is maintained and preserved with “.deeper wealth divisions in the longer term between those who own houses and those who do not” (Munro 1988 p 435). The United Nations report that there are 370 million Indigenous people worldwide (5% of the total population) and that Indigenous people represent 15% of the world’s poor and one-third of the world’s extremely poor (United Nations nd). Although this chapter only focuses on developed countries, Indigenous people in developed countries continue to lag behind on almost all indicators of well-being including: life expectancy, health, educational outcomes and employment (United Nations nd). In this chapter the trend to educate some of the most vulnerable individuals in society with generic financial literacy education is examined. Generic and/or one-size-fits-all financial literacy education targeted at individuals living on low incomes developed by financial institutions (or organisations funded by these institutions) is commonplace in training offered and targeted at the adult population. This chapter is guided by answering the research question how might financial literacy education practices be more reasonable, just and sustainable? The aim of this chapter to articulate how financial literacy education practices can be conceived as a more meaningful process so as to be rationale and reasonable, productive and sustainable, and just and inclusive