Bilateral Salpingo-Oophorectomy Versus GnRH Analogue in the Adjuvant Treatment of Premenopausal Breast Cancer Patients: Cost-Effectiveness Evaluation of Breast Cancer Outcome, Ovarian Cancer Prevention and Treatment

Oophorectomy in Premenopausal Patients with Estrogen Receptor-Positive Breast Cancer: New Insights into Long-Term Effects

Approximately 80% of breast cancers are estrogen receptor-positive (ER+), and 68-80% of those occur in premenopausal or perimenopausal women. Since the introduction of tamoxifen for adjuvant endocrine therapy in women with non-metastatic ER+ breast cancer, subsequent trials have demonstrated an oncologic benefit with the addition of ovarian function suppression (OFS) to adjuvant endocrine therapy. Subsequently, therapies to either suppress or ablate ovarian function may be included in the treatment plan for patients that remain premenopausal or perimenopausal after upfront or adjuvant chemotherapy and primary surgery. One strategy for OFS, bilateral salpingo-oophorectomy (BSO), has lasting implications, and the routine recommendation for this strategy warrants a critical analysis in this population. The following is a narrative review of the utility of ovarian suppression or ablation (through either bilateral oophorectomy or radiation) in the context of adjuvant endocrine therapy, including selective estrogen receptor modulators (SERMs) and aromatase inhibitors (AIs). The long-term sequelae of bilateral oophorectomy include cardiovascular and bone density morbidity along with sexual dysfunction, negatively impacting overall quality of life. As gynecologists are the providers consulted to perform bilateral oophorectomies in this population, careful consideration of each patient's oncologic prognosis, cardiovascular risk, and psychosocial factors should be included in the preoperative assessment to assist in shared decision-making and prevent the lifelong adverse effects that may result from overtreatment.

Flavonoids Targeting the mTOR Signaling Cascades in Cancer: A Potential Crosstalk in Anti-Breast Cancer Therapy

Cancer is one of the leading causes of death worldwide. Breast cancer is the second leading cause of death in women, with triple-negative breast cancer being the most lethal and aggressive form. Conventional therapies, such as radiation, surgery, hormonal, immune, gene, and chemotherapy, are widely used, but their therapeutic efficacy is limited due to adverse side effects, toxicities, resistance, recurrence, and therapeutic failure. Many molecules have been identified and investigated as potential therapeutic agents for breast cancer, with a focus on various signaling pathways. Flavonoids are a versatile class of phytochemicals that have been used in cancer treatment to overcome issues with traditional therapies. Cell proliferation, growth, apoptosis, autophagy, and survival are all controlled by mammalian target of rapamycin (mTOR) signaling. Flavonoids target mTOR signaling in breast cancer, and when this signaling pathway is regulated or deregulated, various signaling pathways provide potential therapeutic means. The role of various flavonoids as phytochemicals in targeting mTOR signaling pathways in breast cancer is highlighted in this review.

Comparison of outcomes in patients with luminal type breast cancer treated with a gonadotropin-releasing hormone analog or bilateral salpingo-oophorectomy: A cohort retrospective study

Introduction

Premenopausal patients with hormone receptor-positive breast cancer require ablation therapy via a pharmacological or surgical approach. Data comparing outcomes between treatment with gonadotropin-releasing hormone (GnRH) analogs and treatment with bilateral salpingo-oophorectomy (BSO) in Indonesia remains limited. Therefore, this study aimed to compare incidence of local recurrence and metastasis, and overall survival (OS) in patients with luminal type breast cancer treated using the two approaches.

Methods

This observational retrospective cohort study examined 100 premenopausal patients diagnosed with luminal type hormone receptor-positive breast cancer who registered at Dr. Wahidin Sudirohusodo Hospital and its networking hospitals in Makassar City from January to December 2017.

Result

Among the 100 study patients, 50 were given GnRH analogs and 50 underwent BSO. Incidence of local recurrence (P = 0.408) and metastasis (P = 0.419) did not significantly differ between the GnRH analog and BSO groups, although the incidence of local recurrence was higher in the GnRH analog group (68% vs. 58%) and incidence of metastasis was higher in the BSO group (24% vs 19%). The 5-year survival rate did not significantly differ between the GnRH analog and BSO groups.

Conclusion

Incidence of local recurrence and metastasis, and 5-year survival rate did not significantly differ between premenopausal breast cancer patients treated using a GnRH analog and those treated with BSO. Further large-scale studies to compare the efficacy and safety of both approaches are warranted.

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Data comparing outcomes between breast cancer treatment with GnRH or BSO in Indonesia remains limited.

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The patients in SOB and GnRH groups were in the advanced and locally advanced breast cancer stage, respectively.

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Incidence of local recurrence and metastasis, and OS did not significantly differ between GnRH and BSO groups.

Patient preferences and adherence to adjuvant GnRH analogs among premenopausal women with hormone receptor positive breast cancer

PURPOSE

Adjuvant ovarian function suppression (OFS) in premenopausal hormone receptor (HR) positive breast cancer (BC) improves survival. Adherence to adjuvant gonadotropin-releasing hormone analogs (GnRHa) remains a challenge and is associated with toxicities and inconvenient parenteral administration. The goal of this study was to describe real-world adherence patterns and patient preferences surrounding adjuvant GnRHa.

METHODS

We analyzed the medical records of premenopausal women with non-metastatic HR positive BC from January 2000 to December 2017; participants received adjuvant monthly goserelin or leuprolide at The Ohio State University. Data collected included demographics, clinicopathologic characteristics, and OFS adherence/side effects. We defined non-adherence as discontinuation of GnRHa within 3 years for a reason other than switching to an alternate OFS, delay > 7 days from a dose, or a missed dose. Chi-square tests assessed associations between clinical characteristics and outcomes.

RESULTS

A total of 325 patients met eligibility. Of these, 119 (37%) patients were non-adherent to GnRHa; 137 (42%) underwent elective bilateral salpingo-oophorectomy after initial GnRHa. Those opting for surgery reported significantly more hot flashes (74% vs 48%, p < 0.001), arthralgias (46% vs 30%, p = 0.003), and vaginal dryness (37% vs 21%, p = 0.001) compared with patients remaining on GnRHa.

CONCLUSION

Non-adherence to adjuvant GnRHa occurred in over a third of patients and almost half the patients initiating GnRHa underwent subsequent surgical ablation. These high frequencies highlight real-world patterns of OFS. Additionally, treatment toxicities may impact personal preference of OFS modality. Personalized practices to target predictors of adjuvant GnRHa non-adherence are critical to optimize symptoms, adherence, and survivorship.

Awareness of the Causes Leading to Surgical Ablation of Ovarian Function in Premenopausal Breast Cancer-A Single-Center Analysis

Background and Objectives: Ovarian surgical ablation (OSA) in estrogen receptor-positive (ER+) breast cancer is usually performed to halt ovarian function in premenopausal patients. Since alternative pharmacological therapy exists and few studies have investigated why surgery is still performed, we aimed to analyze the reasons for the use of OSA despite the remaining controversy. Materials and Methods: Premenopausal ER+ breast cancer patients treated at a tertiary center (2005–2011) were selected, and patients with germline mutations were excluded. Results: Seventy-nine patients met the inclusion criteria. Globally, the main reasons for OSA included: continued menstruation despite hormone therapy with or without ovarian medical ablation (OMA) (34.2%), patient informed choice (31.6%), disease progression (16.5%), gynecological disease requiring surgery (13.9%), and tamoxifen intolerance/contraindication (3.8%). In women aged ≥45 years, patient choice was significantly more frequently the reason for OSA (47.4% versus 17.1% (p = 0.004)). For those aged <45 years, salvation attempts were significantly more frequent as compared to older women (26.8% versus 5.3% (p = 0.01)). In 77.8% of women undergoing OSA with menstrual cycle maintenance, surgery was performed 1–5 years after diagnosis, while surgery was performed earlier (0–3 months after diagnosis) in patients undergoing OSA as an informed choice (56.0%), as a salvation attempt (53.8%), or due to gynecological disease (63.6%). The leading reason for OSA in women previously undergoing OMA was continued menstruation (60.0%). Conclusions: This study suggests a possible failure of pharmacological ovarian suppression and reinforces the need for shared decision-making with patients when discussing treatment strategies, although validation by further studies is warranted due to our limited sample size.

Surgical ovarian suppression for adjuvant treatment in hormone receptor positive breast cancer in premenopausal patients

OBJECTIVE

Ovarian suppression is recommended to complement endocrine therapy in premenopausal women with breast cancer and high-risk features. It can be achieved by either medical ovarian suppression or therapeutic bilateral salpingo-oophorectomy. Our objective was to evaluate characteristics of patients with stage I-III hormone receptor positive primary breast cancer who underwent bilateral salpingo-oophorectomy at our institution.

MATERIALS AND METHODS

Premenopausal women with stage I-III hormone receptor positive primary breast cancer diagnosed between January 2010 and December 2014 were identified from a database. Patients with confirmed BRCA1/2 mutations were excluded. Distribution of characteristics between treatment groups was assessed using χ² test and univariate logistic regression. A multivariate model was based on factors significant on univariate analysis.

RESULTS

Of 2740 women identified, 2018 (74%) received endocrine treatment without ovarian ablation, 516 (19%) received endocrine treatment plus ovarian ablation, and 206 (7.5%) did not receive endocrine treatment. Among patients undergoing ovarian ablation 282/516 (55%) received medical ovarian suppression, while 234 (45%) underwent bilateral salpingo-oophorectomy. By univariate logistic analyses, predictors for ovarian ablation were younger age (OR 0.97), histology (other vs ductal: OR 0.23), lymph node involvement (OR 1.89), higher International Federation of Gynecology and Obstetrics (FIGO) stage (stage II vs I: OR 1.48; stage III vs I: OR 2.86), higher grade (grade 3 vs 1: OR 3.41; grade 2 vs 1: OR 2.99), chemotherapy (OR 1.52), and more recent year of diagnosis (2014 vs 2010; OR 1.713). Only year of diagnosis, stage, and human epidermal growth factor receptor 2 (HER-2) treatment remained significant in the multivariate model. Within the cohort undergoing ovarian ablation, older age (OR 1.05) was associated with therapeutic bilateral salpingo-oophorectomy. Of 234 undergoing bilateral salpingo-oophorectomy, 12 (5%) mild to moderate adverse surgical events were recorded.

CONCLUSIONS

Bilateral salpingo-oophorectomy is used frequently as an endocrine ablation strategy. Older age was associated with bilateral salpingo-oophorectomy. Perioperative morbidity was acceptable. Evaluation of long-term effects and quality of life associated with endocrine ablation will help guide patient/provider decision-making.

Comparison of clinicopathological features and treatments between pre- and postmenopausal female breast cancer patients - a retrospective study

Introduction

To find out if there are clinical and biological differences in breast cancer characteristics of premenopausal and postmenopausal women. For this reason, we investigated the differences in terms of the clinicopathological features and treatment methods of premenopausal and postmenopausal breast cancer patients in our study.

Material and methods

In this study, the files of 428 patients who were operated due to breast cancer between 1 January 2007 and 31 December 2017 in Ankara Atatürk Training and Research Hospital were examined retrospectively. The age, tumour size, tumour grade, oestrogen receptor, progesterone receptor, HER2 score, Ki-67 proliferation index, perineural invasion, and lymphovascular invasion were investigated.

Results

In patients with premenopausal breast cancer, the tumour diameter was larger (p = 0.047) and the lymph node metastasis was higher (p < 0.001). Oestrogen receptor (OR) expression (p = 0.002), progesterone receptor (PR) expression (p = 0.014), negative human epidermal growth factor receptor 2 (HER2) expression (p = 0.038), and Ki-67 expression (p = 0.017) were higher in the premenopausal group. In the premenopausal group, breast conserving surgery (p = 0.004), chemotherapy (p = 0.007), radiotherapy (p = 0.008), and endocrine therapy (p = 0.025) were higher than in the postmenopausal group.

Conclusions

Premenopausal and postmenopausal female breast cancer patients have significant differences in tumour size, tumour grade, axillary lymph node metastasis, hormone receptor status, HER2 expression, and treatment modalities.