Eraso International Journal for Equity in Health (2019) 18:35

https://doi.org/10.1186/s12939-019-0936-z

R ES EARCH Open
Access

Factors influencing oncologists’

prescribing hormonal therapy in women
with breast cancer: a qualitative study in
Córdoba, Argentina
Yolanda Eraso

Abstract
Background: Hormonal therapy is an integral component for breast cancer treatment in women with oestrogen
receptor positive tumours in early-stage and advanced cases of the disease. Little is known about what factors
influence oncologists’ prescribing practices, especially non-biological factors, although this information may have
important implications for understanding inequalities in health care quality and outcomes. This paper presents
findings from research on factors influencing oncologists’ prescribing hormonal therapy for women with early and
advanced cases of breast cancer in the city of Córdoba, Argentina.
Methods: A qualitative study using in-depth, semi-structured interviews with 16 oncologists was conducted. A
stratified purposive sampling was used to recruit female and male participants and working at 3 health subsystems
(private, social security, public). Data was analysed using the Framework approach.
Results: According to the respondents, factors influencing prescribing practices of hormonal therapy are varied.
Women’s socio-economic status (poverty and wealth) and their level of health literacy can affect oncologists’
prescribing practices. Overall, in comparison to male, female oncologists reported more awareness of patients’
needs, more involvement in communicating drug side-effects, and in offering treatment options in private health
settings. The 3 health subsystems provided a differential access to drugs and lines of hormonal treatment, which
ranged from a limited availability in the public sector, to administrative restrictions imposed by the social security
system, and to a lesser extent, the private sector. This happened in the backdrop of national legislation covering
oncological treatments and drugs free of charge.
Conclusions: Addressing prescribing practices for hormonal therapy as a distinct type of breast cancer treatment
(chronic care) is fundamental in the understanding of breast cancer care and can shed light on inequalities in
treatments. Identifying the underlying care gaps in the prescription of hormonal therapy can help in the design of
tailored interventions.
Keywords: Breast cancer, Hormonal therapy, Oncologists’ prescribing, Health system provider, Gender, Inequalities

Correspondence: y.eraso@londonmet.ac.uk
School of Social Professions, London Metropolitan University, 166-220
Holloway Road, London N7 8DB, UK

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommon s.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Eraso International Journal for Equity in Health (2019) 18:35 Page 2 of 13
Eraso International Journal for Equity in Health (2019) 18:35 Page 3 of 13
B Tamoxifen (TAM) Socio-demographic data province, concluded that
a reduces the risk of for the province of Cór- urbanisation was
c recurrence by about a doba indicates that the inversely as- sociated to
k half and mortality by population group most BC incidence, whereas
g about 30%, and affected by BC (65+) is deprivation (measured as
r Aromatase Inhibi- tors 23.4% of the population index of unmet basic
o (AI) reduce recurrence in 2016, and fe- male life needs per households)
u by about two-thirds and expectancy, according to showed a direct
n mor- tality rate by around the last census (2010), is relationship [13]. Other
d 40%, during 10 years 79.2 years, in both cases indicators associated to
Breast cancer (BC) is the after initiation of showing higher values BC such as a good
most common cancer in treatment [5, 6]. than that for Argentina supply of health services
women worldwide. In Argentina, BC is the [12]. Also, an 8.7% of in the cap- ital (see Study
According to WHO, the cancer with the highest the population of setting below) that has
burden of BC is in- incidence considering Córdoba has unmet traditionally served the
creasing in less both sexes, followed by basic needs (lower than demand of nearby
developed countries colorectum and pros- tate national level at 12,5%), provinces, two University
where mortality rates are cancer. According to and 1.3% of women teaching hospitals with
higher due to late GLOBOCAN (2018) [7] are classified as illiterate specialisation in
diagnosis and lack of the (ASR) incidence is (lower than national oncology, together with
treatment facilities [1]. In 73, and (ASR) mortality average) [12]. However, an ageing female
Argentina, approximately is 18 cases × a recent ecology study population and a higher
30–40% of BCs are 100.000. Although on sociodemographic than average BC
diagnosed at advanced mortality rates for BC in determinants associated mortality rate make
stages of the disease Argentina have followed a to the spatial Córdoba a relevant
(stages III and IV) [2], decreasing trend since distribution of BC in case to explore. Scholars
and the survival rate of 1997 [8] (p.31), it still oc- the have long emphasised
BC is 68.2%, below the cupies the second highest the fragmented nature
85% considered an in South America after of the Argentinian
international benchmark Uruguay. health system, which
[3]. In addition, In the province of com- prises three main
inequalities in diagnosis Córdoba, the second subsystems (public,
are observed within the most popu- lated private, and social
different health province with 3.308.876 security) with scarce
subsystems whereby, inhabitants in the last synergy amongst them.
according to RITA cen- sus (2010) [9], BC Deficiencies in cancer
hospital database, private has an (ASR) incidence control have been
centres detect most cases of 65.8 and mortality of observed not only in
at clin- ical stages 0, I and 21.4 × 100.000, whereas terms of providers and
II, whilst public hospitals in the capital city both resource management
do so at stages III and IV rates are higher 77.1 and [14–16], but also in
[4] (p.36). 23.7 respectively [10]. terms of the lack of a
Treatment Ac- cording to National Cancer
developments in the last epidemiological regional Programme [17, 18], and
decades, in particu- lar data collected by the inequalities in access to
hormonal therapy (HT) National Institute of diagnosis and treat-
for women with Cancer (2016), Córdoba ments [19–21]. The
oestrogen positive is located in the Centre health system in Córdoba
receptors, which Region - alongside is broadly organised as
accounts for ~ 70% of Buenos Aires, Entre follows: The majority of
all BC cases, has proven Ríos, Santa Fe and the the working-age
effective in reducing the city of Buenos Aires population has the
risk of recur- rence and (Federal capital) - a social security health
in extending survival region that has insurance sys- tem (Obra
from the disease: in post- concentrated a higher Social), each insurance
menopausal women, 5 BC mortality rate (18.1) plan being organised
years of the anti- than the national according to the
oestrogen drug average (17.4) [11]. occupation of the
 Eraso International Journal for Equity in Health (2019) 18:35 Page 4 of 13
beneficiary and are study based on a survey
administered by of oncologists
different workers prescribing adjuvant BC
unions. Within this treatment in 2008,
subsystem are also the concluded that there
provincial insurance were con- siderable
plans for civil servants, disparities between what
and a Comprehensive oncologists thought was
Medical Assistance an ideal treatment and
Program for retired what they actually
people (Programa de could prescribe to
Asistencia Médica patients due to different
Integral, PAMI). A restrictions. Re-
second group of high- vealingly, only 40%
income earners have were satisfied with the
private health hormonal treatment
insurance (Medicina given [24]. This raises
pre-paga) offered by questions about acces-
employers or contracted sibility to treatment in a
on an indi- vidual basis. context of, in principle,
Finally, the public sector univer- sal drug
subsystem, for un- coverage.
insured people, is
offered free of charge
and financed with
resources from the
provincial budget and
national funds for
specific health
programmes. According
to data from 2010, 69%
of women were insured
by the social se- curity
(49.73%), private health
(17.44%), or state plan
(1.83%); whilst a 31%
were uninsured [22].
Oncological
treatments and cancer
drugs approved by
national protocols are
covered free of charge
in Argentina through the
compulsory medical
programme (Programa
Médico Obligatorio -
PMO) [23], which ap-
plies to all health
insurers including the
public sector that
provides drugs
(approved by a
protocol) through
provincial health
ministries. Despite these
provisions to guarantee
free access to
oncological drugs, a
Eraso International Journal for Equity in Health (2019) 18:35 Page 5 of 13
Eraso International Journal for Equity in Health (2019) 18:35 Page 6 of 13
Inequalities related to practices, the challenges The study was offer the most
BC treatments outcomes they face and how they undertaken in the city of prestigious, state-of-the-
have been extensively overcome them. In Córdoba, capital of the art hospitals and clinics,
documented in the US addition, oncologists’ homonymous province, many of which are owned
and European countries, gender is a variable that where cancer treatment by the providers them-
where modifiable social has rarely been explored is provided by different selves. It is also worth
factors such as ethnicity, in terms of inter- actions specialised services emphasising that the
literacy, doctor-patient’s with patients and available through the patients assisted in each
communication, socio- decision-making three health subsystems. of these subsystems
economic status (SES), patterns, although it is These comprise the often move across
drug accessibility, and known from studies on follow- ing: 1) the services making the
health system provider physicians more broadly, institute of oncology boundaries between them
amongst others, have that female doctors tend (public sector) concen- not so de- marcated. On
been variously identified to deliver a more patient- trates services on the one hand, the public
as drivers for different centred style of clinical oncology and institution grants access
outcomes between communication [27]. radiotherapy for the to any person free of
affluent and disadvantaged Hence, to help fill this province, and provides charge, so a patient in the
groups [25]. gap in the literature, the oncological drugs to pri- vate/social insurance
Understanding how aim of this study was to patients there assisted sector can seek a second
these different factors explore the factors and by referral from opinion for their
interact in complex ways influencing oncolo- gists’ other provincial/uni- treatment in the public
is relevant to ensure an prescribing practices of versity hospitals. 2) sector or become a
equitable access to HT HT for women with oncology services service user when they
treatment, especially if early and advanced BC provided by 4 pri- vate have lost their jobs and
we consider that the in the city of Córdoba. hospitals and their insurance plans. On
benefits associated with The research questions approximately 14 clinics the other, a private clinic
HT imply a long-term the study explored were: with various levels of that predominantly re-
process, as recent 1) What biological and complexity that have ceives users from the
guidelines recommend a non-biological factors contracts with the social security system can
10-year course of therapy. influence oncologists different social security also offer services to a
The significance of the prescribing HT?; 2) and private health handful of private health
latter has led authors, How does the insurance plans. The dif- insurers. What is clearer,
such as Beryl and others oncologist’s gender ference between these is that uninsured patients
[26], to differentiate affect HT prescribing providers is that the only have access to the
patients’ decision- practices?; 3) How does latter tend to public health system. For
making process into the health system this study, the main
acute treatments provider affect public on- cology
(surgery, radiotherapy oncologists' prescribing institute, three private
and chemotherapy) and practices? clinics (mostly social
chronic care (HT), secur- ity), and three
because of the irre- M private hospitals (mostly
versible/reversable e private health) were
nature of the decision, t purposively selected to
and the passive/ active h encompass the three
role of treatment o health subsystems based
administration d on the list of oncology
respectively. Much of the s services available at the
quantitative and S provincial social security
qualitative research on t Web site [28] and
u
HT treat- ments have d through communication
focused on patients’ y with hospitals directors
perceptions and experi- and heads of oncology
ences in relation to s services (See Table 1).
adherence to treatments. e
t
Yet there is a dearth of S
t
analysis focusing on what t
i
u
factors influence oncol- n
d
ogists’ prescribing g
 Eraso International Journal for Equity in Health (2019) 18:35 Page 7 of 13
y Gender
Participants (n) Female
d 7
e
s Male
9
i
g Profession
n Participants (n) Clinical Oncologist
A qualitative study 13
design was developed to
Gynaecologic
obtain insight from Oncologist
oncologists who prescibe 2
HT in the city of Radiation
Córdoba. The study Oncologist
1
employed individual
No. Years Oncology practice
semi-structured in-depth Participants (n)
interviews to explore
0˗5
biological and non- 2
biological factors, 6˗10
structural factors (health 3
system) and personal 11˗20
character- istics (gender) 4
associated with HT 21˗30
decision-making and 4

prescribing practices as More than 30

3
perceived by oncologists
Health System Provider
them- selves. Adopting a
thematic analysis Participants (n) Public health
approach (Framework 6
Social Security
T (Obra social)
a 5
b Private health
l insurance (Pre-
e paga)
5
1

S
t
u
d
y

P
a
r
t
i
c
i
p
a
n
t
s

(
n

1
6
)
Eraso International Journal for Equity in Health (2019) 18:35 Page 8 of 13
Eraso International Journal for Equity in Health (2019) 18:35 Page 9 of 13
method) allowed for the total of 16 individ- ual and lasted between 37 years in BC practice: For
identification of these semi-structured in-depth and 101 min. women, the median
pre-se- lected themes as interviews were An interview question number of practising
well as emergent themes conducted with guide was developed years was 16.4 (range:
generated from the data. oncologists who prior to the recruitment 5–40); and for men
Moreover, a qualitative regularly prescribed HT process, which included 21.3 (range: 5–54). This
approach can offer depth to women in adjuvant a set of questions for reflects the late
and detail on the and metastatic stages of three different themes feminisation of the
experiences of BC disease. related to HT: oncology profession in
oncologists’ prescribing Participants were prescribing, adher- ence, the last 40 years.
practices that could elicit identified and recruited and novel hormonal Regarding the health
the development of through initial contact therapies. In this article, service provider,
only results on participants
complemen- tary with oncologists located
prescribing are worked at different
quantitative studies. at the 3 health subsystems
presented, and the settings (clinics,
(1 director of hospital, 2
D question guide is hospitals, and insti- tutes)
heads of services). All
a available in Additional corresponding to the 3
oncologists interviewed
t file 1. health subsystems. For
a
were asked to further
this study, the
identify other potential
S identification given to
c participants with
t each of the 3 subsystems
o personal contacts, to
u has followed, in the case
l whom the researcher
l d of private/social security,
contacted via telephone y
e the main type of
c and email. The sample
s population that the
t size was ini- tially
i a service assisted. Finally, it
planned for around 20
o m is also common for
participants and it p
n doctors in Argentina to
followed the concept of l
For data collection, a work at different insti-
‘information power’ [30] e
stratified purposeful tutions, and within this
whereby the nar- row Participants for this
sample was used to sample, a few oncologists
aim of the study, the study were 9 male and
obtain representatives of worked simultaneously in
specificity of the 7 female doctors, with
male/female oncologists two different subsystems
participants in- cluded specialisation in clinical
working at the different (one worked in the
and the theoretical oncology, radi- ation
health subsystems. private and public sector,
background (health oncology, and
Because this study and three did so at the
system and gender) would gynaecological oncology.
wanted to explore the social security and the
offer sufficient focus for All with experience in
perspectives of public sector). In this
the interviews. 18 prescribing HT, and with
oncologists in prescribing sense, the questions were
oncologists were a wide breath of
HT, social aspects such focused on their
approached and only 16
as gender, and health perceptions and working
participated (1 interested
service provider – here experience of the specific
but did not provide
used as a proxy to class setting where the
interview dates; 1
– were considered as interview took place.
non-respondent). All
relevant variables within After preliminary
interviews were
the sample. Ac- cording analysis of the data it
conducted in Spanish by
to Patton [29] (p. 240), was considered that
the author, who is a
‘the purpose of a sufficient information
native speaker, and is
stratified purposeful power regarding relevant
familiar with health
sample is to capture pat- terns of prescribing
studies research on BC
major variations rather practices was obtained
endocrine treatment and
than to identify a before complet- ing the
its use amongst eligible
common core, although 16 interviews.
patients. Interviews were
the latter may also Characteristics of the
digitally re- corded at
emerge in the analysis. sample are provided in
participants’ consulting
Each of the strata would Table 1.
rooms and hospital of-
con- stitute a fairly
fices during July 2016,
homogeneous sample.’ A
 Eraso International Journal for Equity in Health (2019) 18:35 Page 10 of
13
D patterns and associations
a during the map- ping and
t
interpretation process of
a
the similarities and dif-
a ferences in relation to
n gender and the health
a system provider.
l
Data interpretation is
y
s reported here by using
i relevant verbatim quotes
s to illustrate.
.
All interviews were Q
recorded with u
participants’ consent, and a
transcribed verbatim by l
i
a research assistant t
with experience in y
qualitative data
management. The a
author subsequently s
s
double checked the u
transcripts with the r
recordings and a
translated it into n
English. Framework c
e
analysis was used to
In order to increase
analyse the data where
the internal validity of
a combined approached
the data collected,
was adopted, first,
member checking was
through a deductive
systematically used during
process based on the
the interview and
literature that informed
through the presentation
the research questions
of a summary of the
and secondly, through
information collected to
and inductive process
each participant at the
based on par- ticipants’
end. This allowed the
accounts [31]. Data were
investigator to
analysed following the
paraphrase answers
five methodological steps
of the framework
analysis: famil- iarisation
with the data,
identification of a
thematic frame- work,
indexing, charting, and
mapping and
interpretation of themes
[32]. Data was entered
into a case chart for each
respondent were notes
and extracts of relevant
passages were included
for all identified themes
(see Additional file 2 for
an example of the case
chart used). This allowed
further identification of
Eraso International Journal for Equity in Health (2019) 18:35 Page 11 of
13
Eraso International Journal for Equity in Health (2019) 18:35
provided by each respondent, and to ensure
understanding and accuracy in the presentation of ideas.
To ensure reliability and confirmability of data
collected and analysed by a single researcher, the
process of index- ing (using textual codes) and
charting was conducted in two different stages. First,
indexing and charting was de- veloped by using the
Spanish transcript. After translation into English, a
second round of indexing and charting took place
fourth months after the first one. The recoding
(crosschecking) of the two versions enhanced the
process of refining themes and subthemes, and
ensured the elim- ination of ambiguity of terms and
lack of clarity, as well as the researcher’s subjectivity
and bias.
Results
Four core themes emerged from the analysis of the
inter- views: Biological and clinical factors; treatment
guidelines; patients’ socio-economic status; and the
health-care pro- vider (access to drugs). Several
subthemes are clustered under each core theme.
Biological and clinical factors
Tumour biology and age
The oncologists interviewed stated that the main
indicator for prescribing HT was the presence of
oestrogen receptors (ER+) alongside other markers such
as progesterone values, HER-2, and proliferation
marker Ki-67. These corre- sponded to the standard
assessment of predictive factors, with the exception of
multi-gene profiling assay, which due to costs, was not
readily available. Other indicators consid- ered were,
disease stage: HT is prescribed for primary (early)
stage, and locally advanced BC where treatment
aims to reduce the risk of recurrence and is
considered
‘curative and in advanced cases (metastasis) with
,’
low tumour volume, where the role of HT is to
extend years of life. They also referred to prognostic
factors such as nodal status, especially for indication of
chemotherapy in young women before initiation of
HT. Finally, the age of the patient (pre or post
menopause), and women < 35 year- s-old who were
considered as ‘higher risk’ patients. Oncolo- gists were
asked to describe in broad terms the indication of HT
for BC, and some described it this way:
With the immunohistochemistry report that
expresses the hormonal receptors, we have a
predictive factor of response. From there, we select
which will be the therapeutic tool of the hormonal
therapy directed to that disease: anti-oestrogens,
aromatase inhibitors. If pre-menopause, one
therapeutic strategy will be pro- vided for them,
which is Tamoxifen; for post- menopause it is
possible to offer Tamoxifen and Aro- matase
Page 12 of
13
comorbidities, both will direct the selection of the
therapeutics, the hormone therapy more
appropriated for each case (09, male, social
security).
Here [public hospital] we use the same as it is used
in the standard protocols whether national or
international. We use Tamoxifen as first line only as
long as receptors are positive in pre and
postmenopausal women. Then we will see in the
postmenopausal, depending on age, if we need to
use an Aromatase Inhibitor, such as Anastrazole or
Letrozole (02, female, public sector).
Whilst there were no relevant differences amongst
re- spondents in terms of the biological factors
considered for prescribing HT, most participants
remarked on the many biological considerations
involved.
It is difficult to resume in few words because
breast cancer is one of the largest chapters in
cancer treatment (01, female, social security).
You are asking a question that is too general, which
demands a more specific answer. All depends on
the type of cancer, the receptors, the age of
patients, […] if you say a woman with 80 years-old
with a conserv- ing surgery, has receptors highly
positive, it is a small tumour, early stage, or doesn’t
have risk factors, we
can go with conserving surgery, radiotherapy and
hor- mone therapy, yes, we can do [..] But if you
have posi- tive hormonal receptors with a HER-2++
+, is totally different (02, female, public sector).
Inhibitors which is not possible to give in pre-
menopausal women. […] Either because of risk
issues related to the disease or because one must
weight
 Eraso International Journal for Equity in Health (2019) 18:35 Page 13 of
13
Co-morbidities
Oncologist also expressed that patients’ clinical
morbid- ities at the start of the treatment alongside
known drug toxicities were important factors in the
decision-making process. For example, women with
varicose veins and vas- cular pathology were not
prescribed TAM, and in patients with osteoporosis, AIs
were contraindicated. Also, because AIs inhibit the
conversion of androgens to oestrogens in peripheral
adipose tissue of postmenopausal women, in the
case of obese patients, AI-Letrozole was preferred to
AI-Anastrazole because of its treatment efficacy.
Clinical morbidity and drug toxicity, added to tumour
biology, led oncologists to develop a disease
narrative of individual, each case scenario. As these
oncologists described it:

Each patient is unique. To one we make one

scheme, to another other (03, female, public
sector).

The therapeutic guidelines start to personalise for

each case. From the general recommendation, one
has
 to personalise, for private health pro- viders that have disappeared TAM or AI for early
each case, for each also used international because it has been stage ER+
patient by name and guidelines, however, they proven that they were postmenopausal women,
surname […] Women cov- ered different drugs not so useful as it was an oncologist expressed,
with the same disease in their respective initially thought (11,
can have different insurance plans. male, private health There is a tendency
therapies because each insurance). to use Aromatase
of them has its own E Inhibitors in
biological history (09, x There are ‘grey’ postmenopausal
p situations, where the
male, social security). patients over TAM.
e
experience and In my case no, I
r
i opinion of each prefer TAM and
T e doctor sometimes [Aromatase]
r n counts more than the Inhibitors I only use
e c guidelines, isn’t it? [..]
a e
them in those
t In general the patients that could
Some oncologists,
m guidelines benefit due to the risk
however, provided a
e contemplate all the of disease recurrence
n more nuanced account
options, if one sees (08, male, social
t about the strict
the guidelines they security).
attachment to these
are not categoric
g guidelines, in particular
u because they are
those with more years
i guidelines precisely, U
d of practice, who n
are consensus of
e expressed some reserve c
experts based in the
l based on experience, a e
i evidence (10, male, r
preference for meta-
n social security). t
analysis, and familiarity
e a
s with a drug. These were i
In another case, and
In general terms, the identified in both male n
although the ASCO
and female participants t
protocols in use followed (2016) guide- lines and
and in all service y
the clinical practice provincial protocol
providers: Some oncologists referred
guidelines from the recommended the use to the constant updating
American Society of of
I hate the guidelines of guide- lines, and the
Clinical Oncology
... here there is a need to follow-up the new
(ASCO), National
great use of consensus achieved by
Comprehensive Cancer
guidelines, because expert meetings. One
Net- work (NCCN), the
doctors follow the oncologist described this
European Society for
guidelines and they as:
Medical Oncology
(ESMO), and St Gallen don’t read. […] I only
follow meta-analysis What I am using
International Breast
and all RCT with now [2016], maybe it
Cancer Con- sensus
more than 10 years will be discussed in
Conference. These
follow-up (04, fe- March 2017 (01,
guidelines have largely
male, social security). female, social
informed the provincial
security)
protocol elaborated by
the Córdoba Associ- One has acquired a
certain experience that Another oncologist
ation of Clinical tried to reflect on the
Oncologists [33], whose allows you to continue
practising with good reason why the
recommendations are guidelines for a drug like
harmonised with the parameters and with
acceptable results. TAM has changed so
largest provincial social much over time:
security provider Even though you are
(APPROS) that mainly not using the latest
trend! […] Because we When I graduated, we
covered workers in the used to give
public health sector. have seen many drugs,
things and projects Tamoxifen for life.
Social security and Later, it was for 5
 years, then for 3 treatment options, and
years, then it returned believed that their
to 5 years, and now is decisions were made in
10 years. There must the patient’s interest.
be a bias in all this… This was mentioned in
There is more money two scenarios, when
to deciding amongst all
research certain treatments available,
things than others, especially chemother-
which are the ones apy; and when
that the industry is prescribing a particular
interested in, and drug (molecules)
they allocate more corresponding to a
money for that. I hormonal line.
mean, not everything
is researched with the We need to bear in
same allocation of mind the [social]
funds… (05, male, conditions and the
private health reality of patients.
insurance). Sometimes we assist
patients of very poor
social condition, that
P live in total
a deprivation,
t
i
overcrowded, so one
e needs to consider
n these issues. How
t will you prescribe
s chemotherapy, that
’
can lead to
s neutropenia,
o leokopenia if you
c know that the patient
i won’t have the
o
-
support that she
e needs? […] In those
c cases, we discuss
o within the team, but
n we give hormonal
o
m therapy instead (14,
i male,
c public sector).

s
t
a
t
u
s
Socio-
economic
position and
life
circumstances
In making a treatment
decision, oncologists
expressed that patients’
socio-economic and
socio-environmental
factors affected their
 A poor woman, who read, they don’t o patients and when we
n
lives isolated in a understand it (13, tell them, “if you
s
rural area, we cannot female, public sector). don’t want to do
The discussion of
use new molecules anything, it is your
treatment options with
due to the toxicity Valuing the patient’s right”, they say “no,
patients elic- ited
(neutropenia, quality of life, women’s doctor, if you are
different perceptions.
diarrhoea). They daily ac- tivities and asking me, I will do
One respondent reflected
need to be near a responsibilities, emerged it”. […] The patient
with a comparison with
hospital! (16, female, as important factors only knows everything
the shared decision-
private health for some female [treatments and side
making model that
insurance). oncologists in the effects] because one
prevails in US and
private sector. For these tells them, and they
European contexts in
Male oncologists in doctors, assessing need to sign an
relation to patients’
the public sector clinical factors was informed consent. We
engagement, information
tended to see socio- consid- ered in tandem do have patients that
sharing and participa-
economic limitations as with social ones, thus reject treatment,
tion in treatment
less problematic for the both being weighed in although not
decisions.
pre- scription of HT in prescribing a particular frequently (02, female,
comparison to the weekly hormonal line: public sector).
In Argentina and
hospital visits, transport
Latin America
costs, and health risks The patient decides. Male oncologists in
there is a more
from chemotherapy: We consult all with particular, saw the issue
paternalistic
the patient. Sometimes of dis- cussing
attitude, that the
The hormonal they have a very active treatment options with
population
treatment is totally life, a work life, etc. patients as a process
knows. When
manageable. The and we recommend a given by the whole
one presents this
patient that uses therapeutic line based therapeutic spectrum,
[treatment
TAM, the Ministry on toxicity. We as information-sharing
options] to
gives her 2/3 boxes, mention side effects, and patient’s decision
so for 3 months she such as fatigue regarding acute
doesn’t come, and [aromatase inhibitors], treatment (surgery,
you realise in 3 and discuss options radiotherapy and
months when she with them (16, female, chemother- apy).
comes back to ask private health However, in the case
for the renewal of insurance). of HT, male
the prescription (14, oncologists tended to
male, public sector). consider it as a benign,
D non-toxic treatment in
Female oncologists, i comparison to the acute
s
however, considered HT c ones, hence they did not
prescrip- tion as being u con- template the need
sometimes problematic s to discuss with women
when low health literacy s the available options. As
was involved: i
one participant
n
g explained, the decision
Many times it has of which hormonal line
happened to us that t can be prescribed
we give them the r needed to be taken by
medication and they e the specialist after
a
return in 3 months, assessing a woman’s
t
and they say ‘I took it m clinical condition
once Dr.’, this means e (comorbidities).
that often they don’t n
understand the t
In hormone
treatment even when therapy one
o
you write it down for p evaluates the risk
them, and even when t of the patient.
they know how to i Today I saw a
 patient with They largely concurred
phlebitis, this about a clear
makes her no distinction of patients’
eligible to behaviour across the
treatment with three health subsystems
Tam. in terms of
The election passive/active interaction
[aromatase when treatment was
inhibitor] was mine! communicated, and pa-
I proposed what I tients’ expectations
considered to be during the encounter.
more effective for Female oncologists in
her. But with the public sector
chemotherapy no. acknowledged that for
Because we have patients with low health
many more adverse literacy, good communi-
effects, from the cation and information,
aggressiveness for contention and
health, to what encouragement since the
affects emotions, initiation of
psychological, chemotherapy for
aesthetics and advanced cases (mostly
psychospiritual observed in the public
wellbeing for the sector) was fundamental
patient. There, yes, for their ability to
it is possible to prescribe HT. A range of
discuss, and the social support offered by
patient participates the provincial Ministries
actively in the and a cancer NGO in-
election of cluding transport
therapeutics or the costs, education, and
rejection of the workshops,
therapeutics. In
hormonal therapy
no, because
fortunately they are
very well tolerated
(09, male, social
security).

H
e
a
l
t
h

l
i
t
e
r
a
c
y
Most respondents
perceived patients’
health literacy as being
stratified by social class.
secured patients’ generate a huge provider referred that each
(access to
contention and burden on us because provider in the public,
drugs)
prescription of HT as they don’t ask you social security and
Oncologists were asked
chronic treatment. anything, you see private sector covered
about the main issue
them totally different drugs, and
that af- fected
Breast cancer is a surrendered to what therefore, allowed them
prescribing practices,
chronic disease, so you tell them (14, to prescribe different
and the one that the
you need to give tools male, public sector). lines of hormonal
major- ity identified
to the person so she treatments. Some of
was the different access
can be able to do Dr Google is an the challenges that
to drugs. They
something with her important colleague respondents identified
life. So, if she hasn’t we have! There for each of the providers
finished school… or is a lot of information are presented below:
another activity is the out there but there is
prevention of a need to organise it. P
lymphedema, so we People read more, are r
more informed, and e
give women the tools
s
for them to do Dr Google would be
c
exercise for free, the first problem and r
because they don’t Dr Neighbour would i
have money (02, be the second one. A b
neighbour i
female, public sector). n
that tells her g
Male oncologists [patient] that she
considered that the has an aunt, or a o
most deprived and the cousin that has the u
same [disease] like t
most affluent patients
s
could pose a ‘burden’ her but she was
i
dur- ing consultations prescribed another d
for treatment thing... (05, male, e
prescription due to the private health
former not asking any insurance) t
h
questions at all, and the e
latter asking too many We need to give
questions. The following them [patients] the p
quotes exem- plify how information why… r
they experienced these the truth is that o
people ask for t
interactions: o
explanations. On the c
The lower the socio- other hand, today o
economic position, the they are very l
higher the tendency to informed by the Oncologists working in
accept what the state internet, so they the public sector spoke
offers them. The keep abreast. […] about the limitations in
higher the socio- Women ask why accessing drugs that are
economic level, the this, why the other, outside the protocol,
more demanding are which benefits and which is the list of drugs
the individuals in so on… Here we are that are provided by the
relation to the health very nosy, you know Ministry of Health of the
insurer, in- stitutional that we are an province.
services, doctors and exigent society (07,
the time they give to male private health In the public sector is
them (10, male, social insurance). totally different from
security). the [HT] that is used
in the private sector.
If the doctor tells The [...] We have fewer
health- resources and they
them what to do, they
care
go and do it. They have imposed to us a
 protocol that is very But we have access to
poor (14, male, public other new
sector). medications like
Palbociclib or others
We usually do like Fulvestrant, that
Tamoxifen in we don’t have in our
adjuvancy, that is what protocol.
we’ve got faster in
terms of approval by […]
the Ministry. […] We
use more Tamoxifen For a medication so
in postmenopausal. common [Fulvestrant]
That will be perhaps that we normally ask
the difference with in the private sector
other institutions. Yes, or for patient in the
due to cost and social security, to have
accessibility perhaps to fill in a thousand
the [Aromatase] forms [in the public
Inhibitors are more sector] and every 3
used in private months to send all the
settings. In general, clinical records that
we use Inhibitors as a demonstrate that [the
second line, or patient] is responding
intolerance to to treatment… We
Tamoxifen (12, have overloaded with
female, public patients, and many
sector). appointments and, on
top of it,
At the same time, they the bureaucratic side
referred that they did … it tires you (14,
have access to other male, public sector).
drugs outside the
protocol through a
request to the National
Ministry of Social
Development, but they
found the procedure
very onerous. The
comments were that it
was bureaucratic in
terms of the paperwork
in- volved, time-
consuming for the
doctor, and tiring for
the patient. Some of them
described this as follows:

We can have access to

other type of
medications, but the
procedure is a bit
bothersome for the
doctors and also for
the patient, because it
is too much
paperwork involved,
and the delays is
around 60/90 days.
Dealing with social
security and private
insurance plans
For these providers there
was, according to
participants, a larger
range of drugs available,
yet the accessibility to
these drugs varied
according to the provider.
Those who offered newly
available and expensive
drugs also attempted to
re- strict access, through
a highly bureaucratic
process that in- volved
patients and oncologists.
Most oncologists were
able to name specific
drugs as accessible or not
in the main so- cial
security and private
insurance plans. They
also men- tioned
certain, more
expensive drugs
(Exemestane, Fulvestrant,
Goserelin) that were
covered in principle, but
doctors needed to justify
why the drug has been
recom- mended. As many
oncologists working in
this subsector concurred:
Treatment is
according to patient
and her social
insurance plan. […]
In adjuvancy there is
a strong tendency to
use Anastrozole in
postmenopause
because a study gave
2.5% of benefit. Well,
I’ll see… because for
the insurance plan is
much more expensive
Anastrazole and the
differences are very
little. If I see that they
[social security] are
not going to give the
medication, or they
will delay it, or for the
patient is a cost, I am
sure I will use
Tamoxifen (04,
female, social patient, the objective on, every time we
security). why a drug is use a new
requested, for how medication, they ask
What we observe is long. We make a kind us to fill in a form
of protocol that we explaining why we
that the insurer
won’t reject up front always do for the first change. But no more
time, but it is not that than that (06, male,
a drug prescribed
because it doesn’t they oblige us to put private health
something special. It insurance).
want to enter into
conflict with the is something standard
[…] an initial auditory. We are here within
patient […] and it
starts, in a subtle […] later the private sector
and we have greater
way, to put obstacles
in the way of the accessibility, but we
know that in the
provision, avoiding to
say up-front ‘I won’t public sector that is
a bit more limited
cover it’, but the
patient enters in a (07, male, private
health insurance).
complicated process
with paperwork and
medical check-ups
that wears the pa- D
i
tient out in the
request of the drug s
c
(09, male, social
security). u
s
For a [drug] request, s
we have to deal with i
each social security o
plan to see whether n
they will accept it or This qualitative study
not, some ask for explored factors
more requirements, associated with
other less … It is oncologists’ prescribing
practices of HT for
complex. It implies
for doctors an onerous women with oestrogen
positive BC. To my
task, because of
paperwork, forms, knowledge, is the first
qualitative study on this
reports, engagement
with auditors (10, topic conducted in
Córdoba, Argentina. HT
male, social security).
is highly standardised in
However, the request Western medi- cine
of drugs in the private through consensus
health insurance was not guidelines elaborated by
perceived as a problem. profes- sional
associations in the US
In general, it is and Europe, based on
standardised in the evidence-based clinical
social security and studies on populations.
private health Whilst adherence to
insurance to fill in a these guidelines, in the
questionnaire for the sample studied, seems to
first time that one offer a consistent
prescribes to a approach to treatment
patient: to state deci- sions, patient-
diagnosis, age of the specific factors such as
tumour biology, clinical drugs in the public sec-
morbidity, drug toxicity, tor pointed to the
and tumour resistance existence of ‘a cultural
allowed oncologist to profile of the public
develop an individual- sector patient and the
case ap- proach. The health professionals that
role of experience in assist them, [as
the older generation also characterised by] a
offered oncologists a tendency to accept the
way to exert choice and disease and its associated
regain clinical judgment problems with
in relation to the resignation, including the
standardisation im- limitations of the care
posed by guidelines. In services’ [36] (n/p).
addition, two other Overall, this study has
factors re- garding shown that SES factors
guidelines’ applicability played a role in
explored by the prescribing HT
literature have been treatment, and that
expressed by the there were different
respondents: firstly, the approaches observed
local resource according to
implications (drug oncologists’ gender. Even
availability), which when most respondents
requires adaptability acknowledged the
and consensus by the
team of specialists, as
observed by a study on
cytotoxic drugs
prescribing in the city
of Rosario (Argentina)
[34]. Sec- ondly, the
constant following of
updates to guidelines to
keep peace with
emerging data [35].
More importantly, a
range of non-biological
factors appears to add
complexity to the way
the prescribing of
treatment is formulated.
Factors associated with
patients’ SES was an
influencing component
in decision-making
observed in this study,
comprising three
interrelated ele- ments,
socio-economic position,
discussing treatment
options, and health
literacy. Although
patients’ SES has not
been specifically
analysed in Argentina, a
report ex- ploring
inequalities in access to
difficulties that women living in very deprived manage chronic conditions such as BC [26]. Hence,
conditions can pose to chemotherapy, male tended to further research is needed on health information
consider HT as a more acceptable treatment ‘for all interventions such as patient decision aids, as
social classes’ (14, male public sector). This approach is, evidenced by a Cochrane review [46], designed to meet
however, problematic, as it the information needs of the
associates HT with ‘taking a without different group of patients, according to their level
pill,’ considering of
women’s self-management skills and understanding of this can also have further implications for effective self-
the treatment. Health literacy, i.e. having the skills, management, where oncolo- gists and coordinated
knowledge and confidence to take decisions on medical support from the health team is needed for patients
instructions, is largely associated with socio- to make treatment decisions and
economic circumstances, whereby the most deprived
groups are more likely to have low health literacy [37].
However, as shown in this study, highly educated
women could also have limited health liter- acy − which
is understandable considering the complexity associated
with treatments regimes in HT − and therefore, they
were perceived by male oncologists as often demand-
ing and asking too many questions. There are only a
hand- ful of studies that have measured health literacy
in specific contexts in Argentina [38, 39], but there are
none for can- cer. This is an area that will require
more research to find out the implications it may
have for health inequal- ities: a study has
demonstrated that BC oncologists spend more time
in consultations with highly educated patients than
with low-income, less educated ones [40], whilst
other studies, similarly to what have been identi- fied
here, have shown that most deprived patients have
greatest information needs and support in
understand- ing their disease and treatment [41, 42].
Previous research has noted that discussion of BC
treat- ment choices between oncologists and patients
has been associated with better health outcomes
[43], and more shared decision-making in adjuvant
therapy was associated with greater treatment
satisfaction [44]. Whilst the process of shared decision-
making is not incorporated into Argen- tina’s health
policy, where a rather ‘paternalistic model’ pre- vails
with a right to informed consent [45], by considering
oncologists’ gender as a variable, this qualitative study
has shed light into how gendered power dynamics
may affect the process of prescribing in different
ways: On the one hand, female oncologists were more
considered of the dif- ferent side-effects that drugs can
have in women’s quality of life and so they were more
prone to consider women’s life circumstances and
allow more educated women to share their views
and discuss treatment options. On the other, the data
collected suggest that prescribing practices in male
oncologists seem not to be influenced by these
considerations. Furthermore, male perceptions of both
low and upper-class women can inadvertently normalise
issues regarding women’s needs and understanding of
treatment options, foster a sense of adherence to
treatment initiation which may have implications for
the amount of health information provided. Moreover,
health literacy.
The fragmented nature of the Argentinian health
sys- tem has often been identified as a cause of main
health inequalities, between and within provinces,
including cancer diagnosis and treatment [47] as well
as access to oncological drugs [36]. The perspective
of oncologists indicates that HT is strongly
contingent on the health system providers, which
limit the line of treatments (drugs) available from
approximately 2 in the public sec- tor to 7 in the
private health insurance. Although oncol- ogists
tended to view these differences in the adjuvant
setting as non-fundamental in terms of a reported 2–
3% variation in drug effectiveness, in cases of
metastatic BC the differences between lines of
treatments and health outcomes can be more
marked in overall survival as shown in a recent
review [48]. New drugs improving the action of anti-
oestrogens as well as different generations of anti-
oestrogens (SERD) and AIs open different se-
quence and combinations of treatments
(Everolimus with Exemestane or TAM; Palbociclib
with Letrozole or Fulvestrant). Precisely some of
these targeted drugs are the ones that appear as
more challenging to access in the social security and
the public sector.
The recurrent mentioning of bureaucracy and
paper- work involved in accessing drugs that are
not covered within the Provincial/National protocol
menu (public sector), or that are covered (social
security) but its ac- cess is made very difficult by
insurance plans can also make the prescription of
treatment dependent on both determined oncologists
and patients. Participants’ re- sponses are in line
with findings from Argentinian re- ports whereby
oncological patients in the public sector referred
to delays in access to medication due to wrong
prescriptions and complicated paperwork from
social services, as well as from national or pro-
vincial drug suppliers [18, 36]. For insured
patients, lawsuits have increasingly become an
alternative way of accessing oncological medicines
[49]. In the private health subsystem respondents
saw the request of drugs as less challenging.
This could be due to a more manageable
workload for professionals, a better coverage from
the insurance plan or a simpler admin- istrative
procedure from the insurer. Finally, in
requesting drugs outside the protocol,
oncologists needed to consider, as one of them
expressed, ‘The possibility to sustain treatment in
the future’ (07, male private health insurance),
that is, to balance the risk of discontinuing
treatment after an initial medi- cation approval.
L expressed by oncologists ation, and designed Of significance, the
i in their prescribing according to the fragmented health
m practices of HT for BC perceived health literacy system can lead to a
i women in Córdoba. needs (e.g. for low- differential access to
t Overall, the empirical literacy groups, a web- drugs or lines of HT in
a data collected suggests based interactive audio- the metastatic BC
t that HT is largely visual intervention setting between the
i perceived by oncolo- provided at the hos- public and private
o gists as a ‘different type’ pital with the assistance sector; and also to a
n of treatment, which is set of a nurse; for high- restricted access to
s ‘in com- parison’ to the literacy groups, a booklet drugs that are covered
Some limitations of this acute ones (surgery, or DVD using plain through the insurance
study require careful chemotherapy and language), can facilitate plans. Health system co-
consider- ation. Although radiation). Considering women’s informed ordination amongst the
the participants within HT as a form of chronic decisions and make it subsectors, a role
the sample repre- sented care is fun- damental to easier for oncolo- gists to assumed by the Ministry
the three health address the specificities discuss treatment options. of Health of the
subsystems and involved in oncologists’ In this study, Province, should be im-
oncologists’ gender, it is prescribing practices and oncologists’ gender can proved in terms of drugs
possible that their views in the understanding of be a contributory factor accessibility if equity in
in relation to gender HT use among breast on treatment decision- access is to be achieved.
ap- proaches to care, is cancer patients. The making. Female Initiatives should be
not representative of all intersections of oncologists in the private taken to make the
male/female oncologists biological (tumour type, and public sector, provision of oncological
working in these age and co-morbidities) tended to be more re- drugs more streamlined
different settings. Also, and non- biological sponsive to women’s and ac- cessible to all
the prescribing practices factors (HT guidelines, needs, more prone to service providers.
here described for the patients’ SES, women’s discuss treat- ment
city of Córdoba cannot ability to understand options and drug toxicity. Additional files
be generalised to HT, and access to More qualitative
Argentina, even in the drugs), alongside the research, including Additional file 1: Interview
question guide. (PDF 65 kb)
presence of the same tri- physician’s gender and patients, will contribute
A
partite health system. the health system to advance knowledge on d
Gender notions, in provider can variously oncologists’ gender as a di
specific factor, before ti
particular, are informed and simultaneously o
by societal factors, influence oncologists’ policy implications can n
which may largely differ be drawn. al
decis ion-making. Given fil
amongst cities with the different lines of e
different levels of commu- treatments available 2:
C
nity values, medical within HT (according to as
education and training, tumour type, age, co- e
ch
and patients’ demands morbidities, and ar
and expectations of care. prognostic factors) t.
(X
effective communication LS
C of medica- tion options X
o can pose a challenge to 12
kb
n oncologists and may )
c disadvantage women
l affected by the disease, Abbreviations
u by inhibiting their AI: Aromatase inhibitors; BC: breast
cancer; HT: hormonal therapy; SES:
s comprehension of Socio- economic status; TAM:
i treatments options, Tamoxifen
o benefits and risks. The Acknowledgements
n use of tailored The author would like to express
s interventions such as gratitude to the participants of this
study, without their contribution
The findings of the patient deci- sion aids this study would have not been
study identified a delivered to BC women possible. Preliminary results were
number of themes presented at conferences and
pre or during consult-
workshops at the Federal
University of Rio de Janeiro,
London Metropolitan University
and The University of Manchester,
where discussions and comments
from colleagues and attendees
were invaluable in preparation of
this paper. The author
would also like to extend her thanks
to the reviewers.

Funding
The study was financially
supported by the School of
Social Professions, London
Metropolitan University,
Quality-related research
funding.

Availability of data and materials

The datasets generated and/or
analysed during the current study
are not publicly available due to
the risk of revealing the identity
of interview participants but are
available from the corresponding
author on reasonable request.

Authors’ contributions
YE prepared the project design,
collected and analysed the data,
interpreted the findings and wrote
the manuscript.

Ethics approval and consent to

participate
Ethics approval for this study was
obtained from London
Metropolitan University Research
Ethics Committee (4053016). All
the participants were presented
with the aim and objectives of the
study and the question guide.
They were asked to read the
questionnaire before starting the
interviews and were offered time
to raise any questions and
clarification regarding the study.
Written consent was obtained
from all participants. They were
also informed of their right to
withdraw their participation from
the study at any time. Anonymity
of participants was preserved
through the use of codes in the
notes collected.

Consent for publication

Written consent was obtained
from participants for publication
of the data collected in
academic journals.

Competing interests
The author declares that she has no
competing interest.

Publisher’s Note
Springer Nature remains neutral with
regard to jurisdictional claims in
published maps and institutional
affiliations.
Received: 18 October 2018
Accepted: 4 February 2019
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