Cyclophosphamide, methotrexate, and fluorouracil versus tamoxifen plus ovarian suppression as adjuvant treatment of estrogen receptor-positive pre-/perimenopausal breast cancer patients: results of the Italian Breast Cancer Adjuvant Study Group 02 randomized trial. boccardo@hp380.ist.unige.it

Adjuvant ovarian suppression for premenopausal hormone receptor-positive breast cancer: A network meta-analysis

BACKGROUND

Ovarian function suppressor (OFS) plus either tamoxifen (TAM) or aromatase inhibitor (AI) could improve the survival outcome for premenopausal hormone receptor-positive (HR+) breast cancer. However, the optimal OFS-based regimen and medication duration remain uncertain. This article aims to systematically evaluate the OFS-based adjuvant endocrine therapy for premenopausal breast cancer.

METHODS

We searched several public databases from January 1980 to November 2020. A random model was adopted in this meta-analysis. We used the hazard ratio (HR) with a 95% confidence interval (CI) for the statistical analysis of efficacy. The primary outcome measures included overall survival and disease-free survival.

RESULTS

A total of 32 articles with 37,224 cases were included in this network meta-analysis. OFS+TAM improved 5-year disease-free survival (HR -0.09, 95% CI -0.16 to -0.01) and 5-year overall survival (HR -0.18, 95% CI -0.33 to -0.03) compared with TAM monotherapy. For OFS+AI, although the 5-year disease-free survival was improved (HR -0.18, 95% CI -0.29 to -0.08), the 5-year overall survival was not improved (HR -0.13, 95% CI -0.43 to 0.18). In subgroup analysis, both OFS+AI and OFS+TAM showed a protective effect in stage I-III patients compared with stage I-II patients. For the course of therapy, OFS+TAM for 2-years could achieve clinical benefit and the best course of therapy of OFS+AI still waits for further study.

CONCLUSIONS

OFS+TAM might be a better option than OFS+AI for premenopausal intensive adjuvant endocrine therapy. Stage III patients are more suitable for the OFS-based therapy. For the medication duration, the 2-years course of OFS+TAM could be effective. This analysis provides helpful information for selecting therapeutic regimen in intensive adjuvant endocrine therapy and identifying the target population.

Management of hormone receptor-positive, HER2-negative early breast cancer

The majority of breast cancers are diagnosed at an early stage and are hormone receptor (HR)-positive and human epidermal growth factor receptor 2 (HER2)-negative. Significant advances have been made in the management of early stage HR-positive, HER2-negative breast cancer, resulting in improved survival outcomes. In this review, we discuss important factors to consider in the management of this disease. In particular, we discuss the role of adjuvant endocrine therapy, specific endocrine therapy agents, the duration of adjuvant endocrine therapy, treatment-related side effects, and the role of genomic assays and other biomarkers when considering treatment recommendations for individuals with HR-positive, HER2-negative early breast cancer. Finally, we address emerging data to individualize therapeutic decision-making and provide future considerations.

Ovarian suppression for adjuvant treatment of hormone receptor-positive early breast cancer

BACKGROUND

Approximately 80% of breast cancers amongst premenopausal women are hormone receptor-positive. Adjuvant endocrine therapy is an integral component of care for hormone receptor-positive breast cancer and in premenopausal women includes oestrogen receptor blockade with tamoxifen, temporary suppression of ovarian oestrogen synthesis by luteinising hormone releasing hormone (LHRH) agonists, and permanent interruption of ovarian oestrogen synthesis with oophorectomy or radiotherapy. Recent international consensus statements recommend single-agent tamoxifen or aromatase inhibitors with ovarian function suppression (OFS) as the current standard adjuvant endocrine therapy for premenopausal women (often preceded by chemotherapy). This review examined the role of adding OFS to another treatment (i.e. chemotherapy, endocrine therapy, or both) or comparing OFS to no further adjuvant treatment.

OBJECTIVES

To assess effects of OFS for treatment of premenopausal women with hormone receptor-positive early breast cancer.

SEARCH METHODS

For this review update, we searched the Specialised Register of the Cochrane Breast Cancer Group, MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 8), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov on 26 September 2019. We screened the reference lists of related articles, contacted trial authors, and applied no language restrictions.

SELECTION CRITERIA

We included all randomised trials assessing any method of OFS, that is, oophorectomy, radiation-induced ovarian ablation, or LHRH agonists, as adjuvant treatment for premenopausal women with early-stage breast cancer. We included studies that compared (1) OFS versus observation, (2) OFS + chemotherapy versus chemotherapy, (3) OFS + tamoxifen versus tamoxifen, and (4) OFS + chemotherapy + tamoxifen versus chemotherapy + tamoxifen.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias and certainty of evidence using the GRADE approach. Hazard ratios (HRs) were derived for time-to-event outcomes, and meta-analysis was performed using a fixed-effect model. The primary outcome measures were overall survival (OS) and disease-free survival (DFS). Toxicity, contralateral breast cancer, and second malignancy were represented as risk ratios (RRs), and quality of life data were extracted when provided.

MAIN RESULTS

This review update included 15 studies involving 11,538 premenopausal women with hormone receptor-positive early breast cancer; these studies were conducted from 1978 to 2014. Some of these treatments are not current standard of care, and early studies did not assess HER2 receptor status. Studies tested OFS versus observation (one study), OFS plus chemotherapy versus chemotherapy (six studies), OFS plus tamoxifen versus tamoxifen (six studies), and OFS plus chemotherapy and tamoxifen versus chemotherapy and tamoxifen (two studies). Of those studies that reported the chemotherapy regimen, an estimated 72% of women received an anthracycline. The results described below relate to the overall comparison of OFS versus no OFS. High-certainty evidence shows that adding OFS to treatment resulted in a reduction in mortality (hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.78 to 0.94; 11 studies; 10,374 women; 1933 reported events). This treatment effect was seen when OFS was added to observation, to tamoxifen, or to chemotherapy and tamoxifen. The effect on mortality was not observed when OFS was added to chemotherapy without tamoxifen therapy (HR 0.95, 95% CI 0.82 to 1.09; 5 studies; 3087 women; median follow-up: range 7.7 to 12.1 years). The addition of OFS resulted in improved DFS (HR 0.83, 95% CI 0.77 to 0.90; 10 studies; 8899 women; 2757 reported events; high-certainty evidence). The DFS treatment effect persisted when OFS was added to observation, to tamoxifen, and to chemotherapy and tamoxifen. The effect on DFS was reduced when OFS was added to chemotherapy without tamoxifen therapy (HR 0.90, 95% CI 0.79 to 1.01; 5 studies; 2450 women). Heterogeneity was low to moderate across studies for DFS and OS (respectively). Evidence suggests that adding OFS slightly increases the incidence of hot flushes (grade 3/4 or any grade; risk ratio (RR) 1.60, 95% CI 1.41 to 1.82; 6 studies; 5581 women; low-certainty evidence, as this may have been under-reported in these studies). Two other studies that could not be included in the meta-analysis reported a higher number of hot flushes in the OFS group than in the no-OFS group. Seven studies involving 5354 women collected information related to mood; however this information was reported as grade 3 or 4 depression, anxiety, or neuropsychiatric symptoms, or symptoms were reported without the grade. Two studies reported an increase in depression, anxiety, and neuropsychiatric symptoms in the OFS group compared to the no-OFS group, and five studies indicated an increase in anxiety in both treatment groups (but no difference between groups) or no difference overall in symptoms over time or between treatment groups. A single study reported bone health as osteoporosis (defined as T score < -2.5); this limited evidence suggests that OFS increases the risk of osteoporosis compared to no-OFS at median follow-up of 5.6 years (RR 1.16, 95% CI 1.10 to 28.82; 2011 women; low-certainty evidence). Adding OFS to treatment likely reduces the risk of contralateral breast cancer (HR 0.75, 95% CI 0.57 to 0.97; 9 studies; 9138 women; moderate-certainty evidence). Quality of life was assessed in five studies; four studies used validated tools, and the fifth study provided no information on how data were collected. Two studies reported worse quality of life indicators (i.e. vaginal dryness, day and night sweats) for women receiving OFS compared to those in the no-OFS group. The other two studies indicated worsening of symptoms (e.g. vasomotor, gynaecological, vaginal dryness, decline in sexual interest, bone and joint pain, weight gain); however these side effects were reported in both OFS and no-OFS groups. The study that did not use a validated quality of life tool described no considerable differences between groups.

AUTHORS' CONCLUSIONS

This review found evidence that supports adding OFS for premenopausal women with early, hormone receptor-positive breast cancers. The benefit of OFS persisted when compared to observation, and when added to endocrine therapy (tamoxifen) or chemotherapy and endocrine therapy (tamoxifen). The decision to use OFS may depend on the overall risk assessment based on tumour and patient characteristics, and may follow consideration of all side effects that occur with the addition of OFS.

Survival outcome of combined GnRH agonist and tamoxifen is comparable to that of sequential adriamycin and cyclophosphamide chemotherapy plus tamoxifen in premenopausal patients with early breast cancer

Survival outcome of ovarian suppression plus tamoxifen has been shown to be comparable with chemotherapy in premenopausal women; however, there are a few previous studies that compared this treatment to the current standard adriamycin and cyclophosphamide (AC) regimen. The aim of the present study was to compare the survival outcome of gonadotropin-releasing hormone (GnRH) agonist plus tamoxifen (GnRH-TAM) and chemotherapy AC plus tamoxifen (AC-TAM) in premenopausal patients with early breast cancer who were hormone receptor-positive. Premenopausal patients with early breast cancer who were treated at The Siriraj Hospital between January 2005 and December 2015 were retrospectively recruited. The inclusion criteria included newly diagnosed breast cancer, size ≤3 cm, node-negative and hormone receptor-positive. All patients received adjuvant systemic therapy and were divided into two groups. In the GnRH-TAM group, the patients received subcutaneous injection of 10.8 mg of goserelin every 3 months for 2-3 years and TAM (20 mg/day) for 5 years. In the AC-TAM group, AC was administered every 3 weeks for 4 cycles followed by TAM (20 mg/day) for 5 years. In total, 40 patients received GnRH-TAM and 130 patients received AC-TAM. The mean age at diagnosis was 44.4±6.3 years while the median follow up time was 77 (36-167) months. There was no mortality in either group and no significant difference in disease-free survival between the two groups. No adverse effect occurred and good compliance was observed in all patients who received GnRH-TAM. Treatment with GnRH-TAM resulted in a comparable survival outcome and better quality of life compared with AC-TAM.

Effects of ovarian ablation or suppression in premenopausal breast cancer: A meta-analysis of randomized controlled trials

BACKGROUND

The effect of ovarian ablation or suppression (OAS) in premenopausal women with breast cancer is controversial. The overall survival (OS), disease-free survival (DFS) and adverse event of OAS versus no OAS were compared.

METHODS

A literature review of EMBASE, Web of Science, PUBMED, and Cochrane Library was conducted. The hazard ratio (HR) and 95% confidence interval (CI) for OS and DFS, as well as risk ratio (RR) and 95% CI for adverse events were evaluated. I-squared statistic (I²) represents heterogeneity.

RESULTS

Twenty-nine studies with a total of 21,249 women were included. In premenopausal women aged 40 years or younger, there were significant differences in OS (HR 0.78, 95% CI: 0.66-0.94, P=0.008, I² = 0%) and DFS (HR 0.84, 95% CI: 0.73-0.97, P=0.02, I² = 0%) between OAS and no OAS. In advanced stage breast cancer, a significant difference was found in OS (HR 0.76, 95% CI: 0.60-0.96, P=0.02, I² = 0%). Patients treated with OAS had more chances to have hot flushes (RR 1.91, 95% CI: 1.62-2.26, P < 0.01, I² = 0%) and vaginal dryness (RR 1.19, 95% CI: 1.08-1.31, P=0.0003, I² = 0%). No significant difference in depression (RR 1.28, 95% CI: 0.94-1.74, P=0.12, I² = 0%).

CONCLUSIONS

The study shows that OAS plays a beneficial role in premenopausal women aged 40 years or younger and advanced stage breast cancer. However, OAS is associated with increase in hot flushes and vaginal dryness.

Goserelin plus tamoxifen compared to chemotherapy followed by tamoxifen in premenopausal patients with early stage-, lymph node-negative breast cancer of luminal A subtype

OBJECTIVES

To study the outcomes of adjuvant goserelin combined with tamoxifen (GosTam) compared to chemotherapy followed by tamoxifen (ChemTam) in premenopausal patients with early stage, luminal A breast cancer.

METHODS

From 2008 until 2013, data were retrospectively collected for premenopausal patients who underwent surgery for invasive tumors that were ≤2.0 cm, node-negative, strongly positive for estrogen and progesterone receptors, HER-2-negative, and Ki-67 < 25%. The patients were divided into two groups according to adjuvant regimen, either GosTam or ChemTam. All patients who underwent different adjuvant regimens were excluded.

RESULTS

In total, 235 patients underwent GosTam and 171 patients underwent ChemTam. There were significantly more patients younger than 40 years in the GosTam group (32% GosTam vs. 22% ChemTam, p = 0.031). Mean tumor size was significantly smaller (1.19 cm vs. 1.48 cm, p < 0.001), Ki-67 significantly lower (p = 0.049), and nuclear grade was low in a significant number of patients in the GosTam group (2% vs. 13%, p < 0.001). After a median follow-up of 51.3 months, there was no mortality in either group. There was no significant difference in 5-year disease-free survival (DFS) between the two groups even after univariate analysis considering age, tumor size, nuclear grade, and P53% (GosTam = 98.9% vs. ChemTam = 95.7%, HR = 0.404, 95% CI = [0.073, 2.222], p = 0.248).

CONCLUSION

There was no difference between treatment groups, and neither chemotherapy nor ovarian suppression seemed to improve the outcome. Thus, tamoxifen alone might be a sufficient option for this low-risk patient population.

Adjuvant endocrine therapy for premenopausal women with hormone-responsive breast cancer

Multiple strategies for endocrine treatment of premenopausal women with hormone-responsive breast cancer have been assessed and results have been presented over the last two years. These include tamoxifen for 5-10 years (ATLAS and aTTom), tamoxifen for 5 years followed by aromatase inhibitor (AI) for 5 years for women who have become postmenopausal (MA-17); ovarian ablation (OA) by surgery (EBCTCG overview); ovarian function suppression (OFS) by LHRH agonist (LHRH agonist meta-analysis); or combinations of approaches including OFS plus tamoxifen or AI (SOFT, TEXT, ABCSG 12 and E3193). Many of these trials have taken place in the backdrop of (neo)adjuvant chemotherapy which can confound interpretation because such therapy can suppress ovarian function either transiently or permanently. Nonetheless these trials suggest in aggregate that 10 years of tamoxifen are better than 5 years and that a program of extended adjuvant therapy of tamoxifen for 5 years followed by aromatase inhibitor for 5 years is effective for suitable candidates. The SOFT and E3193 trials do not show a major advantage for use of OFS + tamoxifen compared to tamoxifen alone. The joint SOFT/TEXT analysis and ABCGS12 trials both suggest that outcomes can be excellent with the use of combined endocrine therapy alone in properly selected patients but give conflicting results with regard to potential benefits for OFS + AI compared with OFS + tamoxifen. Further work will be needed to ascertain long-term outcomes, identify factors that predict who will benefit from extended adjuvant endocrine therapy, and assess role of OFS by medical or surgical means. It is clear, however, that endocrine therapy is a critical part of the adjuvant regimen for most premenopausal women with hormone-responsive breast cancer, and a subset of these women with luminal A-type tumors can be safely treated with endocrine therapy alone.

Survival Outcome of Combined GnRH Agonist and Tamoxifen Is Comparable to That of Sequential Adriamycin and Cyclophosphamide Chemotherapy Plus Tamoxifen in Premenopausal Patients with Lymph-Node-Negative, Hormone-Responsive, HER2-Negative, T1-T2 Breast Cancer

Purpose

The purpose of this study was to compare treatment outcomes between combined gonadotropin-releasing hormone agonist and tamoxifen (GnRHa+T) and sequential adriamycin and cyclophosphamide chemotherapy and tamoxifen (AC->T) in premenopausal patients with hormone-responsive, lymph-node–negative breast cancer.

Materials and Methods

In total, 994 premenopausal women with T1-T2, lymph-node–negative, hormone-receptor-positive, HER2-negative breast cancer between January 2003 and December 2008 were included in this retrospective cohort study. GnRHa+T and AC->T were administered to 608 patients (61.2%) and 386 patients (38.8%), respectively. Propensity score matching and inverse probability weighting were applied to the original cohort, and 260 patients for each treatment arm were included in the final analysis. Recurrence-free, cancer-specific, and overall survival was compared between the two treatment groups.

Results

A total of 994 patients were followed up for a median of 7.4 years (range, 0.5 to 11.4 years). The 5-year follow-up rate was 98.7%, and 13 patients were lost to follow-up. In propensity-matched cohorts (n=520), there was no difference in recurrence-free, cancer-specific, and overall survival rates between the two treatment groups (p=0.306, p=0.212, and p=0.102, respectively), and this was maintained after applying inverse probability weighting.

Conclusion

GnRHa+T is a reasonable alternative to AC->T in patients with premenopausal, hormone-responsive, HER2-negative, lymph-node–negative, T1-T2 breast cancer.

Tamoxifen with ovarian function suppression versus tamoxifen alone as an adjuvant treatment for premenopausal breast cancer: a meta-analysis of published randomized controlled trials

Background

Ovarian function suppression (OFS) significantly downregulates the concentration of plasma estrogens. However, it is unclear whether it offers any survival benefits if combined with adjuvant tamoxifen treatment in premenopausal women. This meta-analysis was designed to assess data from previous studies involving adjuvant tamoxifen treatment plus OFS in premenopausal breast cancer.

Methods

Electronic literature databases (PubMed, Embase, the Web of Science, and the Cochrane Library) were searched for relevant randomized controlled trials published prior to February 1, 2015. Only randomized controlled trials that compared tamoxifen alone with tamoxifen plus OFS for premenopausal women with breast cancer were selected. The evaluated endpoints were disease-free survival and overall survival.

Results

Four randomized controlled trials comprising 6,279 patients (OFS combination, n=3,133; tamoxifen alone, n=3,146) were included in the meta-analysis. There was no significant improvement in disease-free survival or overall survival with addition of OFS in either the whole population or the hormone receptor-positive subgroup. The risk of distant recurrence was not reduced with the addition of OFS in the whole population. A subgroup analysis showed that addition of OFS significantly improved overall survival in patients who were administered chemotherapy.

Conclusion

Based on the available studies, concurrent administration of OFS and adjuvant tamoxifen treatment for premenopausal women with breast cancer has no effect on prolonging disease-free survival and overall survival, excluding patients who were administered chemotherapy. It should not be widely recommended, except perhaps for women who were hormone-receptor positive and who were also administered adjuvant chemotherapy.

Phase III comparison of tamoxifen versus tamoxifen plus ovarian function suppression in premenopausal women with node-negative, hormone receptor-positive breast cancer (E-3193, INT-0142): a trial of the Eastern Cooperative Oncology Group

PURPOSE

The effects of ovarian function suppression (OFS) on survival and patient-reported outcomes were evaluated in a phase III trial in which premenopausal women were randomly assigned to tamoxifen with or without OFS.

PATIENTS AND METHODS

Premenopausal women with axillary node-negative, hormone receptor-positive breast cancer tumors measuring ≤ 3 cm were randomly assigned to tamoxifen alone versus tamoxifen plus OFS; adjuvant chemotherapy was not permitted. Primary end points were disease-free survival (DFS) and overall survival (OS). Secondary end points included toxicity and patient-reported outcomes. Patient-reported outcome data included health-related quality of life, menopausal symptoms, and sexual function. These were evaluated at baseline, 6 months, 12 months, and then annually for up to 5 years after registration.

RESULTS

In all, 345 premenopausal women were enrolled: 171 on tamoxifen alone and 174 on tamoxifen plus OFS. With a median follow-up of 9.9 years, there was no significant difference between arms for DFS (5-year rate: 87.9% v 89.7%; log-rank P = .62) or OS (5-year rate: 95.2% v 97.6%; log-rank P = .67). Grade 3 or higher toxicity was more common in the tamoxifen plus OFS arm (22.4% v 12.3%; P = .004). Patients treated with tamoxifen plus OFS had more menopausal symptoms, lower sexual activity, and inferior health-related quality of life at 3-year follow-up (P < .01 for all). Differences diminished with further follow-up.

CONCLUSION

When added to tamoxifen, OFS results in more menopausal symptoms and sexual dysfunction, which contributes to inferior self-reported health-related quality of life. Because of early closure, this study is underpowered for drawing conclusions about the impact on survival when adding OFS to tamoxifen.

Insights on adjuvant endocrine therapy for premenopausal and postmenopausal breast cancer

In 2005, cancer accounted for 13% of all deaths worldwide. Breast cancer is the number-one cause of cancer-related death among women in the USA, affecting 178,480 of them in 2007. As 75% of tumors in postmenopausal women and half in premenopausal women express estrogen receptor, endocrine therapy plays a significant role as a systemic treatment. Robust datasets have demonstrated the impact of tamoxifen in reducing breast cancer recurrence and mortality, regardless of the age of the patient. Other estrogen-deprivation strategies, such as aromatase inhibitors in postmenopausal women and luteinizing hormone-releasing hormone agonists in premenopausal women, are being increasingly used for estrogen receptor-positive breast cancer. This review discusses basic principles regarding endocrine therapy, the need for accurate estrogen receptor testing and the role of menopause in therapy selection.

Optimal management of the premenopausal patient with estrogen receptor-positive breast cancer

Tamoxifen is the standard of care in the adjuvant treatment of premenopausal women with estrogen receptor-positive (ER+) breast cancer. Ovarian suppression (OS) is another method of endocrine therapy and has been shown to decrease the risk of recurrence and confer a survival advantage when used as the sole source of hormone therapy. However, there is no evidence that OS is superior to treatment with tamoxifen. Studies comparing OS with or without tamoxifen compared with chemotherapy have demonstrated comparable effects. There does not appear to be any additional benefit when OS is combined with chemotherapy, although there is a suggestion that there may be an effect in the subgroup of young women (aged younger than 40 years) who are least likely to experience chemotherapy-induced cessation of ovarian function. Interpretation of existing data is hampered by the lack of studies incorporating modern chemotherapy regimens and the absence of molecular analyses that would allow us to better define populations most likely to benefit from endocrine therapy. Last, the role of aromatase inhibitors (AI) in the premenopausal setting remains undefined. Two recent studies, SOFT and TEXT, aim to shed light on the effect of OS and AI in premenopausal ER+ breast cancer and are pending analysis.

Adjuvant therapies for very young women with early stage breast cancer

Approximately 16,000-19,000 women aged ≤ 45 are diagnosed annually with breast cancer in the United States and thousands more are diagnosed worldwide. Compared to older women, young women are more likely to have cancers with aggressive tumor biology and present with higher stage disease, both of which likely lead to their worse outcomes. We review the available evidence for adjuvant systemic therapy as well as treatment considerations for younger women with breast cancer. Although we have begun to appreciate the issues that younger women with breast cancer face, we need a better understanding of how we can optimally prevent disease recurrence while carefully considering their unique physical and emotional needs with regard to diagnosis, treatment, and survivorship.

Hormonal therapy in breast cancer: a model disease for the personalization of cancer care

The treatment of breast cancer is driven by subtype classification, of which the assessment of hormone receptor status is one of the important determinants of therapy. The use of hormonal therapy to treat estrogen-receptor positive breast cancer has been studied for over a century and is one of the well-described uses of personalized medicine. In this review, we will describe the classification of hormone receptor status and the various endocrine treatment strategies. Opportunities for personalization of care are illustrated.

A Phase II trial of Zoladex combined with CEF chemotherapy as neoadjuvant therapy in premenopausal women with hormone-responsive, operable breast cancer

The purpose of this study was to evaluate the efficacy and safety of Zoladex combined with CEF chemotherapy as neoadjuvant therapy in hormone-responsive, premenopausal, operable breast cancer. One hundred and nineteen patients with hormone-responsive, premenopausal, operable breast cancer were enrolled in the study. Zoladex at 3.6 mg was given by subcutaneous injection every 4 weeks for 3 cycles. CEF (cyclophosphamide, 600 mg/m(2), epirubicin, 60-90 mg/m(2), and fluorouracil 500 mg/m(2)) was administered every 3 weeks for 4 cycles as neoadjuvant therapy. The primary objective was a pathologic complete response (PCR) rate in the breast. Thirty-one patients (26.1%) achieved a clinical complete response, and 76 patients (63.9%) achieved a clinical partial response; the clinical response rate was 90.0%. Fourteen patients (11.8%) achieved a pathologic complete response (T0/Tis, N0), and 20 patients (16.8%) achieved a pathologic complete response (T0/Tis, Nx). When stratified by the clinical lymph node status, the clinical partial response rate in the clinical lymph node negative group was significantly higher than in the clinical lymph node positive group (P = 0.02). When stratified by hormonal status, the clinical partial response rate in the ER and PR + group was significantly better than the ER or PR- group (P = 0.0471). There were no treatment-related deaths and no grades 3 or 4 toxicity. The most common adverse event was nausea (grade 1 65.5%, grade 2 18.5%), vomiting (grade 1 58.8%, grade 2 13.4%), and alopecia (grade 1 45.4%, grade 2 54.6%). Zoladex combined with CEF chemotherapy was effective as neoadjuvant therapy in hormone-responsive, premenopausal breast cancer. This regimen was particularly effective in the clinical lymph node negative group and in the ER/PR double positive group. (ClinicalTrials.gov number, NCT00488722).

Monthly versus 3-monthly goserelin acetate treatment in pre-menopausal patients with estrogen receptor-positive early breast cancer

This study compared the efficacy and safety of a 3-monthly 10.8-mg depot goserelin (Zoladex(TM)) injection with the current 3.6 mg monthly dose in pre-menopausal Japanese women with estrogen receptor-positive (ER+) early breast cancer. This was a multicenter, open-label, randomized study. Primary endpoint was a non-inferiority analysis (10.8/3.6 mg) of the area under the concentration-time curve (AUC) of estradiol (E(2)) over the first 24 weeks. Secondary endpoints included E(2) and follicle-stimulating hormone (FSH) concentrations, menstruation, and safety and tolerability. In total, 170 patients were randomized to receive goserelin 10.8 mg every 3 months (n = 86) or 3.6 mg every month (n = 84). Mean AUCs for E(2) were similar between treatment groups (18.32 and 18.95 pg/ml·week for goserelin 10.8 and 3.6 mg, respectively). AUC ratio was 0.974 (95% confidence interval, 0.80, 1.19), indicating non-inferiority for goserelin 10.8 mg. Serum E(2) and FSH remained suppressed throughout the study and no patient experienced menses after week 16. No clinically important differences in safety and tolerability were observed between the two groups. In terms of E(2) suppression, 3-monthly goserelin 10.8 mg was non-inferior to monthly goserelin 3.6 mg in pre-menopausal women with ER+ breast cancer.

Biological characteristics and medical treatment of breast cancer in young women-a featured population: results from the NORA study

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.

Optimal adjuvant endocrine therapy for early breast cancer

Adjuvant endocrine therapy substantially reduces tumor recurrence and mortality in pre- and post-menopausal women with hormone receptor-positive early breast cancer but is ineffective in women with hormone receptor-negative tumors. Tamoxifen has been the standard adjuvant endocrine therapy for both pre- and post-menopausal women with hormone receptor-positive early breast cancer and remains the standard of care for premenopausal women. In addition to tamoxifen, ovarian ablation by surgery or radiotherapy remains an option for selected premenopausal women and trials are evaluating the role of ovarian function suppression using luteinizing hormone-releasing hormone agonists. For postmenopausal women, aromatase inhibitors are more effective than tamoxifen therapy and aromatase inhibitors and tamoxifen are regarded as standards of care. Prolonging adjuvant endocrine therapy in postmenopausal women by the sequencing of aromatase inhibitors and tamoxifen can improve outcomes further. Adjuvant endocrine therapy will probably be used for longer durations in selected postmenopausal women.

Adjuvant endocrine therapy of premenopausal women with early breast cancer: an overview

Tamoxifen is currently the standard of care for premenopausal women with hormone receptor-positive early breast cancers. However, endocrine strategies in premenopausal women include not only estrogen receptor blockade with tamoxifen but also temporary suppression of ovarian estrogen synthesis by luteinizing hormone-releasing hormone (LHRH) agonists, or permanent interruption of ovarian estrogen synthesis with oophorectomy or radiotherapy. Luteinizing hormone-releasing hormone agonists have proven to be as effective as surgical oophorectomy in adjuvant treatment of premenopausal breast cancer. The addition of LHRH agonists compared to no therapy reduces the annual odds of recurrence and death in premenopausal women aged less than 50 years with estrogen receptor-positive tumors. Luteinizing hormone-releasing hormone agonists alone or in combination with tamoxifen have shown disease-free survival rates similar to chemotherapy with CMF (cyclophosphamide/methotrexate/5-fluorouracil) and other second-generation chemotherapies. The role of aromatase inhibitors in combination with ovarian suppression is still not established, especially as a large phase III randomized study (Austrian Breast and Colorectal Cancer Study Group Trial 12) did not show superior efficacy compared with ovarian suppression plus tamoxifen in premenopausal early stage disease. Patients currently continue to receive ovarian suppression and tamoxifen. CYP2D6 status may become an important discriminator for the type of endocrine therapy for the premenopausal patient in the future.

Adjuvant endocrine therapy for premenopausal women with breast cancer

AIMS

Endocrine therapy is a pivotal treatment for women with hormone-receptor positive breast cancer. In premenopausal women, endocrine therapy primarily consists of tamoxifen and ovarian suppressive strategies. Younger women experience improvements in the risks of relapse or death from breast cancer with the use of chemotherapy as well, with part of this benefit explained by resultant premature amenorrhea. Unfortunately despite a centuries worth of clinical trials, the most efficacious combination of hormonal therapies and chemotherapy has yet to be determined. This paper serves as a comprehensive review of the substantial data in the adjuvant treatment of premenopausal, hormone receptor-positive women with breast cancer.

METHODS AND RESULTS

PubMed and American Society of Clinical Oncology (ASCO) Proceedings searches from 1896 to present were performed. All of the trials examining the role of ovarian suppression and tamoxifen with and without chemotherapy in premenopausal women were included. The current data suggests that endocrine therapy can be an important alternative to chemotherapy in select patient populations, and improvements in outcome are also seen with the combination of hormonal and chemotherapy strategies in other populations. A majority of the trials examined did not use what is considered to be current standards of care regarding chemotherapy regimens and durations of adjuvant hormonal therapy. Many unanswered questions remain particularly regarding the combined use of ovarian suppression and tamoxifen in women who are also receiving chemotherapy.

CONCLUSION

There is a persistent need to define optimal endocrine therapy in premenopasusal women with hormone-receptor positive breast cancer. Contemporaneous trials, such as the SOFT trial will provide direction, and additional biomarker and pharmacogenomic data will further supplement individualized patient decision making.

LHRH agonists for adjuvant therapy of early breast cancer in premenopausal women

BACKGROUND

Approximately 60% of breast cancers amongst premenopausal women express the nuclear oestrogen receptor (ER+ breast cancer). Adjuvant endocrine therapy is an integral component of care for ER+ breast cancer, exerting its effect by reducing the availability of oestrogen to micrometastatic tumour cells. Endocrine strategies in premenopausal women include oestrogen receptor blockade with tamoxifen, temporary suppression of ovarian oestrogen synthesis by luteinising hormone releasing hormone (LHRH) agonists, or permanent interruption of ovarian oestrogen synthesis with oophorectomy or radiotherapy. Aromatase inhibitors are also available with concurrent suppression of ovarian oestrogen synthesis, either through LHRH agonists, surgery, or radiotherapy. Chemotherapy can also have an endocrine action in premenopausal women by interrupting ovarian oestrogen production, either temporarily or permanently. International consensus statements recommend single agent tamoxifen as the current standard adjuvant endocrine therapy for premenopausal women (often preceded by chemotherapy), and the role of LHRH agonists remains under active investigation.

OBJECTIVES

To assess LHRH agonists as adjuvant therapy for women with early breast cancer.

SEARCH STRATEGY

The Cochrane Breast Cancer Group Specialised Register was searched on 19 February 2009. This register incorporates references from CENTRAL (The Cochrane Library) (to 2002), MEDLINE (1966 to July 2008), EMBASE (until 2002); and handsearches of abstracts from the San Antonio Breast Cancer Symposium, American Society of Clinical Oncology Annual Meeting, and the Clinical Oncological Society of Australia Annual Meeting. MEDLINE references (from August 2008 to 19th February 2009) were checked by the authors. The reference lists of related reviews were checked. A final check of the list of trials maintained by the Early Breast Cancer Trialists' Collaborative Group was made in January 2008.

SELECTION CRITERIA

All randomised trials assessing LHRH agonists as adjuvant treatment in premenopausal women with early stage breast cancer were included. Specifically, we included trials that compared:(A) LHRH agonists (experimental arm) versus another treatment;(B) LHRH agonists + anti-oestrogen (experimental arm) versus another treatment;(C) LHRH agonists + chemotherapy (experimental arm) versus another treatment;(D) LHRH agonists + anti-oestrogen + chemotherapy (experimental arm) versus another treatment.

DATA COLLECTION AND ANALYSIS

Data were collected from trial reports. We reported estimates for the differences between treatments on recurrence free survival, overall survival, toxicity and quality of life using data available in the reports of each trial. Meta-analyses were not performed because of variability in the reporting of the trials.

MAIN RESULTS

We identified 14 randomised trials that involved over 13,000 premenopausal women with operable breast cancer, most of whom were ER+. The numbers of trials making the different comparisons were:(A) i. LHRH versus tamoxifen (three trials),ii. LHRH versus chemotherapy (four trials);(B) i. LHRH + tamoxifen versus tamoxifen (two trials),ii. LHRH + tamoxifen versus LHRH (three trials),iii. LHRH + tamoxifen versus chemotherapy (two trials),iv. LHRH + aromatase inhibitor versus LHRH + tamoxifen (one trial);(C) i. LHRH + chemotherapy versus LHRH (one trial),ii. LHRH + chemotherapy versus chemotherapy (five trials);(D) LHRH + tamoxifen + chemotherapy versus chemotherapy (three trials).The LHRH agonist in most of these trials was goserelin.For most of the treatment comparisons there are too few trials, too few randomised patients, or too little follow up to draw reliable estimates of the relative effects of different treatments.(A) LHRH monotherapy: results suggest that adjuvant LHRH agonist monotherapy is similar to older chemotherapy protocols (eg. CMF) in terms of recurrence-free and overall survival in ER+ patients. There are insufficient data to compare LHRH agonist monotherapy to tamoxifen alone, but available results suggest that these treatments are comparable in terms of recurrence-free survival.(B) LHRH + anti-oestrogen therapy: there are insufficient data to compare the combination of an LHRH agonist plus tamoxifen to tamoxifen alone. Results suggest that the LHRH agonist plus tamoxifen combination may be superior to an LHRH agonist alone or to chemotherapy alone, but the chemotherapy protocols tested are outdated. The data comparing LHRH agonists plus aromatase inhibitors to LHRH agonists plus tamoxifen are currently inconclusive.(C) LHRH + chemotherapy: there are insufficient data to compare the LHRH + chemotherapy combination to an LHRH agonist alone, although results from a single study suggest comparable efficacy in ER+ patients. There is a trend towards improved recurrence-free and overall survival in patients who received an LHRH agonist plus chemotherapy combination in comparison to chemotherapy alone.(D) LHRH agonist + chemotherapy + tamoxifen: there is a trend towards improved recurrence-free and overall survival in patients who received an LHRH agonist plus tamoxifen plus chemotherapy in comparison to chemotherapy alone.There are insufficient data to assess the effect of the addition of LHRH agonists to the current standard treatment of chemotherapy plus tamoxifen.Endocrine therapy with LHRH agonists appears to have fewer side-effects than the forms of chemotherapy assessed. The optimal duration of LHRH therapy in the adjuvant setting is unclear.

AUTHORS' CONCLUSIONS

Overall, the data from currently published clinical trials of LHRH agonists in the adjuvant setting for premenopausal women with endocrine-sensitive breast cancer are supportive of clinical benefit. Nonetheless, definitive comparisons against current clinical standards of care that include third generation chemotherapy regimens and tamoxifen are required before their place in the adjuvant setting can be properly defined. The authors conclude that the current data strongly support the continuation of current trials that definitively compare a variety of combinations of LHRH agonists and anti-oestrogenic strategies to the current standard of five years of tamoxifen.

Breast cancer before age 40 years

Approximately 7% of women with breast cancer are diagnosed before the age of 40 years, and this disease accounts for more than 40% of all cancer in women in this age group. Survival rates are worse when compared to those in older women, and multivariate analysis has shown younger age to be an independent predictor of adverse outcome. Inherited syndromes, specifically BRCA1 and BRCA2, must be considered when developing treatment algorithms for younger women. Chemotherapy, endocrine, and local therapies have the potential to significantly impact both the physiologic health-including future fertility, premature menopause, and bone health-and the psychological health of young women as they face a diagnosis of breast cancer.

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)

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.

LHRH agonists for adjuvant therapy of early breast cancer in premenopausal women

BACKGROUND

Approximately 60% of breast cancer tumours in premenopausal women are hormone sensitive (ER+). These patients may be suitable for hormonal treatment. The goal of hormonal therapy is to reduce the availability of oestrogen to the cancer cell. This can be achieved by blocking oestrogen receptors with drugs such as tamoxifen, suppression of oestrogen synthesis by LHRH agonists, or ovarian ablation either surgically or by radiotherapy. Chemotherapy can also have a hormonal action by inducing amenorrhoea in premenopausal women.

OBJECTIVES

To assess LHRH agonists as adjuvant therapy for women with early breast cancer.

SEARCH STRATEGY

The specialised register of the Cochrane Breast Cancer Group was searched on 19 December 2006. The reference lists of related reviews were checked. A final check of the list of trials maintained by the Early Breast Cancer Trialists' Collaborative Group was made in January 2008.

SELECTION CRITERIA

Randomised trials of LHRH agonist versus LHRH agonist and tamoxifen, LHRH agonist versus chemotherapy, LHRH agonist versus ovarian ablation, or LHRH agonist versus LHRH agonist and chemotherapy, that recruited premenopausal women with early breast cancer.

DATA COLLECTION AND ANALYSIS

Data were collected from trial reports. We report estimates for the differences between treatments on recurrence free survival, overall survival, toxicity and quality of life using data available in the reports of each trial. Meta-analyses were not performed because of variability in the reporting of the trials and the need for more mature data.

MAIN RESULTS

We identified 14 randomised trials, involving nearly 12,000 premenopausal women with operable breast cancer, most of whom were ER+. The LHRH agonist in most of these trials was goserelin. For most of the treatment comparisons there are too few trials, too few randomised patients or too little follow-up to draw reliable estimates of the relative effects of different treatments. Four trials (nearly 5000 women) addressed the integration of LHRH agonists into adjuvant hormonal therapy, showing that a combination of an LHRH agonist and tamoxifen might be better than either alone. Insufficient data are available to inform a choice between tamoxifen and goserelin as sole adjuvant therapy. We included twelve trials (more than 10,000 women) of the integration of LHRH agonists into adjuvant chemo-hormonal therapy. Four trials assessed the effects of an LHRH agonist compared to chemotherapy and three other trials investigated a combination of an LHRH agonist and tamoxifen versus chemotherapy. One trial assessed the effects of adding chemotherapy to an LHRH agonist, five trials compared a combination of an LHRH agonist and chemotherapy versus chemotherapy alone, and three trials compared the combination of LHRH agonist, tamoxifen and chemotherapy versus chemotherapy alone. No trials compared an LHRH agonist containing regimen against chemotherapy and tamoxifen. No significant differences in recurrence free survival or overall survival were found between LHRH agonists, with or without adjuvant tamoxifen, and chemotherapy for premenopausal women with ER+ tumours, but hormonal therapy had fewer distressing side effects. The trials point to reductions in recurrence and death for premenopausal women with ER+ tumours who take LHRH agonists, with or without tamoxifen, along with chemotherapy.

AUTHORS' CONCLUSIONS

For premenopausal women with early breast cancer who are not known to be ER negative, the use of an LHRH agonist, with or without tamoxifen as adjuvant therapy is likely to lead to a reduction in the risk of recurrence and a delay in death. The evidence is insufficient to support the LHRH agonists over chemotherapy, or vice versa, in regard to recurrence free survival and overall survival, but LHRH agonists have fewer or less severe adverse effects. Further follow-up of women in these trials is needed to provide reliable evidence on long term outcomes. Direct randomised comparisons of different durations of LHRH agonists (for example, two years versus longer) and, in the presence of uncertainty, of different LHRH agonists among ER+ or ER unknown premenopausal women are also needed. It is also uncertain how the findings from the CMF-based trials in this review would relate to the use of LHRH agonists with more modern chemotherapy regimens or the comparison of LHRH agonist containing regimens with combinations such as chemotherapy and tamoxifen.

Controversies of adjuvant endocrine treatment for breast cancer and recommendations of the 2007 St Gallen conference

Endocrine treatment for breast cancer was introduced more than a century ago. The discovery of hormone receptors has allowed targeting of endocrine treatment to patients whose primary tumours express these receptors. In the adjuvant setting, different approaches are used in premenopausal or postmenopausal women. In premenopausal patients, suppression of ovarian function and the use of tamoxifen are the most important therapeutic options, even though questions on timing, duration, and combination of these compounds remain unanswered. The use of aromatase inhibitors in combination with ovarian-function suppression is currently under investigation in the premenopausal setting. In postmenopausal patients, aromatase inhibitors given after 2-3 years or 5 years of tamoxifen have shown a significant benefit over tamoxifen alone. However, questions on this treatment also remain unanswered. For example, whether all patients should receive an aromatase inhibitor or whether some subgroups of patients might be optimally treated by tamoxifen alone is yet to be established. In this paper we review the published work on adjuvant endocrine treatment in breast cancer and provide recommendations from the 2007 St Gallen International Conference on Primary Therapy of Early Breast Cancer.

Current clinical trials of endocrine therapy for breast cancer

Breast cancer is a hormone-dependent cancer like prostate cancer and endometrial cancer. Estrogen plays important roles in the development and progression of breast cancer. Endocrine therapy is the treatment of choice for estrogen receptor- and/or progesterone receptor-positive breast cancer. Endocrine therapy has been used for several purposes, including chemoprevention, preoperative treatment, postoperative adjuvant treatment and treatment for recurrent diseases. A large number of clinical trials have provided evidence showing the clinical benefits of various endocrine therapies for the treatment of breast cancer. The current status and recent advances in endocrine therapy for breast cancer are reviewed based on the results of current clinical trials. Future perspectives of endocrine therapy are also discussed.

Adjuvant endocrine treatment of early breast cancer

Endocrine therapy plays a pivotal role in the early treatment of estrogen receptor (ER)-positive breast cancer. Although evidence suggests that chemotherapy may work partly through ovarian ablation in young women who have ER-positive tumors, combined chemotherapy and endocrine therapy are generally advocated. In postmenopausal women, aromatase inhibition has become the new "gold standard" of treatment. More research is needed to define optimal regimens (aromatase inhibitor monotherapy versus tamoxifen sequential application), optimal duration of therapy and potential advantages of particular compounds. The optimal use of estrogen suppression (ovarian ablation with or without aromatase inhibition) and tamoxifen (administered sequentially or in concert with ovarian ablation) in premenopausal women has yet to be defined.

Current controversies in the management of early breast cancer

Medical professionals in general, and medical oncologists in particular, have highly stressful practices because they are under constant pressure to have the highest-quality, up-to-date evidence available in order to make the right decision for each individual patient. From a practical point of view, being updated on oncological and other medical specialties may seem an insurmountable task because the number of scientific publications has increased dramatically. The use of systematic reviews of randomised controlled trials or the application of results obtained from high-quality randomised controlled trials are some of the most common ways to address this need. Unfortunately, they do not cover all complex clinical situations that the majority of medical oncologists face in their outpatient consultations. In this review, we report the conclusions achieved in a multiexpert meeting where five important controversies in the treatment of breast cancer were analysed. Five highly experienced medical oncologists were required to defend an affirmative answer and another five were required to defend a negative answer for each of the clinical questions. After that, a one-day meeting was organised to debate each clinical question and to reach a consensus. We report here the content of this multi-expert meeting along with the conclusions drawn.

Adjuvant endocrine therapies for premenopausal women

Adjuvant endocrine treatment for premenopausal woman remains a controversial area in the therapeutical approach of early stages of breast cancer. Metaanalysis show that ovarian ablation and suppression produce, in a global way, significant benefits in terms of reduction of the risk of recurrence and death. Nevertheless, in the presence of adjuvant chemotherapy, the benefits of ovarian suppression or ablation are clearly reduced, probably in relation to the impact that amenorrhoea induced by chemotherapy. On the other hand, in premenopausal patients, the same metaanalysis show that the use of adjuvant tamoxifen produces benefits in disease- free survival and overall survival very similar to those observed in postmenopausal women. Additionally, the benefits from tamoxifen persist independently of whether or not adjuvant chemotherapy is being received. Thus, some of the questions to answer are: first, is there, in premenopausal women, an additional benefit when ovarian suppression is associated to tamoxifen? Second, it remains controversial if ovarian suppression must be indicated for all patients who receive chemotherapy or only those that have not reached amenorrhoea when adjuvant chemotherapy is completed. Moreover, although in the last decades more than 15,000 premenopausal patients have been included in specific trials of adjuvant endocrine therapy with ovarian suppression or ablation, the best modality of treatment has not been established, and what is more important, the role of its association with tamoxifen has not been completely defined. Many of these aspects remain controversial and the decision about the best therapeutical approach must be individualised in each patient.

Leuprorelin Acetate Every-3-Months Depot Versus Cyclophosphamide, Methotrexate, and Fluorouracil As Adjuvant Treatment in Premenopausal Patients With Node-Positive Breast Cancer: The TABLE Study

Purpose

Ovarian suppression with luteinizing hormone–releasing hormone (LHRH) agonists is an effective adjuvant treatment for premenopausal women with estrogen receptor (ER) –positive breast cancer. Whereas monthly LHRH agonist therapy has been well established, the value of every-3-months (3-monthly) formulations is unclear.

Patients and Methods

This randomized phase III trial was performed to compare the 3-monthly depot LHRH agonist leuprorelin acetate (LAD-3M; n = 299) and chemotherapy with cyclophosphamide, methotrexate, and fluorouracil (CMF; n = 300) in pre- or perimenopausal patients with ER-positive, node-positive breast cancer.

Results

With a median follow-up of 5.8 years, recurrence-free survival was similar for patients treated with LAD-3M or CMF (hazard ratio [HR], 1.19; 95% CI, 0.94 to 1.51; P = .15). There was no substantial heterogeneity in the relative treatment effect among subgroups defined by age, progesterone receptor (PR) status, nodal status, hormone levels, or menstrual recovery after treatment. Exploratory overall survival analysis favored LAD-3M (HR, 1.50; 95% CI, 1.13 to 1.99; P = .005). Chemotherapy-related adverse effects such as nausea, vomiting, and alopecia were more common with CMF, whereas symptoms of estrogen suppression such as hot flushes and sweating were initially more pronounced with LAD-3M.

Conclusion

The 3-monthly depot LHRH-agonist leuprorelin acetate is an effective adjuvant treatment in premenopausal patients with hormone receptor–positive, node-positive breast cancer that is not inferior to CMF.

Use of luteinising-hormone-releasing hormone agonists as adjuvant treatment in premenopausal patients with hormone-receptor-positive breast cancer: a meta-analysis of individual patient data from randomised adjuvant trials

BACKGROUND

Several trials have been done to assess treatment of premenopausal breast cancer with luteinising-hormone-releasing hormone (LHRH) agonists, but results have been inconclusive, especially for patients with hormone-receptor-positive cancer.

METHODS

We collected individual patients' data from published trials and did analyses focused on women with tumours positive for oestrogen receptor, progesterone receptor, or both. The main endpoints were recurrence and death after recurrence.

FINDINGS

We obtained data for 11 906 premenopausal women with early breast cancer randomised in 16 trials. When used as the only systemic adjuvant treatment, LHRH agonists did not significantly reduce recurrence (28.4% relative reduction, 95% CI consistent with 50.5% reduction to 3.5% increase, p=0.08) or death after recurrence (17.8%, 52.8% reduction to 42.9% increase, p=0.49) in hormone-receptor-positive cancers. Addition of LHRH agonists to tamoxifen, chemotherapy, or both reduced recurrence by 12.7% (2.4-21.9, p=0.02); and death after recurrence by 15.1% (1.8-26.7, p=0.03). LHRH agonists showed similar efficacy to chemotherapy (recurrence 3.9% increase, 7.7% reduction to 17.0% increase; death after recurrence 6.7% reduction, 20.7% reduction to 9.6% increase; both not significant). No trials had assessed an LHRH agonist versus chemotherapy with tamoxifen in both arms. LHRH agonists were ineffective in hormone-receptor-negative tumours.

INTERPRETATION

LHRH agonists provide an additional class of agents for treatment of premenopausal women with hormone-receptor-positive breast cancer. Optimum duration of use is unknown.

Breast Cancer Adjuvant Endocrine Therapy

Adjuvant endocrine therapy with the selective estrogen receptor modulator, tamoxifen, has significantly improved mortality from early-stage breast cancer for both pre- and postmenopausal women with hormone receptor-positive breast cancer. Recent large clinical trials have demonstrated a clear and consistent benefit for the incorporation of aromatase inhibitor (AI) therapy within adjuvant endocrine regimens for postmenopausal women. The AIs, which are associated with myalgias, arthralgias, and a reduction in bone mineral density, are generally well tolerated and have lower risks of endometrial carcinoma and thromboembolic events than tamoxifen. Data are awaited from ongoing trials to better define the optimal sequencing strategy, duration, and AI agent. Attempts to further optimize adjuvant endocrine therapy by identifying predictive biomarkers of response, as well as by developing strategies to overcome endocrine resistance are underway. In premenopausal women AI monotherapy is currently contraindicated and tamoxifen remains the standard of care. The role of ovarian function suppression in addition to tamoxifen or combined with AI therapy is being explored. The hope is that continued advances in endocrine therapy will translate into improved survival among both pre- and postmenopausal women with receptor-positive breast cancer.

Luteinizing hormone-releasing hormone agonists in premenopausal hormone receptor-positive breast cancer

Ovarian function suppression for the treatment of premenopausal breast cancer was first used in the late 19th century. Traditionally, ovarian function suppression had been accomplished irreversibly via irradiation or surgery, but analogues of the luteinizing hormone-releasing hormone (LH-RH) have emerged as reliable and reversible agents for this purpose, especially the LH-RH agonists. Luteinizing hormone-releasing hormone antagonists are in earlier stages of development in breast cancer and are not currently in clinical use. Luteinizing hormonereleasing hormone agonists act by pituitary desensitization and receptor downregulation, thereby suppressing gonadotrophin release. Limited information is available comparing the efficacies of the depot preparations of various agonists, but pharmacodynamic studies have shown comparable suppressive capabilities on estradiol and luteinizing hormone. At present, only monthly goserelin is Food and Drug Administration-approved for the treatment of estrogen receptor-positive, premenopausal metastatic breast cancer in the United States. Luteinizing hormone-releasing hormone agonists have proven to be as effective as surgical oophorectomy in premenopausal advanced breast cancer. They offer similar outcomes compared with tamoxifen, but the endocrine combination appears to be more effective than LH-RH agonists alone. In the adjuvant setting, LH-RH agonists versus no therapy reduce the annual odds of recurrence and death in women aged>50 years with estrogen receptor-positive tumors. Luteinizing hormone-releasing hormone agonists alone or in combination with tamoxifen have shown disease-free survival rates similar to chemotherapy with CMF (cyclophosphamide/methotrexate/5-fluorouracil). Outcomes of chemotherapy with or without LH-RH agonists are comparable, though a few trials favor the combination in young premenopausal women (aged<40 years). Adjuvant LH-RH agonists with or without tamoxifen might be as efficacious as tamoxifen alone, and the additional benefit from chemotherapy is unclear. Adequately powered studies are now studying the relative merits of combining adjuvant tamoxifen or aromatase inhibitors with ovarian function suppression, the additional benefits of adding ovarian function suppression to chemotherapy, and the need for adjuvant chemotherapy for women treated with combined ovarian function suppression and anti-estrogen therapy.

Adjuvant systemic therapy for operable breast cancer

Breast cancer is the leading cause of cancer death in women in England and Wales. Systemic adjuvant therapy for breast cancer reduces recurrence and mortality both in early and advanced breast cancer. This review primarily looks at the role of adjuvant systemic therapy following surgery. Chemotherapy and hormonal therapy has changed dramatically in the last few decades with the advent of newer aromatase inhibitors and newer chemotherapy drugs like taxol. Monoclonal antibodies targeted against breast cancer cells like trastuzumab are gaining ground recently in the adjuvant settings. In this article we have reviewed the recent evidences for the appropriate adjuvant therapy in operable breast cancer.

Treatment of Premenopausal Women with Early Breast Cancer

Breast cancer occurring in women before the age of menopause continues to be a major medical and psychological challenge. Endocrine therapy has emerged as the mainstay of adjuvant treatment for women with estrogen receptor-positive tumours. Although the suppression of ovarian function (by oophorectomy, irradiation of the ovaries or gonadotropin releasing factor analogues) is effective as adjuvant therapy if used alone, its value has not been proven after chemotherapy. This is presumably because of the frequent occurrence of chemotherapy-induced amenorrhoea. Tamoxifen reduces the risk of recurrence by approximately 40%, irrespective of age and the ovarian production of estrogens. The worth of ovarian function suppression in combination with tamoxifen is unproven and is being investigated in an intergroup randomised clinical trial (SOFT [Suppression of Ovarian Function Trial]). Aromatase inhibitors are more effective than tamoxifen in postmenopausal women but are only being investigated in younger patients. The use of chemotherapies is identical in younger and older patients; however, at present the efficacy of chemotherapy in addition to ovarian function suppression plus tamoxifen is unknown in premenopausal patients with endocrine responsive disease. 'Targeted' therapies such as monoclonal antibodies to human epidermal growth factor receptor (HER)-2, HER1 and vascular endothelial growth factor, 'small molecule' inhibitors of tyrosine kinases and breast cancer vaccines are rapidly emerging. Their use depends on the function of the targeted pathways and is presently limited to clinical trials. Premenopausal patients are best treated in the framework of a clinical trial.

Adjuvant therapy of the very young woman

Women under 35 or 40 with primary breast cancer have a poor prognosis independent of other factors [Albain K, Allred C, Clark G. Breast cancer outcome and predictors of outcome: are there age differentials? J Natl Cancer Inst Monogr 1994;35-42]. In some recent studies, however, age is not independent in multivariate analyses, which include gene signatures [Van De Vijver M, He YD, Van'T Veer L, et al. A gene-expression signature as a predictor of survival in breast cancer. N Engl J Med 2002;347:1999-2009.(132)]. Dissection of such molecular signatures may identify mechanisms, which can be targeted. Today, positive estrogen receptors identify women who require endocrine therapy, and HER2/neu positivity those who require herceptin and also benefit most from anthracyclines. Locoregional recurrences are also more common in younger women. Radiation boost therapy can reduce in-breast recurrence [Bartelink H, Horiot JC, Poortmans PM, Struikmans H, et al. Impact of radiation dose on local control, fibrosis and survival after breast conserving treatment: 10 year results of the EORTC trial 22881-10882. Br Cancer Res Treat 2006;100:S8-10]. There are also particular quality of life issues in young women, for whom fertility concerns and symptoms of premature menopause loom large. Some young women with lower risk may be candidates for endocrine therapy alone but it may be difficult to identify these with current prognostic and predictive factors. In the future more sophisticated molecular factors may identify those who require hormones alone, chemotherapy alone, newer biologic therapies, or combinations of these approaches.

Identifying breast cancer patients most likely to benefit from aromatase inhibitor therapy after adjuvant radiation and tamoxifen

BACKGROUND

The purpose of the current study was to examine patient selection for an aromatase inhibitor in breast cancer patients who were free from adverse events 5 years after treatment with tamoxifen.

METHODS

In all, 471 women were treated with breast-conserving surgery, axillary lymph node dissection, and radiation. Eligibility included T1-2 disease, tamoxifen use, follow-up of >/=5 years, no prior breast cancer, and freedom from all events at 5 years of follow-up. Patients treated with chemotherapy more often had T2 disease and positive lymph nodes, and were aged <60 years compared with patients treated with tamoxifen alone. No patient during the period of the current study (1982-1999) received an aromatase inhibitor. The median follow-up was 8.25 years.

RESULTS

There were 36 events: 10 contralateral breast cancers (CBCs) and 26 recurrences (8 local, 1 regional, and 17 distant). The 10-year risk of locoregional recurrence was 2.5%, the 10-year risk of CBC was 3.6%, and the 10-year risk of distant metastasis was 4.4%. The event-free survival rate for all patients was 93%. Only >/=4 positive lymph nodes and premenopausal status were found to be independent variables for decreased event-free survival on multivariate analysis. The overall survival rate was 89%. Only younger age and lower lymph node status were found to be significant predictors of improved overall survival.

CONCLUSIONS

In the current study, a 40% reduction in recurrence/CBC with the addition of an aromatase inhibitor after 5 years of tamoxifen treatment would have had a marginal benefit of 1% to 2%. Women who were premenopausal and patients with >/=4 positive lymph nodes would have the greatest absolute benefit of >3% in the 10-year event-free survival rate from extended therapy. The decision needs to be individualized for patients aged >/=60 years based on their initial lymph node status and the presence of comorbidities that could lower their 5-year life expectancy.

Tolerability and safety of classic cyclophosphamide, methotrexate, and fluorouracil treatment in Japanese patients with early breast cancer

BACKGROUND

Few reports have addressed the feasibility and safety of classic Cyclophosphamide, Methotrexate, and Fluorouracil (CMF) therapy in Japanese female breast cancer patients.

METHODS

Twenty-four Japanese patients who received classic CMF, identical to the originally described treatment regimen were studied in terms of treatment dose, treatment delay, and toxicity.

RESULTS

Classic CMF was not discontinued in any of the cases. The median delay in treatment was 14 days, and the mean administered dose of cyclophosphamide was 98.2% of the planned dose. None of the patients suffered severe side-effects such as febrile neutropenia; however, in 22 patients in whom the effect of CMF on hair loss could be assessed, 7 (31.8%) had to wear hats or wigs.

CONCLUSIONS

Classic CMF is a feasible and safe regimen in Japanese breast cancer patients. In Japan, this regimen is still available for some specific groups of early breast cancer patients.