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Valenza C, Trapani D, Loibl S, Chia SKL, Burstein HJ, Curigliano G. Optimizing Postneoadjuvant Treatment in Patients With Early Breast Cancer Achieving Pathologic Complete Response. J Clin Oncol 2024:JCO2301935. [PMID: 38569132 DOI: 10.1200/jco.23.01935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/03/2023] [Accepted: 01/22/2024] [Indexed: 04/05/2024] Open
Abstract
pCR should be integrated with other prognostic factors to optimize postneoadjuvant treatments in BC.
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Affiliation(s)
- Carmine Valenza
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Dario Trapani
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Sibylle Loibl
- Center for Hematology and Oncology Bethanien, Frankfurt, Germany
| | | | - Harold J Burstein
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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2
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Francis PA. Role of Ovarian Suppression in Early Premenopausal Breast Cancer. Hematol Oncol Clin North Am 2023; 37:79-88. [PMID: 36435615 DOI: 10.1016/j.hoc.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The benefit from removing ovaries to control premenopausal breast cancer growth was identified more than 100 years ago. Subsequent identification of estrogen receptor (ER) enabled targeting of this approach. Development of gonadotropin-releasing hormone agonists facilitated a reversible method of ovarian function suppression, suitable for young women with early breast cancer. Clinical trials have established the value of including ovarian suppression to reduce recurrence of ER-positive premenopausal early breast cancer. Ovarian suppression administered with chemotherapy can reduce the risk of premature menopause in ER-negative cancer, and increase the prospect of future pregnancy in premenopausal women, regardless of tumor hormone receptor status.
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Affiliation(s)
- Prudence A Francis
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, Univeristy of Melbourne, Melbourne, Australia; St Vincent's Hopsital Melbourne, Australia.
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Arboleda B, Bartsch R, de Azambuja E, Hamilton E, Harbeck N, Klemp J, Knauer M, Kuemmel S, Mahtani R, Schwartzberg L, Villarreal-Garza C, Wolff A. Ovarian Function Suppression: A Deeper Consideration of the Role in Early Breast Cancer and its Potential Impact on Patient Outcomes: A Consensus Statement from an International Expert Panel. Oncologist 2022; 27:722-731. [PMID: 35704278 PMCID: PMC9438910 DOI: 10.1093/oncolo/oyac101] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 04/26/2022] [Indexed: 01/07/2023] Open
Abstract
It has been suggested that the benefit of adjuvant chemotherapy (CT) in premenopausal women with hormone receptor-positive (HR+), human epidermal growth factor receptor 2 negative (HER2-) early breast cancer may be related, at least in part, to CT-induced ovarian function suppression (OFS) in this subgroup of patients. Although this hypothesis has not been directly tested in large randomized clinical trials, the observations from prospective studies have been remarkably consistent in showing a late benefit of CT among the subgroup of patients who benefit (ie, women who were close to menopause). The hypothesis has important clinical implications, as it may be possible to spare the associated adverse effects of adjuvant CT in a select group of women with early breast cancer, in favor of optimizing OFS and endocrine therapy (ET), without compromising clinical outcomes. Such an approach has the added benefit of preserving the key quality of life outcomes in premenopausal women, particularly by preventing the irreversible loss of ovarian function that may result from CT use. For this reason, we convened an international panel of clinical experts in breast cancer treatment to discuss the key aspects of the available data in this area, as well as the potential clinical implications for patients. This article summarizes the results of these discussions and presents the consensus opinion of the panel regarding optimizing the use of OFS for premenopausal women with HR+, HER2- early breast cancer.
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Affiliation(s)
- Bolivar Arboleda
- Puerto Rican Society of Mastology, HIMA San Pablo Oncology Hospital, Caguas, Puerto Rico
| | - Rupert Bartsch
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | | | - Erika Hamilton
- Breast and Gynecologic Research Program, Sarah Cannon Research Institute, Tennessee Oncology PLLC, Nashville, TN, USA
| | - Nadia Harbeck
- LMU Munich, University Hospital, Department of Obstetrics and Gynecology, Breast Center and Comprehensive Cancer Center (CCLMU), Munich, Germany
| | - Jennifer Klemp
- University of Kansas Cancer Center, Kansas City, KS, USA
| | - Michael Knauer
- Department of Pathology and Laboratory Medicine, Western University and London Health Sciences Centre, London, ON, Canada
| | - Sherko Kuemmel
- Department of Gynecology with Breast Center, Charité-Universitätsmedizin Berlin, Germany
| | | | | | - Cynthia Villarreal-Garza
- Breast Cancer Center, Hospital Zambrano Hellion, Tecnologico de Monterrey, San Pedro Garza Garcia, Mexico
| | - Antonio Wolff
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
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4
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Partridge AH, Niman SM, Ruggeri M, Peccatori FA, Azim HA, Colleoni M, Saura C, Shimizu C, Sætersdal AB, Kroep JR, Mailliez A, Warner E, Borges VF, Amant F, Gombos A, Kataoka A, Rousset-Jablonski C, Borstnar S, Takei J, Lee JE, Walshe JM, Borrego MR, Moore HC, Saunders C, Cardoso F, Susnjar S, Bjelic-Radisic V, Smith KL, Piccart M, Korde LA, Goldhirsch A, Gelber RD, Pagani O. Who are the women who enrolled in the POSITIVE trial: A global study to support young hormone receptor positive breast cancer survivors desiring pregnancy. Breast 2021; 59:327-338. [PMID: 34390999 PMCID: PMC8365381 DOI: 10.1016/j.breast.2021.07.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/22/2021] [Accepted: 07/30/2021] [Indexed: 11/17/2022] Open
Abstract
Background Premenopausal women with early hormone-receptor positive (HR+) breast cancer receive 5–10 years of adjuvant endocrine therapy (ET) during which pregnancy is contraindicated and fertility may wane. The POSITIVE study investigates the impact of temporary ET interruption to allow pregnancy. Methods POSITIVE enrolled women with stage I-III HR + early breast cancer, ≤42 years, who had received 18–30 months of adjuvant ET and wished to interrupt ET for pregnancy. Treatment interruption for up to 2 years was permitted to allow pregnancy, delivery and breastfeeding, followed by ET resumption to complete the planned duration. Findings From 12/2014 to 12/2019, 518 women were enrolled at 116 institutions/20 countries/4 continents. At enrolment, the median age was 37 years and 74.9 % were nulliparous. Fertility preservation was used by 51.5 % of women. 93.2 % of patients had stage I/II disease, 66.0 % were node-negative, 54.7 % had breast conserving surgery, 61.9 % had received neo/adjuvant chemotherapy. Tamoxifen alone was the most prescribed ET (41.8 %), followed by tamoxifen + ovarian function suppression (OFS) (35.4 %). A greater proportion of North American women were <35 years at enrolment (42.7 %), had mastectomy (59.0 %) and received tamoxifen alone (59.8 %). More Asian women were nulliparous (81.0 %), had node-negative disease (76.2%) and received tamoxifen + OFS (56.0 %). More European women had received chemotherapy (69.3 %). Interpretation The characteristics of participants in the POSITIVE study provide insights to which patients and doctors considered it acceptable to interrupt ET to pursue pregnancy. Similarities and variations from a regional, sociodemographic, disease and treatment standpoint suggest specific sociocultural attitudes across the world. Fertility and pregnancy are priority concerns for young breast cancer survivors. POSITIVE explores a transient interruption of endocrine therapy to allow conception. Patients' characteristics highlight features considered suitable to study enrolment. Overall, patients enrolled had a relatively high median age and low-risk disease. Variations emerged across continents suggesting specific sociocultural attitudes.
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Affiliation(s)
- Ann H Partridge
- Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA.
| | - Samuel M Niman
- International Breast Cancer Study Group Statistical Center, Department of Data Science, Division of Biostatistics, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Monica Ruggeri
- International Breast Cancer Study Group, Program for Young Patients, Coordinating Center, Effingerstrasse 40, Bern, 3008, Switzerland.
| | - Fedro A Peccatori
- Fertility and Procreation Unit, Gynecologic Oncology Program, European Institute of Oncology IRCCS, Via Ripamonti 435, Milan, 20141, Italy.
| | - Hatem A Azim
- Breast Cancer Center, Hospital Zambrano Hellion, School of Medicine, Tecnologico de Monterrey, Av. Batallon de San Patricio 112, San Pedro Garza Garcia, 66278, Mexico.
| | - Marco Colleoni
- International Breast Cancer Study Group, Division of Medical Senology, IEO, European Institute of Oncology, IRCCS, Milan, Italy.
| | - Cristina Saura
- Vall d'Hebron University Hospital and Vall d'Hebron Institute of Oncology, Medical Oncology Service, Barcelona, Spain.
| | - Chikako Shimizu
- Department of Breast and Medical Oncology, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, 1-21-1, Japan.
| | - Anna Barbro Sætersdal
- Department of Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway.
| | - Judith R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Audrey Mailliez
- Department of Medical Oncology, Centre Oscar Lambret, Lille, France.
| | - Ellen Warner
- Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, Canada.
| | - Virginia F Borges
- Division of Medical Oncology, Department of Medicine, University of Colorado Cancer Center, Aurora, CO, USA.
| | - Frédéric Amant
- Department of Oncology, KU Leuven and Leuven Cancer Institute, Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam University Medical Center, Amsterdam, the Netherlands.
| | - Andrea Gombos
- Institut Jules Bordet and L'Universite Libre de Bruxelles, Brussels, Belgium.
| | - Akemi Kataoka
- Breast Oncology Cancer, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | | | - Simona Borstnar
- Division of Medical Oncology, Institute of Oncology, Ljubljana, Slovenia.
| | - Junko Takei
- St Luke's International Hospital, Breast Center, Tokyo, Japan.
| | - Jeong Eon Lee
- Breast Division, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Department of Clinical Research and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea.
| | - Janice M Walshe
- Cancer Trials Ireland and Medical Oncology Department, St. Vincent's University Hospital and Tallaght University Hosptial, Dublin, Ireland.
| | - Manuel Ruíz Borrego
- Hospital Virgen del Rocio Sevilla, GEICAM Spanish Breast Cancer Group, Sevilla, Spain.
| | - Halle Cf Moore
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.
| | - Christobel Saunders
- Division of Surgery, Faculty of Health and Medical Sciences, University of Western Australia, Crawley, WA, Australia.
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal.
| | - Snezana Susnjar
- Department of Medical Oncology, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia.
| | - Vesna Bjelic-Radisic
- Breast Unit, Helios University Hospital Wuppertal, University Witten/Herdecke, Wuppertal, Germany; Medical University Graz, Department Gynaecology, Graz, Austria.
| | - Karen L Smith
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA.
| | - Martine Piccart
- Institut Jules Bordet and L'Universite Libre de Bruxelles, Brussels, Belgium.
| | - Larissa A Korde
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD, USA.
| | - Aron Goldhirsch
- International Breast Cancer Study Group, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Richard D Gelber
- International Breast Cancer Study Group Statistical Center, Department of Data Science, Division of Biostatistics, Dana-Farber Cancer Institute, Frontier Science and Technology Research Foundation, Harvard TH Chan School of Public Health and Harvard Medical School, Boston, MA, USA.
| | - Olivia Pagani
- Interdisciplinary Cancer Service Hospital Riviera-Chablais Rennaz, Geneva University Hospitals, Lugano University, Swiss Group for Clinical Cancer Research (SAKK), Vaud, Switzerland.
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Ugras SK, Layeequr Rahman R. Hormone replacement therapy after breast cancer: Yes, No or maybe? Mol Cell Endocrinol 2021; 525:111180. [PMID: 33508379 DOI: 10.1016/j.mce.2021.111180] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/13/2021] [Accepted: 01/21/2021] [Indexed: 01/16/2023]
Abstract
Over nine million breast cancer survivors worldwide suffer compromised quality of life attributable to estrogen depletion related symptoms of menopause and side effects of cancer therapy. Hormone Replacement Therapy (HRT) is very effective in managing these symptoms in general population and in breast cancer survivors. However, the concern of breast cancer recurrence as a result of HRT use keeps many oncologists from using this approach in symptom management. Evidence from randomized trials, observational studies and met-analyses on the impact of HRT use on breast cancer recurrence and survival remains controversial. Climacteric symptoms in breast cancer survivors should be delineated for type and severity for methodical management. Lifestyle modifications are effective for mild symptoms, while non-hormonal pharmaceutical approaches can be used as second-line therapy for control of hot flashes, vulvo-vaginal atrophy, arthralgia, mood swings, sleep disturbance, and depression. Evidence does not conclusively render HRT, as a contraindicated approach for these patients; informed consent and shared-decision-making is a reasonable approach for HRT use in symptomatic breast cancer survivors.
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Affiliation(s)
- Stacy K Ugras
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
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Coyne K, Silverman P, Liu JH. Oral GnRH Antagonist Ovarian Suppression After Escape From GnRH Agonist in Breast Cancer Patients. Clin Breast Cancer 2020; 20:e551-e554. [PMID: 32616435 DOI: 10.1016/j.clbc.2020.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/01/2020] [Accepted: 05/18/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Kathryn Coyne
- Department of Obstetrics and Gynecology, University Hospital MacDonald Women's Hospital, University Hospital Cleveland Medical Center, Cleveland, OH
| | - Paula Silverman
- Department of Medicine, University Hospitals Seidman Cancer Center, Cleveland, OH
| | - James H Liu
- Department of Obstetrics and Gynecology, University Hospital MacDonald Women's Hospital, University Hospital Cleveland Medical Center, Cleveland, OH.
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Abstract
Breast cancer in young women requires special vigilance because of the unique condition and complex management that is involved. The indication for chemotherapy should not be based on age alone but in association with the biological characteristics of the tumour. In addition, age is not considered as demonstrated predictor of chemosensitivity. The choice of adjuvant or neoadjuvant chemotherapy should be guided by the histological type of the tumour, the stage of the tumour and the patient's comorbidities. In this subgroup of patients, the recommendations for the use of molecular signatures follow those of the general population. This manuscript summarizes the main data and recommendations on the management of breast cancer in young women in term of chemotherapy.
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Affiliation(s)
- Elise Deluche
- Institut Gustave-Roussy, Comité de pathologie mammaire, 114, rue Édouard-Vaillant, 94800 Villejuif, France.
| | - Jean-Yves Pierga
- Institut Curie, Département de médecine oncologique, 26, rue d'Ulm 75005 Paris, France
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Regan MM, Fleming GF, Walley B, Francis PA, Pagani O. Adjuvant Systemic Treatment of Premenopausal Women With Hormone Receptor-Positive Early Breast Cancer: Lights and Shadows. J Clin Oncol 2019; 37:862-866. [PMID: 30811287 DOI: 10.1200/jco.18.02433] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Meredith M Regan
- 1 Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | - Barbara Walley
- 3 University of Calgary and Canadian Cancer Trials Group, Calgary, Alberta, Canada
| | - Prudence A Francis
- 4 Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - Olivia Pagani
- 5 Geneva University Hospitals, Lugano Viganello, Switzerland and Institute of Oncology of Southern Switzerland, Geneva, Switzerland
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Paluch-Shimon S, Pagani O, Partridge AH, Abulkhair O, Cardoso MJ, Dent RA, Gelmon K, Gentilini O, Harbeck N, Margulies A, Meirow D, Pruneri G, Senkus E, Spanic T, Sutliff M, Travado L, Peccatori F, Cardoso F. ESO-ESMO 3rd international consensus guidelines for breast cancer in young women (BCY3). Breast 2017; 35:203-217. [DOI: 10.1016/j.breast.2017.07.017] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 07/24/2017] [Indexed: 12/11/2022] Open
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Pruneri G, Boggio F. Prognostic and Predictive Role of Genetic Signatures. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Torrisi R, Rota S, Losurdo A, Zuradelli M, Masci G, Santoro A. Aromatase inhibitors in premenopause: Great expectations fulfilled? Crit Rev Oncol Hematol 2016; 107:82-89. [DOI: 10.1016/j.critrevonc.2016.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 07/14/2016] [Accepted: 08/23/2016] [Indexed: 11/30/2022] Open
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Regan MM, Francis PA, Pagani O, Fleming GF, Walley BA, Viale G, Colleoni M, Láng I, Gómez HL, Tondini C, Pinotti G, Price KN, Coates AS, Goldhirsch A, Gelber RD. Absolute Benefit of Adjuvant Endocrine Therapies for Premenopausal Women With Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Early Breast Cancer: TEXT and SOFT Trials. J Clin Oncol 2016; 34:2221-31. [PMID: 27044936 DOI: 10.1200/jco.2015.64.3171] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE Risk of recurrence is the primary consideration in breast cancer adjuvant therapy recommendations. The TEXT (Tamoxifen and Exemestane Trial) and SOFT (Suppression of Ovarian Function Trial) trials investigated adjuvant endocrine therapies for premenopausal women with hormone receptor-positive breast cancer, testing exemestane plus ovarian function suppression (OFS), tamoxifen plus OFS, and tamoxifen alone. We examined absolute treatment effect across a continuum of recurrence risk to individualize endocrine therapy decision making for premenopausal women with human epidermal growth factor receptor 2 (HER2) -negative disease. PATIENTS AND METHODS The TEXT and SOFT hormone receptor-positive, HER2-negative analysis population included 4,891 women. The end point was breast cancer-free interval (BCFI), defined as time from random assignment to first occurrence of invasive locoregional, distant, or contralateral breast cancer. A continuous, composite measure of recurrence risk for each patient was determined from a Cox model incorporating age, nodal status, tumor size and grade, and estrogen receptor, progesterone receptor, and Ki-67 expression levels. Subpopulation treatment effect pattern plot methodology revealed differential treatment effects on 5-year BCFI according to composite risk. RESULTS SOFT patients who remained premenopausal after chemotherapy experienced absolute improvement of 5% or more in 5-year BCFI with exemestane plus OFS versus tamoxifen plus OFS or tamoxifen alone, reaching 10% to 15% at intermediate to high composite risk; the benefit of tamoxifen plus OFS versus tamoxifen alone was apparent at the highest composite risk. The SOFT no-chemotherapy cohort-for whom composite risk was lowest on average-did well with all endocrine therapies. For TEXT patients, the benefit of exemestane plus OFS versus tamoxifen plus OFS in 5-year BCFI ranged from 5% to 15%; patients not receiving chemotherapy and with lowest composite risk did well with both treatments. CONCLUSION Premenopausal women with hormone receptor-positive, HER2-negative disease and high recurrence risk, as defined by clinicopathologic characteristics, may experience improvement of 10% to 15% in 5-year BCFI with exemestane plus OFS versus tamoxifen alone. An improvement of at least 5% may be achieved for women at intermediate risk, and improvement is minimal for those at lowest risk.
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Affiliation(s)
- Meredith M Regan
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru.
| | - Prudence A Francis
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Olivia Pagani
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Gini F Fleming
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Barbara A Walley
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Giuseppe Viale
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Marco Colleoni
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - István Láng
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Henry L Gómez
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Carlo Tondini
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Graziella Pinotti
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Karen N Price
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Alan S Coates
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Aron Goldhirsch
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
| | - Richard D Gelber
- Meredith M. Regan and Richard D. Gelber, Dana-Farber Cancer Institute, Harvard Medical School; Karen N. Price and Richard D. Gelber, Frontier Science and Technology Research Foundation; Richard D. Gelber, Harvard T.H. Chan School of Public Health, Boston, MA; Prudence A. Francis, MacCallum Cancer Center, St Vincent's Hospital, University of Melbourne, Melbourne; University of Newcastle, Newcastle; Alan S. Coates, University of Sydney, Sydney, Australia; Olivia Pagani, Institute of Oncology of Southern Switzerland, Lugano Viganello, Switzerland; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Barbara A. Walley, National Cancer Institute of Canada Clinical Trials Group, Calgary, Alberta, Canada; Giuseppe Viale, University of Milan; Giuseppe Viale, Marco Colleoni, and Aron Goldhirsch, European Institute of Oncology, Milan; Carlo Tondini, Ospedale Papa Giovanni XXIII, Bergamo; Graziella Pinotti, Ospedale di Circolo and Fondazione Macchi, Varese, Italy; István Láng, National Institute of Oncology, Budapest, Hungary; Henry L. Gómez, Instituto Nacional de Enfermedades Neoplásticas, Lima, Peru
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Paluch-Shimon S, Pagani O, Partridge AH, Bar-Meir E, Fallowfield L, Fenlon D, Friedman E, Gelmon K, Gentilini O, Geraghty J, Harbeck N, Higgins S, Loibl S, Moser E, Peccatori F, Raanani H, Kaufman B, Cardoso F. Second international consensus guidelines for breast cancer in young women (BCY2). Breast 2016; 26:87-99. [DOI: 10.1016/j.breast.2015.12.010] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 12/19/2015] [Indexed: 11/12/2022] Open
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Layeequr Rahman R, Baker T, Crawford S, Kauffman R. SOFT trial can be very hard on young women. Breast 2015; 24:767-8. [DOI: 10.1016/j.breast.2015.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/29/2015] [Accepted: 08/23/2015] [Indexed: 11/16/2022] Open
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15
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Coates AS, Winer EP, Goldhirsch A, Gelber RD, Gnant M, Piccart-Gebhart M, Thürlimann B, Senn HJ. Tailoring therapies--improving the management of early breast cancer: St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2015. Ann Oncol 2015; 26:1533-46. [PMID: 25939896 PMCID: PMC4511219 DOI: 10.1093/annonc/mdv221] [Citation(s) in RCA: 1217] [Impact Index Per Article: 135.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 04/28/2015] [Indexed: 12/16/2022] Open
Abstract
The 14th St Gallen International Breast Cancer Conference (2015) reviewed substantial new evidence on locoregional and systemic therapies for early breast cancer. Further experience has supported the adequacy of tumor margins defined as 'no ink on invasive tumor or DCIS' and the safety of omitting axillary dissection in specific cohorts. Radiotherapy trials support irradiation of regional nodes in node-positive disease. Considering subdivisions within luminal disease, the Panel was more concerned with indications for the use of specific therapies, rather than surrogate identification of intrinsic subtypes as measured by multiparameter molecular tests. For the treatment of HER2-positive disease in patients with node-negative cancers up to 1 cm, the Panel endorsed a simplified regimen comprising paclitaxel and trastuzumab without anthracycline as adjuvant therapy. For premenopausal patients with endocrine responsive disease, the Panel endorsed the role of ovarian function suppression with either tamoxifen or exemestane for patients at higher risk. The Panel noted the value of an LHRH agonist given during chemotherapy for premenopausal women with ER-negative disease in protecting against premature ovarian failure and preserving fertility. The Panel noted increasing evidence for the prognostic value of commonly used multiparameter molecular markers, some of which also carried prognostic information for late relapse. The Panel noted that the results of such tests, where available, were frequently used to assist decisions about the inclusion of cytotoxic chemotherapy in the treatment of patients with luminal disease, but noted that threshold values had not been established for this purpose for any of these tests. Multiparameter molecular assays are expensive and therefore unavailable in much of the world. The majority of new breast cancer cases and breast cancer deaths now occur in less developed regions of the world. In these areas, less expensive pathology tests may provide valuable information. The Panel recommendations on treatment are not intended to apply to all patients, but rather to establish norms appropriate for the majority. Again, economic considerations may require that less expensive and only marginally less effective therapies may be necessary in less resourced areas. Panel recommendations do not imply unanimous agreement among Panel members. Indeed, very few of the 200 questions received 100% agreement from the Panel. In the text below, wording is intended to convey the strength of Panel support for each recommendation, while details of Panel voting on each question are available in supplementary Appendix S2, available at Annals of Oncology online.
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MESH Headings
- Anthracyclines/administration & dosage
- Antineoplastic Agents, Hormonal/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Axilla
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma, Ductal, Breast/metabolism
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/therapy
- Carcinoma, Intraductal, Noninfiltrating/metabolism
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Carcinoma, Lobular/metabolism
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/therapy
- Chemotherapy, Adjuvant/methods
- Female
- Humans
- Lymph Node Excision/methods
- Mastectomy/methods
- Mastectomy, Segmental/methods
- Neoplasm Staging
- Platinum Compounds/administration & dosage
- Practice Guidelines as Topic
- Radiotherapy, Adjuvant/methods
- Receptor, ErbB-2/metabolism
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/metabolism
- Tamoxifen/administration & dosage
- Taxoids/administration & dosage
- Trastuzumab/administration & dosage
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Affiliation(s)
- A S Coates
- International Breast Cancer Study Group, University of Sydney, Sydney, Australia
| | - E P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - A Goldhirsch
- International Breast Cancer Study Group, Program of Breast Health (Senology), European Institute of Oncology, Milan, Italy
| | - R D Gelber
- International Breast Cancer Study Group Statistical Center, Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - M Gnant
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - M Piccart-Gebhart
- Internal Medicine/Oncology, Institut Jules Bordet, Brussels, Belgium
| | - B Thürlimann
- Breast Center, Kantonsspital St Gallen, St Gallen
| | - H-J Senn
- Tumor and Breast Center ZeTuP, St Gallen, Switzerland
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16
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Francis PA, Regan MM, Fleming GF, Láng I, Ciruelos E, Bellet M, Bonnefoi HR, Climent MA, Da Prada GA, Burstein HJ, Martino S, Davidson NE, Geyer CE, Walley BA, Coleman R, Kerbrat P, Buchholz S, Ingle JN, Winer EP, Rabaglio-Poretti M, Maibach R, Ruepp B, Giobbie-Hurder A, Price KN, Colleoni M, Viale G, Coates AS, Goldhirsch A, Gelber RD. Adjuvant ovarian suppression in premenopausal breast cancer. N Engl J Med 2015; 372:436-46. [PMID: 25495490 PMCID: PMC4341825 DOI: 10.1056/nejmoa1412379] [Citation(s) in RCA: 456] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Suppression of ovarian estrogen production reduces the recurrence of hormone-receptor-positive early breast cancer in premenopausal women, but its value when added to tamoxifen is uncertain. METHODS We randomly assigned 3066 premenopausal women, stratified according to prior receipt or nonreceipt of chemotherapy, to receive 5 years of tamoxifen, tamoxifen plus ovarian suppression, or exemestane plus ovarian suppression. The primary analysis tested the hypothesis that tamoxifen plus ovarian suppression would improve disease-free survival, as compared with tamoxifen alone. In the primary analysis, 46.7% of the patients had not received chemotherapy previously, and 53.3% had received chemotherapy and remained premenopausal. RESULTS After a median follow-up of 67 months, the estimated disease-free survival rate at 5 years was 86.6% in the tamoxifen-ovarian suppression group and 84.7% in the tamoxifen group (hazard ratio for disease recurrence, second invasive cancer, or death, 0.83; 95% confidence interval [CI], 0.66 to 1.04; P=0.10). Multivariable allowance for prognostic factors suggested a greater treatment effect with tamoxifen plus ovarian suppression than with tamoxifen alone (hazard ratio, 0.78; 95% CI, 0.62 to 0.98). Most recurrences occurred in patients who had received prior chemotherapy, among whom the rate of freedom from breast cancer at 5 years was 82.5% in the tamoxifen-ovarian suppression group and 78.0% in the tamoxifen group (hazard ratio for recurrence, 0.78; 95% CI, 0.60 to 1.02). At 5 years, the rate of freedom from breast cancer was 85.7% in the exemestane-ovarian suppression group (hazard ratio for recurrence vs. tamoxifen, 0.65; 95% CI, 0.49 to 0.87). CONCLUSIONS Adding ovarian suppression to tamoxifen did not provide a significant benefit in the overall study population. However, for women who were at sufficient risk for recurrence to warrant adjuvant chemotherapy and who remained premenopausal, the addition of ovarian suppression improved disease outcomes. Further improvement was seen with the use of exemestane plus ovarian suppression. (Funded by Pfizer and others; SOFT ClinicalTrials.gov number, NCT00066690.).
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17
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Zhou J, Wu SG, Wang JJ, Sun JY, Li FY, Lin Q, Lin HX, He ZY. Ovarian Ablation Using Goserelin Improves Survival of Premenopausal Patients with Stage II/III Hormone Receptor-Positive Breast Cancer without Chemotherapy-Induced Amenorrhea. Cancer Res Treat 2014; 47:55-63. [PMID: 25187267 PMCID: PMC4296851 DOI: 10.4143/crt.2013.165] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 11/16/2013] [Indexed: 12/29/2022] Open
Abstract
Purpose The purpose of this study was to assess the value of ovarian ablation using goserelin in premenopausal patients with stage II/III hormone receptor-positive breast cancer without chemotherapy-induced amenorrhea (CIA). Materials and Methods We retrospectively reviewed the data of breast patients treated between October 1999 and November 2007 without CIA. The Kaplan-Meier method was used for calculation of the survival rate. Log rank method and Cox regression analysis were used for univariate and multivariate prognostic analysis. Results The median follow-up period was 61 months. Initially, 353 patients remained without CIA after chemotherapy and 98 among those who received goserelin and tamoxifen (TAM). In univariate analysis, goserelin improved locoregional recurrence-free survival (LRFS) (98.9% vs. 94.1%, p=0.041), distant metastasis-free survival (DMFS) (85.4% vs. 71.9%, p=0.006), disease-free survival (DFS) (85.4% vs. 71.6%, p=0.005), and overall survival (OS) (93.5% vs. 83.5%, p=0.010). In multivariate analysis, goserelin treatment was an independent factor influencing DMFS (hazard ratio [HR], 1.603; 95% confidence interval [CI], 1.228 to 2.092; p=0.001), DFS (HR, 1.606; 95% CI, 1.231 to 2.096; p=0.001), and OS (HR, 3.311; 95% CI, 1.416 to 7.742; p=0.006). In addition, treatment with goserelin resulted in significantly improved LRFS (p=0.039), DMFS (p=0.043), DFS (p=0.036), and OS (p=0.010) in patients aged < 40 years. In patients aged ≥ 40 years, goserelin only improved DMFS (p=0.028) and DFS (p=0.027). Conclusion Ovarian ablation with goserelin plus TAM resulted in significantly improved therapeutic efficacy in premenopausal patients with stage II/III hormone receptor-positive breast cancer without CIA.
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Affiliation(s)
- Juan Zhou
- Departments of Obstetrics and Gynecology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - San-Gang Wu
- Departments of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Jun-Jie Wang
- Department of Medical Oncology, The Central Hospital of Xinxiang, Xinxiang, China
| | - Jia-Yuan Sun
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Feng-Yan Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Qin Lin
- Departments of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Huan-Xin Lin
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Zhen-Yu He
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
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18
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Palmieri C, Patten DK, Januszewski A, Zucchini G, Howell SJ. Breast cancer: current and future endocrine therapies. Mol Cell Endocrinol 2014; 382:695-723. [PMID: 23933149 DOI: 10.1016/j.mce.2013.08.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 07/31/2013] [Accepted: 08/01/2013] [Indexed: 12/29/2022]
Abstract
Endocrine therapy forms a central modality in the treatment of estrogen receptor positive breast cancer. The routine use of 5 years of adjuvant tamoxifen has improved survival rates for early breast cancer, and more recently has evolved in the postmenopausal setting to include aromatase inhibitors. The optimal duration of adjuvant endocrine therapy remains an active area of clinical study with recent data supporting 10 years rather than 5 years of adjuvant tamoxifen. However, endocrine therapy is limited by the development of resistance, this can occur by a number of possible mechanisms and numerous studies have been performed which combine endocrine therapy with agents that modulate these mechanisms with the aim of preventing or delaying the emergence of resistance. Recent trial data regarding the combination of the mammalian target of rapamycin (mTOR) inhibitor, everolimus with endocrine therapy have resulted in a redefinition of the clinical treatment pathway in the metastatic setting. This review details the current endocrine therapy utilized in both early and advanced disease, as well as exploring potential new targets which modulate pathways of resistance, as well as agents which aim to modulate adrenal derived steroidogenic hormones.
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Affiliation(s)
- Carlo Palmieri
- The University of Liverpool, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, Liverpool L69 3GA, UK; Liverpool & Merseyside Breast Academic Unit, The Linda McCartney Centre, Royal Liverpool University Hospital, Liverpool L7 8XP, UK; Academic Department of Medical Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Wiral CH63 4JY, UK.
| | - Darren K Patten
- Department of Surgery, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
| | - Adam Januszewski
- Department of Medical Oncology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
| | - Giorgia Zucchini
- The University of Manchester, Institute of Cancer Studies, Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Sacha J Howell
- The University of Manchester, Institute of Cancer Studies, Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
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19
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Regan MM, Pagani O, Fleming GF, Walley BA, Price KN, Rabaglio M, Maibach R, Ruepp B, Coates AS, Goldhirsch A, Colleoni M, Gelber RD, Francis PA. Adjuvant treatment of premenopausal women with endocrine-responsive early breast cancer: design of the TEXT and SOFT trials. Breast 2013; 22:1094-100. [PMID: 24095609 DOI: 10.1016/j.breast.2013.08.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 08/14/2013] [Accepted: 08/29/2013] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES In 2003 the International Breast Cancer Study Group (IBCSG) initiated the TEXT and SOFT randomized phase III trials to answer two questions concerning adjuvant treatment for premenopausal women with endocrine-responsive early breast cancer: 1-What is the role of aromatase inhibitors (AI) for women treated with ovarian function suppression (OFS)? 2-What is the role of OFS for women who remain premenopausal and are treated with tamoxifen? METHODS TEXT randomized patients to receive exemestane or tamoxifen with OFS. SOFT randomized patients to receive exemestane with OFS, tamoxifen with OFS, or tamoxifen alone. Treatment was for 5 years from randomization. RESULTS TEXT and SOFT successfully met their enrollment goals in 2011. The 5738 enrolled women had lower-risk disease and lower observed disease-free survival (DFS) event rates than anticipated. Consequently, 7 and 13 additional years of follow-up for TEXT and SOFT, respectively, were required to reach the targeted DFS events (median follow-up about 10.5 and 15 years). To provide timely answers, protocol amendments in 2011 specified analyses based on chronological time and median follow-up. To assess the AI question, exemestane + OFS versus tamoxifen + OFS, a combined analysis of TEXT and SOFT became the primary analysis (n = 4717). The OFS question became the primary analysis from SOFT, assessing the unique comparison of tamoxifen + OFS versus tamoxifen alone (n = 2045). The first reports are anticipated in mid- and late-2014. CONCLUSIONS We present the original designs of TEXT and SOFT and adaptations to ensure timely answers to two questions concerning optimal adjuvant endocrine treatment for premenopausal women with endocrine-responsive breast cancer. Trial Registration TEXT: Clinicaltrials.govNCT00066703 SOFT: Clinicaltrials.govNCT00066690.
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Affiliation(s)
- Meredith M Regan
- International Breast Cancer Study Group Statistical Center, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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20
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Joerger M, Thürlimann B. Chemotherapy regimens in early breast cancer: major controversies and future outlook. Expert Rev Anticancer Ther 2013; 13:165-78. [PMID: 23406558 DOI: 10.1586/era.12.172] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The addition of adjuvant chemotherapy in early breast cancer improves overall survival by approximately 10%. Recommendations favor the use of anthracyclines and taxanes in patients with luminal B disease, while the use of an anthracycline, taxane and alkylating agent is recommended in triple-negative disease. In luminal B disease, the addition of chemotherapy to endocrine treatment depends on estrogen receptor expression and overall risk. Chemotherapy is not recommended in most patients with luminal A (highly hormone-sensitive and low proliferation) breast cancer. A major controversy is the addition of adjuvant chemotherapy to endocrine treatment in patients with estrogen receptor-positive breast cancer. In some of these patients, multigene signatures such as the 21-gene recurrence score may be a useful addition to histopathology. The introduction of molecular subtypes and gene signatures improves the complexity of early breast cancer treatment, and individual institutes have to find their policy based on their histopathological information and the availability of gene signatures.
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Affiliation(s)
- Markus Joerger
- Department of Oncology & Hematology, Cantonal Hospital, Rorschacherstrasse 95, 9007 St Gallen, Switzerland.
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Goldhirsch A, Winer EP, Coates AS, Gelber RD, Piccart-Gebhart M, Thürlimann B, Senn HJ. Personalizing the treatment of women with early breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013. Ann Oncol 2013; 24:2206-23. [PMID: 23917950 PMCID: PMC3755334 DOI: 10.1093/annonc/mdt303] [Citation(s) in RCA: 2408] [Impact Index Per Article: 218.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/01/2013] [Accepted: 07/02/2013] [Indexed: 02/07/2023] Open
Abstract
The 13th St Gallen International Breast Cancer Conference (2013) Expert Panel reviewed and endorsed substantial new evidence on aspects of the local and regional therapies for early breast cancer, supporting less extensive surgery to the axilla and shorter durations of radiation therapy. It refined its earlier approach to the classification and management of luminal disease in the absence of amplification or overexpression of the Human Epidermal growth factor Receptor 2 (HER2) oncogene, while retaining essentially unchanged recommendations for the systemic adjuvant therapy of HER2-positive and 'triple-negative' disease. The Panel again accepted that conventional clinico-pathological factors provided a surrogate subtype classification, while noting that in those areas of the world where multi-gene molecular assays are readily available many clinicians prefer to base chemotherapy decisions for patients with luminal disease on these genomic results rather than the surrogate subtype definitions. Several multi-gene molecular assays were recognized as providing accurate and reproducible prognostic information, and in some cases prediction of response to chemotherapy. Cost and availability preclude their application in many environments at the present time. Broad treatment recommendations are presented. Such recommendations do not imply that each Panel member agrees: indeed, among more than 100 questions, only one (trastuzumab duration) commanded 100% agreement. The various recommendations in fact carried differing degrees of support, as reflected in the nuanced wording of the text below and in the votes recorded in supplementary Appendix S1, available at Annals of Oncology online. Detailed decisions on treatment will as always involve clinical consideration of disease extent, host factors, patient preferences and social and economic constraints.
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Affiliation(s)
- A Goldhirsch
- International Breast Cancer Study Group, Division of Medical Oncology, European Institute of Oncology, Milan, Italy.
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Combined effects of goserelin and tamoxifen on estradiol level, breast density, and endometrial thickness in premenopausal and perimenopausal women with early-stage hormone receptor-positive breast cancer: a randomised controlled clinical trial. Br J Cancer 2013; 109:582-8. [PMID: 23860520 PMCID: PMC3738136 DOI: 10.1038/bjc.2013.324] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 05/28/2013] [Accepted: 06/04/2013] [Indexed: 12/02/2022] Open
Abstract
Background: This study is to investigate the effects of geserelin+tamoxifen (TAM) on estradiol level, breast density (BD), endometrial thickness (ET), and blood lipids in premenopausal and perimenopausal women with hormone receptor-positive early-stage breast cancer. Methods: This study recruited 110 premenopausal and perimenopausal patients with hormone receptor-positive early-stage breast cancer between 22 June 2008 and 31 December 2009 and randomly assigned them to receive either goserelin plus TAM or TAM alone for 1.5 years. Blood levels of sex hormones and lipids and ET were determined at 0, 3, 6, 12, and 18 months. Contralateral BD was also measured at 0, 12, and 18 months. Results: Five participants dropped out of the goserelin plus TAM group, and two participants dropped out of the TAM-alone group before initiation of endocrine therapy. The rest of patients received scheduled treatment and 3 years of median follow-up. No serious adverse effects were observed, and only two local recurrences have been observed in these patients. Estradiol level and BD were lower in the goserelin plus TAM group than in the TAM-alone group (P<0.05). The endometrium in the goserelin plus TAM group was significantly thinner than that in the TAM-alone group (P<0.05), and women in the TAM-alone group exhibited endometrial thickening over the course of the study. Furthermore, no significant differences in blood lipid levels were reported between the two groups. Conclusion: The data from the current study demonstrated that the addition of goserelin to TAM results in downregulation of estradiol level, followed by significant reduction in BD and ET in premenopausal and perimenopausal women with hormone receptor-positive breast cancer, which may eventually lead to better outcome in these patients.
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Christinat A, Di Lascio S, Pagani O. Hormonal therapies in young breast cancer patients: when, what and for how long? J Thorac Dis 2013; 5 Suppl 1:S36-46. [PMID: 23819026 DOI: 10.3978/j.issn.2072-1439.2013.05.25] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/19/2013] [Indexed: 12/26/2022]
Abstract
Breast cancer in young women (<40 years) is a rare and complex clinical and psychosocial condition, which deserves multidisciplinary and personalized approaches. In young women with hormone-receptor positive disease, 5 years of adjuvant tamoxifen, with or without ovarian suppression/ablation, is considered the standard endocrine therapy. The definitive role of adjuvant aromatase inhibitors has still to be elucidated: the upcoming results of the Tamoxifen and EXemestane Trial (TEXT) and Suppression of Ovarian Function Trial (SOFT) trials will help understanding if we can widen our current endocrine therapeutic options. The optimal duration of adjuvant endocrine therapy in young women also remains an unresolved issue. The recently reported results of the ATLAS and aTToM trials represent the first evidence of a beneficial effect of extended endocrine therapy in premenopausal women and provide an important opportunity in high-risk young patients. In the metastatic setting, endocrine therapy should be the preferred choice for endocrine responsive disease, unless there is evidence of endocrine resistance or need for rapid disease and/or symptom control. Tamoxifen in combination with ovarian suppression/ablation remains the 1st-line endocrine therapy of choice. Aromatase inhibitors in combination with ovarian suppression/ablation can be considered after progression on tamoxifen and ovarian suppression/ablation. Fulvestrant has not yet been studied in pre-menopausal women. Specific age-related treatment side effects (i.e., menopausal symptoms, change in body image and weight gain, cognitive function impairment, fertility damage/preservation, long-term organ dysfunction, sexuality) and the social impact of diagnosis and treatment (i.e., job discrimination, family management) should be carefully addressed when planning long-lasting endocrine therapies in young women with hormone-receptor positive early and advanced breast cancer.
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Affiliation(s)
- Alexandre Christinat
- Institute of Oncology of Southern Switzerland (IOSI) and Breast Unit of Southern Switzerland (CSSI), Bellinzona, Switzerland
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Joerger M, Thürlimann B, Savidan A, Frick H, Bouchardy C, Konzelmann I, Probst-Hensch N, Ess S. A Population-Based Study on the Implementation of Treatment Recommendations for Chemotherapy in Early Breast Cancer. Clin Breast Cancer 2012; 12:102-9. [DOI: 10.1016/j.clbc.2011.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 09/30/2011] [Accepted: 10/14/2011] [Indexed: 10/14/2022]
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Prise en charge du cancer du sein infiltrant de la femme âgée de 40 ans ou moins. ONCOLOGIE 2011. [DOI: 10.1007/s10269-011-2078-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Pinto Marín A, Ballesteros García AI, Izarzugaza Perón Y, Mansó Sánchez L, López-Tarruella Cobo S, Zamora Auñón P. Adjuvant hormonal therapy in perimenopausal patients. Adv Ther 2011; 28 Suppl 6:39-49. [PMID: 21922394 DOI: 10.1007/s12325-011-0023-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Indexed: 01/01/2023]
Abstract
This section considers the treatment options for perimenopausal women with breast cancer. The perimenopause period begins in the so-called stage 2 of menopausal transition (early menopausal transition, where the length of the cycles changes by 7 days or more) and ends after 12 months of amenorrhea. It is characterized by an early increase in follicle-stimulating hormone and is associated with the presence of anovulatory cycles, irregular periods, and loss of menstrual cycles. The recommended treatment is tamoxifen (TAM) with or without ovarian ablation for 2 or 3 years followed by a re-evaluation. TAM should be maintained if the patient is premenopausal and aromatase inhibitors (AI) are recommended once the menopausal status is confirmed. Ovarian suppression is an acceptable adjuvant therapy in those patients with hormone-sensitive tumors. AI should only be used in postmenopausal women or in combination with chemical castration in premenopausal women. This supplement paper includes the key points of roundtable presentations and discussions of hormonal therapy in breast cancer.
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Affiliation(s)
- A Pinto Marín
- Oncology Department, Hospital Universitario La Paz, Madrid, Spain
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Optimal adjuvant therapy for very young breast cancer patients. Breast 2011; 20:297-302. [DOI: 10.1016/j.breast.2011.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 04/28/2011] [Indexed: 11/22/2022] Open
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Gnant M, Mlineritsch B, Stoeger H, Luschin-Ebengreuth G, Heck D, Menzel C, Jakesz R, Seifert M, Hubalek M, Pristauz G, Bauernhofer T, Eidtmann H, Eiermann W, Steger G, Kwasny W, Dubsky P, Hochreiner G, Forsthuber EP, Fesl C, Greil R. Adjuvant endocrine therapy plus zoledronic acid in premenopausal women with early-stage breast cancer: 62-month follow-up from the ABCSG-12 randomised trial. Lancet Oncol 2011; 12:631-41. [PMID: 21641868 DOI: 10.1016/s1470-2045(11)70122-x] [Citation(s) in RCA: 351] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Analysis of the Austrian Breast and Colorectal Cancer Study Group trial-12 (ABCSG-12) at 48 months' follow-up showed that addition of zoledronic acid to adjuvant endocrine therapy significantly improved disease-free survival. We have now assessed long-term clinical efficacy including disease-free survival and disease outcomes in patients receiving anastrozole or tamoxifen with or without zoledronic acid. METHODS ABSCG-12 is a randomised, controlled, open-label, two-by-two factorial, multicentre trial in 1803 premenopausal women with endocrine-receptor-positive early-stage (stage I-II) breast cancer receiving goserelin (3.6 mg every 28 days), comparing the efficacy and safety of anastrozole (1 mg per day) or tamoxifen (20 mg per day) with or without zoledronic acid (4 mg every 6 months) for 3 years. Randomisation (1:1:1:1 ratio) was computerised and based on the Pocock and Simon minimisation method to balance the four treatment arms across eight prognostic variables (age, neoadjuvant chemotherapy, pathological tumour stage; lymph-node involvement, type of surgery or locoregional therapy, complete axillary dissection, intraoperative radiation therapy, and geographical region). Treatment allocation was not masked. The primary endpoint was disease-free survival (defined as disease recurrence or death) and analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00295646; follow-up is ongoing. FINDINGS At a median follow-up of 62 months (range 0-114.4 months), more than 2 years after treatment completion, 186 disease-free survival events had been reported (53 events in 450 patients on tamoxifen alone, 57 in 453 patients on anastrozole alone, 36 in 450 patients on tamoxifen plus zoledronic acid, and 40 in 450 patients on anastrozole plus zoledronic acid). Zoledronic acid reduced risk of disease-free survival events overall (HR 0.68, 95% CI 0.51-0.91; p=0.009), although the difference was not significant in the tamoxifen (HR 0.67, 95% CI 0.44-1.03; p=0.067) and anastrozole arms (HR 0.68, 95% CI 0.45-1.02; p=0.061) assessed separately. Zoledronic acid did not significantly affect risk of death (30 deaths with zoledronic acid vs 43 deaths without; HR 0.67, 95% CI 0.41-1.07; p=0.09). There was no difference in disease-free survival between patients on tamoxifen alone versus anastrozole alone (HR 1.08, 95% CI 0.81-1.44; p=0.591), but overall survival was worse with anastrozole than with tamoxifen (46 vs 27 deaths; HR 1.75, 95% CI 1.08-2.83; p=0.02). Treatments were generally well tolerated, with no reports of renal failure or osteonecrosis of the jaw. Bone pain was reported in 601 patients (33%; 349 patients on zoledronic acid vs 252 not on the drug), fatigue in 361 (20%; 192 vs 169), headache in 280 (16%; 147 vs 133), and arthralgia in 266 (15%; 145 vs 121). INTERPRETATION Addition of zoledronic acid improved disease-free survival in the patients taking anastrozole or tamoxifen. There was no difference in disease-free survival between patients receiving anastrozole and tamoxifen overall, but those on anastrozole alone had inferior overall survival. These data show persistent benefits with zoledronic acid and support its addition to adjuvant endocrine therapy in premenopausal patients with early-stage breast cancer. FUNDING AstraZeneca; Novartis.
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Affiliation(s)
- Michael Gnant
- Department of Surgery, Comprehensive Cancer Centre Vienna, Medical University of Vienna, A-1090 Vienna, Austria.
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Developing an international network for breast cancer research: the BIG experience. ACTA ACUST UNITED AC 2011. [DOI: 10.4155/cli.11.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Karlsson P, Sun Z, Braun D, Price KN, Castiglione-Gertsch M, Rabaglio M, Gelber RD, Crivellari D, Collins J, Murray E, Zaman K, Colleoni M, Gusterson BA, Viale G, Regan MM, Coates AS, Goldhirsch A. Long-term results of International Breast Cancer Study Group Trial VIII: adjuvant chemotherapy plus goserelin compared with either therapy alone for premenopausal patients with node-negative breast cancer. Ann Oncol 2011; 22:2216-26. [PMID: 21325445 DOI: 10.1093/annonc/mdq735] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The International Breast Cancer Study Group Trial VIII compared long-term efficacy of endocrine therapy (goserelin), chemotherapy [cyclophosphamide, methotrexate and fluorouracil (CMF)], and chemoendocrine therapy (CMF followed by goserelin) for pre/perimenopausal women with lymph-node-negative breast cancer. PATIENTS AND METHODS From 1990 to 1999, 1063 patients were randomized to receive (i) goserelin for 24 months (n = 346), (ii) six courses of 'classical' CMF (cyclophosphamide, methotrexate, 5-fluorouracil) chemotherapy (n = 360), or (iii) six courses of CMF plus 18 months goserelin (CMF→ goserelin; n = 357). Tumors were classified as estrogen receptor (ER) negative (19%), ER positive (80%), or ER unknown (1%); 19% of patients were younger than 40. Median follow-up was 12.1 years. RESULTS For the ER-positive cohort, sequential therapy provided a statistically significant benefit in disease-free survival (DFS) (12-year DFS = 77%) compared with CMF alone (69%) and goserelin alone (68%) (P = 0.04 for each comparison), due largely to the effect in younger patients. Patients with ER-negative tumors whose treatment included CMF had similar DFS (12-year DFS CMF = 67%; 12-year DFS CMF→ goserelin = 69%) compared with goserelin alone (12-year DFS = 61%, P= NS). CONCLUSIONS For pre/perimenopausal women with lymph-node-negative ER-positive breast cancer, CMF followed by goserelin improved DFS in comparison with either modality alone. The improvement was the most pronounced in those aged below 40, suggesting an endocrine effect of prolonged CMF-induced amenorrhea.
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Affiliation(s)
- P Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Pronzato P, Mustacchi G, De Matteis A, Di Costanzo F, Rulli E, Floriani I, Cazzaniga ME. Biological characteristics and medical treatment of breast cancer in young women-a featured population: results from the NORA study. Int J Breast Cancer 2010; 2011:534256. [PMID: 22332011 PMCID: PMC3275934 DOI: 10.4061/2011/534256] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 08/16/2010] [Indexed: 11/20/2022] Open
Abstract
Background. The present paper described the biological characteristics and clinical behavior of young women in the cohort NORA study Patients and Methods. From 2000–2002, patients (N > 3500) were enrolled at 77 Italian hospitals. Women aged ≤50 years (N = 1013) were stratified into age groups (≤35, 36–40, 41–45, and 46–50 years). The relationship between age and patient characteristics, cancer presentation, and treatment was analyzed. Results. Younger women more frequently had tumors with ER/PgR-negative(χ2 = 7.07; P = .008), HER2 amplification (χ2 = 5.76; P = .01), and high (≥10%) Ki67 labelling index (χ2 = 9.53; P = .002). Positive nodal status, large tumors, and elevated Ki67 all associated with the choice for chemotherapy followed by endocrine therapy in hormone receptor-positive patients (P < .0001). At univariate analysis, ER-ve status, chemotherapy and age resulted as the only statistically significant variables (HR = 2.02, P = .004, and >40 versus ≤40, P < .0001, resp.). At multivariate analysis, after adjustment for significant clinical and pathological factors, age remains a significant prognostic variable (HR = 0.93, P = .0021). Conclusion. This cohort study suggests that age per sè is an important prognostic factor. The restricted role of early diagnosis and the aggressive behavior of cancer in this population make necessary the application of targeted medical strategies crucial.
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Affiliation(s)
- P Pronzato
- Oncologia Medica, IST, Genova 16010, Italy
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Gelber RD, Gelber S. Facilitating consensus by examining patterns of treatment effects. Breast 2010; 18 Suppl 3:S2-8. [PMID: 19914537 DOI: 10.1016/s0960-9776(09)70265-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Randomized clinical trials are necessary to provide reliable evidence concerning the effectiveness and safety of adjuvant therapies for breast cancer. Such trials, however, are not sufficient to provide information needed to tailor therapies to individual patients. Trials focus on testing treatments on average for heterogeneous patient populations, while attention to the specific characteristics of the disease and the patient are needed to assess the potential benefit for the individual. While 'across the board' results are useful from a population perspective, examination of patterns of treatment response during the course of follow up and for subpopulations of patients is required to make progress and solidify consensus on how to treat individual patients. For example, for several decades it has been known that the pattern of recurrence risk from time of diagnosis is different for estrogen receptor (ER)-negative and ER-positive disease. Assuming that ER status is accurately assessed and distinguishing absence of receptors from low, intermediate and high expression cohorts, one can recognize patterns of relapse risk that are early versus later during follow up. Treatments effective against ER-negative disease reduce the risk of early relapse, while those acting on ER-positive disease demonstrate effectiveness later during the course of follow up. Another example is HER2-positive disease, where a relatively high proportion of patients tend to relapse early, and treatments such as trastuzumab that reduce the risk of early relapse have demonstrated efficacy. For premenopausal patients with ER-positive disease, ovarian function suppression and endocrine effects of chemotherapy are effective to reduce the risk of late occurring relapses. Examining the influence of patient and disease-related factors on the patterns of recurrence over time and treatment responsiveness within subpopulations in multiple randomized trials can facilitate consensus on progress that has been made and identify areas for improving the care of patients with breast cancer.
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Affiliation(s)
- Richard D Gelber
- International Breast Cancer Study Group Statistical Center, Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA.
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Paridaens RJ, Gelber S, Cole BF, Gelber RD, Thürlimann B, Price KN, Holmberg SB, Crivellari D, Coates AS, Goldhirsch A. Adjuvant! Online estimation of chemotherapy effectiveness when added to ovarian function suppression plus tamoxifen for premenopausal women with estrogen-receptor-positive breast cancer. Breast Cancer Res Treat 2010; 123:303-10. [PMID: 20195744 DOI: 10.1007/s10549-010-0794-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 02/06/2010] [Indexed: 10/19/2022]
Abstract
Adjuvant! Online (Adjuvant!) is a user-friendly, web-based tool that provides estimates of adjuvant therapy outcomes for individual patients. While reliable evidence underpins estimates for most patient cohorts, there is a paucity of data on the effect of adding chemotherapy to complete estrogen blockade for premenopausal women with estrogen-receptor positive breast cancer. International Breast Cancer Study Group (IBCSG) Trial 11-93 enrolled 174 premenopausal women with estrogen-receptor positive, node-positive breast cancer. Among these patients, 55% had one positive axillary lymph node and 97% had three or fewer positive nodes. Patients were randomized to receive ovarian function suppression plus 5 years of tamoxifen with or without anthracycline-based chemotherapy. Estimated hazard rates and corresponding 10-year relapse-free survival percentages obtained from Trial 11-93 data were compared with those predicted using Adjuvant!. The 10-year relapse-free survival percentages predicted from Adjuvant! were 64.4% (95% CI, 61.9-67.2%) for endocrine therapy alone and 74.9% (95% CI, 73.1-76.8%) for chemoendocrine therapy. By contrast, these estimates in Trial 11-93 were 76.4% (95% CI, 65.8-84.0%) for endocrine therapy alone and 74.9% (95% CI, 64.5-82.7%) for chemoendocrine therapy. The Adjuvant! estimate for the endocrine-alone control group is lower than that observed in Trial 11-93 (P = 0.03), while the estimates for the two chemoendocrine therapy groups are similar. Adjuvant! appears to underestimate the effectiveness of adjuvant endocrine therapy alone for premenopausal women with endocrine responsive breast cancer, thus overestimating the added benefit, if any, from chemotherapy for this patient population.
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Affiliation(s)
- Robert J Paridaens
- Department of Medical Oncology, University Hospital Gasthuisberg, Catholic University of Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Blancas I, Gómez FJ, Bermejo B, Hennessy BT, Chirivella I, Magro A, Caballero A, Ferrer J, Valero V, Lluch A. Outcome differences between patients with node-negative breast cancer classified according to the st. Gallen risk categories. Clin Breast Cancer 2009; 9:231-6. [PMID: 19933078 DOI: 10.3816/cbc.2009.n.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE The purpose of this study was to compare the 2007 St. Gallen risk categories with the outcomes of patients with node-negative breast cancer (NNBC). PATIENTS AND METHODS We retrospectively reviewed the medical records of 1500 women with pathologically T1-T3 NNBC treated at the Clinic Hospital, Valencia University (Spain) from 1982 to 2000. Systemic adjuvant treatment was administered to 89.9% of the patients in the whole sample (37% received only hormonal therapy and 52.9% chemotherapy). The 2007 St. Gallen criteria were used to divide the whole sample into 1201 patients with intermediate risk (with > or = 1 of the following: pathologic tumor size > 2 cm, grade 2-3, estrogen receptor and progesterone receptor absent, HER2/neu gene overexpressed or amplified, or age < 35 years) and 299 patients with low risk. Of the 1201 patients with intermediate risk, 56% received adjuvant chemotherapy. The intermediate- and low-risk groups were compared for relapse-free survival (RFS) and breast cancer-specific survival (BCSS). RESULTS Median follow-up of the entire sample was 61 months (range, 2-251 months). At 5 years, the overall RFS rate was 86%, and the BCSS rate was 95%. For low-risk patients, the RFS rate was 92%, and the BCSS rate was 98%. For intermediate-risk patients, the RFS rate was 84%, and the BCSS rate was 94%. There was a statistically significant difference between the 2 groups in terms of RFS (P = .006) and BCSS (P = .041) independent of received treatment. CONCLUSION Using the St. Gallen risk categories resulted in significantly different outcomes for patients with NNBC. The St. Gallen classification might be a valuable clinical tool when assessing patients with NNBC.
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Affiliation(s)
- Isabel Blancas
- Department of Oncology and Hematology, Clinic Hospital, Valencia, Spain.
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Crivellari D, Molino A. Identifying optimal adjuvant treatment for individual patients: young age is still an issue? Ann Oncol 2009; 21:430-431. [PMID: 19940009 DOI: 10.1093/annonc/mdp545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- D Crivellari
- Division of Medical Oncology C, Centro di Riferimento Oncologico, Istituto Nazionale Tumori, Aviano.
| | - A Molino
- Division of Oncology, Ospedale Civile Maggiore, Azienda Ospedaliera-Universitaria, Verona, Italy
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Hackshaw A. Luteinizing hormone-releasing hormone (LHRH) agonists in the treatment of breast cancer. Expert Opin Pharmacother 2009; 10:2633-9. [DOI: 10.1517/14656560903224980] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bramwell VHC, Pritchard KI, Tu D, Tonkin K, Vachhrajani H, Vandenberg TA, Robert J, Arnold A, O'Reilly SE, Graham B, Shepherd L. A randomized placebo-controlled study of tamoxifen after adjuvant chemotherapy in premenopausal women with early breast cancer (National Cancer Institute of Canada--Clinical Trials Group Trial, MA.12). Ann Oncol 2009; 21:283-290. [PMID: 19628570 DOI: 10.1093/annonc/mdp326] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND In the early 1990s, the role of adjuvant tamoxifen in premenopausal women with early breast cancer (EBC) was not established. Similarly, optimum timing relative to adjuvant chemotherapy and efficacy of tamoxifen in hormone receptor-negative tumors were unclear. PATIENTS AND METHODS Premenopausal women with EBC, any hormone receptor status, after surgery received standard adjuvant chemotherapy [doxorubicin (adriamycin)/cyclophosphamide, cyclophosphamide/methotrexate/5-fluorouracil, or cyclophosphamide/epirubicin/5-fluorouracil] followed by randomization to tamoxifen or placebo for 5 years. Outcomes were overall survival (OS), disease-free survival (DFS), toxicity, and compliance with therapy. RESULTS Median follow-up for 672 women was 9.7 years. Multivariate analysis showed improved DFS [78.2% versus 71.3% at 5 years; hazard ratio (HR) 0.77; P = 0.056] and a trend for improved OS (86.6% versus 82.1% at 5 years; HR 0.78; P = 0.12). There was no evidence of greater benefit for the receptor-positive subgroup. Compliance with treatment was suboptimal in both arms, with 103 (31%) women on tamoxifen and 70 (21%) on placebo-stopping therapy early because of toxicity, refusal, or other choices. CONCLUSIONS Adjuvant tamoxifen, given after chemotherapy to premenopausal women with EBC, improved 5-year DFS. Poor compliance may have reduced treatment efficacy.
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Affiliation(s)
- V H C Bramwell
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta.
| | - K I Pritchard
- Department of Medical Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario
| | - D Tu
- Central Office, National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario
| | - K Tonkin
- Department of Medical Oncology, Cross Cancer Institute, Edmonton, Alberta
| | - H Vachhrajani
- Department of Radiation Oncology, Saskatoon Cancer Centre, Saskatoon, Saskatchewan
| | - T A Vandenberg
- Department of Medical Oncology, London Regional Cancer Program, London, Ontario
| | - J Robert
- Department of Surgical Oncology, Hôpital Du Saint-Sacrement, Quebec City, Quebec
| | - A Arnold
- Department of Medical Oncology, Juravinski Cancer Centre, Hamilton, Ontario
| | - S E O'Reilly
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - B Graham
- Central Office, National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario
| | - L Shepherd
- Central Office, National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario
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40
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Greil R. The Dark Side of the Moon - the Side Effects of Therapy in a Dynamic Era of Breast Cancer Management. Breast Care (Basel) 2009; 4:144-147. [PMID: 20847873 PMCID: PMC2931000 DOI: 10.1159/000225388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Richard Greil
- Universitätsklinik für Innere Medizin III mit Hämatologie, internistische Onkologie, Hämostaseologie, Infektiologie und Rheumatologie, Onkologisches Zentrum, Paracelsus Medizinische Privatuniversität Salzburg, Austria
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41
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Morris GJ, Berger AC, Emanuelson RG, Jordan WE, McGuire K, Thomas LC. Breast cancer with positive sentinel lymph node: now what? Semin Oncol 2009; 36:84-9. [PMID: 19332242 DOI: 10.1053/j.seminoncol.2009.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Gloria J Morris
- Current Clinical Practice, Hematology and Oncology Associates of Northeast PA, PC, Dunmore, PA 18512, USA.
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42
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Pagani O, Gelber S, Simoncini E, Castiglione-Gertsch M, Price KN, Gelber RD, Holmberg SB, Crivellari D, Collins J, Lindtner J, Thürlimann B, Fey MF, Murray E, Forbes JF, Coates AS, Goldhirsch A. Is adjuvant chemotherapy of benefit for postmenopausal women who receive endocrine treatment for highly endocrine-responsive, node-positive breast cancer? International Breast Cancer Study Group Trials VII and 12-93. Breast Cancer Res Treat 2008; 116:491-500. [PMID: 18953651 DOI: 10.1007/s10549-008-0225-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/03/2008] [Indexed: 01/26/2023]
Abstract
To compare the efficacy of chemoendocrine treatment with that of endocrine treatment (ET) alone for postmenopausal women with highly endocrine responsive breast cancer. In the International Breast Cancer Study Group (IBCSG) Trials VII and 12-93, postmenopausal women with node-positive, estrogen receptor (ER)-positive or ER-negative, operable breast cancer were randomized to receive either chemotherapy or endocrine therapy or combined chemoendocrine treatment. Results were analyzed overall in the cohort of 893 patients with endocrine-responsive disease, and according to prospectively defined categories of ER, age and nodal status. STEPP analyses assessed chemotherapy effect. The median follow-up was 13 years. Adding chemotherapy reduced the relative risk of a disease-free survival event by 19% (P = 0.02) compared with ET alone. STEPP analyses showed little effect of chemotherapy for tumors with high levels of ER expression (P = 0.07), or for the cohort with one positive node (P = 0.03). Chemotherapy significantly improves disease-free survival for postmenopausal women with endocrine-responsive breast cancer, but the magnitude of the effect is substantially attenuated if ER levels are high.
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Affiliation(s)
- Olivia Pagani
- Oncology Institute of Southern Switzerland, Ospedale Italiano, Viganello, Lugano, Switzerland.
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Iwase H. Current topics and perspectives on the use of aromatase inhibitors in the treatment of breast cancer. Breast Cancer 2008; 15:278-90. [DOI: 10.1007/s12282-008-0071-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 08/06/2008] [Indexed: 01/15/2023]
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44
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Hayes DF, Stearns V, Rae J, Flockhart D. Response: Re: Pharmacogenomic Variation of CYP2D6 and the Choice of Optimal Adjuvant Endocrine Therapy for Postmenopausal Breast Cancer: A Modeling Analysis. J Natl Cancer Inst 2008. [DOI: 10.1093/jnci/djn271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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45
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Del Mastro L. The difficult decision-making process for using or not using adjuvant chemotherapy in premenopausal endocrine-responsive breast cancer patients. Ann Oncol 2008; 19:1213-1215. [DOI: 10.1093/annonc/mdn157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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