Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus)

Hind, Daniel; Wyld, Lynda; Beverley, Catherine; Reed, Malcolm

doi:10.1002/14651858.cd004272.pub2

Cited by 102 publications

(68 citation statements)

References 39 publications

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“…Full details of the methods employed are published elsewhere (Hind et al, 2006). The Cochrane Breast Cancer Group Specialised Register was searched on 29 June 2005.…”

Section: Methodsmentioning

confidence: 99%

“…In some cases, the internal validity of the primary studies was affected by competing risks and informative censoring, which violate the assumptions underlying the Kaplan -Meier survival analysis method (these issues are discussed fully elsewhere in Hind et al, 2006). Heterogeneity between trials, in terms of interventions and outcome assessment, also made assessment of some outcomes problematic.…”

Section: Strengths and Weaknesses Of The Studymentioning

confidence: 99%

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Surgery, with or without tamoxifen, vs tamoxifen alone for older women with operable breast cancer: Cochrane review

2007

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The published literature comparing surgery, with or without adjuvant endocrine therapy, with endocrine therapy alone in older women with operable breast cancer was systematically reviewed.The design used is Cochrane review. Randomised controlled trials retrieved from the Cochrane Breast Cancer Group Specialised Register on 29 June 2005. Eligible studies recruited women aged 70 years or over with operable breast cancer, fit for surgery under general anaesthia. The studies compared surgery (either mastectomy or wide local excision, with or without endocrine therapy) to endocrine therapy alone. Primary outcomes were overall survival (OS) and progression-free survival (PFS). Double data extraction and quality assessment were undertaken. Seven eligible trials were identified of which six had published time-to-event data. The quality of the allocation concealment was adequate in three studies and unclear in the remainder. In each case the endocrine therapy used was tamoxifen. When surgery alone was compared to endocrine therapy alone, there was no significant difference in OS (hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.74 -1.30, P ¼ 0.9), but a significant difference in PFS (HR 0.55, 95% CI 0.39 -0.77, P ¼ 0.0006). When surgery with adjuvant endocrine therapy was compared to endocrine therapy alone, there was no significant difference in OS (HR 0.86, 95% CI 0.73 -1.00, P ¼ 0.06), but a significant difference in PFS (HR 0.65 (95% CI 0.53 -0.81, P ¼ 0.0001) for surgery plus endocrine therapy vs primary endocrine. The regimens have different side effect profiles with one study suggesting increased psychosocial morbidity at 3 months in the surgical arm, which resolves by 2 years. Primary endocrine therapy with tamoxifen is associated with inferior local disease control but noninferior survival to surgery for breast cancer in older women. Trials are needed to evaluate appropriate selection criteria for its use in terms of patient co-morbidity and quality of life. Trials are needed to evaluate the clinical effectiveness of aromatase inhibitors as primary therapy for this population.

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“…Full details of the methods employed are published elsewhere (Hind et al, 2006). The Cochrane Breast Cancer Group Specialised Register was searched on 29 June 2005.…”

Section: Methodsmentioning

confidence: 99%

Section: Strengths and Weaknesses Of The Studymentioning

confidence: 99%

Surgery, with or without tamoxifen, vs tamoxifen alone for older women with operable breast cancer: Cochrane review

2007

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“…A series of randomised trials compared tamoxifen alone versus surgery alone [15][16][17] and a recent meta-analysis comparing surgery with primary endocrine therapy for operable breast cancer in elderly women found no difference in overall survival [18]. Several randomised trials compared tamoxifen alone with surgery followed by tamoxifen and in all but one of these trials there was a significant increase in local events in the tamoxifen alone group [19][20][21][22][23].…”

Section: Discussionmentioning

confidence: 99%

“…One study also showed a significantly higher mortality in patients treated by tamoxifen alone but this increase in mortality was only apparent after 3 years of follow up [11]. A meta-analysis found a non-significant trend in favour of combining surgery with tamoxifen versus tamoxifen alone for overall survival (HR 0.86, P = 0.06) and a significant improvement in local disease control in favour of surgery and tamoxifen (HR 0.28, P \ 0.00001) [18]. Many of these early studies did not select patients based on oestrogen receptor status and all used tamoxifen.…”

Section: Discussionmentioning

confidence: 99%

Increase in response rate by prolonged treatment with neoadjuvant letrozole

Dixon

Renshaw

Macaskill

et al. 2008

Breast Cancer Res Treat

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Purpose The aim of this study was to investigate the potential benefits of prolonged treatment with neoadjuvant letrozole. Patients and Methods About 182 consecutive patients have been treated in Edinburgh with neoadjuvant letrozole for 3 months or longer and 63 patients have continued on letrozole beyond 3 months. Outcomes are reported. Results Of the 63 patients who continued on letrozole, 38 patients took letrozole for more than 1 year and 23 took letrozole for more than 24 months. The median reduction in clinical volume in the first 3 months in these 63 patients was 52%. Similar reductions in median clinical volume were seen between three to 6 months (50%), 6-12 months and 12-24 months (medians 37 and 33%, respectively). At 3 months 69.8% of the 182 patients had a partial or complete response. The response rate increased to 83.5% with prolonged letrozole treatment. Continuing letrozole beyond 3 months increased the number of women who initially required mastectomy or had locally advanced breast cancer who were subsequently suitable for breast conserving surgery from 60% (81/134) at 3 months to 72% (96/134). Thirty-three women remain on letrozole alone (man age at diagnosis 83 years) and at 3 years the median time to treatment failure has not been reached. Conclusion Continuing letrozole in responding patients beyond 3-4 months achieves further clinical reduction in tumour size. For elderly women with a short life expectancy letrozole alone may provide long-term disease control.Keywords Breast conserving surgery Á Endocrine therapy Á Neoadjuvant Á Letrozole Á Large operable and locally advanced breast cancer

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“…PET is effective in around 80% of hormone receptor positive breast cancers [48]; there is, though, at present no way of predicting which receptor positive cancers will respond to endocrine therapy and how long the response will last [49]. The median response duration is about two years with wide variation [50].…”

Section: Primary Endocrine Therapy Vs Surgery Plus Endocrine Therapymentioning

confidence: 99%

Optimising the management of breast cancer in older patients

Tahir

2010

European Journal of Surgical Oncology

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This study aimed to optimise the treatment of early breast cancer in older patients. It tested the hypothesis that comprehensive geriatric assessment (CGA) could be used to predict two-year survival in older breast cancer patients. Based on the CGA scoring a treatment algorithm was devised that could help in recommending whether primary endocrine treatment (PET) or surgery plus endocrine treatment would be best indicated in individual patients.Methods: The study included women >70 years of age with early breast

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Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus)

Cited by 102 publications

References 39 publications

Surgery, with or without tamoxifen, vs tamoxifen alone for older women with operable breast cancer: Cochrane review

Surgery, with or without tamoxifen, vs tamoxifen alone for older women with operable breast cancer: Cochrane review

Increase in response rate by prolonged treatment with neoadjuvant letrozole

Optimising the management of breast cancer in older patients

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