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Trenou KC, Mésidor M, Diorio C, Eslami A, Talbot D. [Effects of extended aromatase inhibitors in women with hormone-dependent breast cancer who have already received five years of adjuvant hormone therapy: A systematic review and meta-analysis]. Bull Cancer 2024; 111:356-362. [PMID: 38453587 DOI: 10.1016/j.bulcan.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Evaluating the benefits and risks of prolonged hormonal treatment with aromatase inhibitors (AIs) for treating hormone-dependent breast cancer. METHODS A systematic review and meta-analysis was conducted. Studies reporting on randomized clinical trials concerning prolongating hormonal therapy with AIs as compared to a placebo or no prolongation, after an initial five years of hormonal therapy, were eligible. RESULTS Seven clinical trials were included. Prolonged AI therapy was associated with a statistically significant improvement in disease-free survival (RR=0.70, 95% CI 0.60 to 0.80). A statistically significant increase was observed for osteoporosis (RR=1.17, 95% CI 1.03 to 1.33), hot flushes/flashes (RR=1.27, 95% CI 1.08 to 1.49), myalgia (RR=1.23, 95% CI 1.09 to 1.39), fractures (RR=1.26, 95% CI 1.09 to 1.45) and arthralgia (RR=1.17, 95% CI 1.10 to 1.25). However, no statistically significant association was observed between prolonged AI therapy and overall survival, cardiovascular events, and bone pain. DISCUSSION Prolonged AI therapy has significant benefits in terms of disease-free survival in women with hormone-dependent breast cancer. However, adverse effects and a lack of evidence for a benefit on overall survival must be considered in the decision-making process regarding adjuvant hormone therapy extension.
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Affiliation(s)
- Kossi Clément Trenou
- Département de médecine sociale et préventive, Université Laval, QC G1V 0A6 Québec, Canada; Axe santé des populations et pratiques optimales en santé, centre de recherche du CHU de Québec - Université Laval, Québec, Canada
| | - Miceline Mésidor
- Département de médecine sociale et préventive, Université Laval, QC G1V 0A6 Québec, Canada; Axe santé des populations et pratiques optimales en santé, centre de recherche du CHU de Québec - Université Laval, Québec, Canada
| | - Caroline Diorio
- Département de médecine sociale et préventive, Université Laval, QC G1V 0A6 Québec, Canada; Axe oncologie, centre de recherche du CHU de Québec - Université Laval, Québec, Canada
| | - Aida Eslami
- Département de médecine sociale et préventive, Université Laval, QC G1V 0A6 Québec, Canada; Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Canada
| | - Denis Talbot
- Département de médecine sociale et préventive, Université Laval, QC G1V 0A6 Québec, Canada; Axe santé des populations et pratiques optimales en santé, centre de recherche du CHU de Québec - Université Laval, Québec, Canada.
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He P, Li J, Chen M, Huang M, Qiu Y, Cai Q, Lin Y, Wang C, Fu F. Comparative efficacy and safety of extended adjuvant endocrine therapy for hormone receptor-positive early breast cancer: a Bayesian network meta-analysis. Breast Cancer Res Treat 2024; 203:13-28. [PMID: 37787817 DOI: 10.1007/s10549-023-07105-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/23/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE Optimal extended adjuvant endocrine therapy (ET) duration and strategy for hormone receptor-positive (HR +) early breast cancer remain unclear. In this network meta-analysis (NMA), the efficacy and safety of all available extended adjuvant ETs were compared and ranked. METHODS PubMed, Embase, and Cochrane Library and abstracts presented at ASCO, SABCS, and ESMO were searched on March 5, 2022. Fourteen randomized controlled trials (RCTs) comprising eight extended adjuvant ETs for HR + breast cancer and 38,070 patients were analyzed. Main outcomes were disease-free survival (DFS), overall survival (OS), grade ≥ 3 adverse events (AEs), and contralateral breast cancer (CBC). Direct and indirect comparisons were integrated via Bayesian NMA. Hierarchical cluster analysis was performed to jointly rank efficacy and safety outcomes. RESULTS Compared with that of 5 year ET, extended 10 year aromatase inhibitor (AI) treatment provided the greatest DFS benefit (HR = 0.45, 95%CrI 0.23-0.83), whereas no strategy differed significantly in terms of the other main outcomes. Extended 10 year AI treatment was the preferred strategy for DFS improvement and CBC prevention (surface under the cumulative ranking curve: 93.51% and 91.29% probability, respectively). All strategies had comparable safeties (grade ≥ 3 AEs). Compared with that of 5 year ET, 10 year extended AI significantly increased arthralgia (OR = 1.65, 95%CrI 1.02-2.93) and osteoporosis (OR = 3.33, 95%CrI 1.19-9.68). CONCLUSION Extended 10 year AI therapy may be optimal for HR + early breast cancer given its relatively high efficacy and safety.
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Affiliation(s)
- Peng He
- Department of Breast Surgery, Fujian Medical University Union Hospital, No.29, Xin Quan Road, Gulou District, Fuzhou, 350001, Fujian, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian, China
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian, China
| | - Jing Li
- Department of Breast Surgery, Fujian Medical University Union Hospital, No.29, Xin Quan Road, Gulou District, Fuzhou, 350001, Fujian, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian, China
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian, China
| | - Minyan Chen
- Department of Breast Surgery, Fujian Medical University Union Hospital, No.29, Xin Quan Road, Gulou District, Fuzhou, 350001, Fujian, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian, China
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian, China
| | - Meng Huang
- Fujian Center for Disease Control and Prevention, Fuzhou, Fujian, China
| | - Yibin Qiu
- Department of Breast Surgery, Fujian Medical University Union Hospital, No.29, Xin Quan Road, Gulou District, Fuzhou, 350001, Fujian, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian, China
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian, China
| | - Qindong Cai
- Department of Breast Surgery, Fujian Medical University Union Hospital, No.29, Xin Quan Road, Gulou District, Fuzhou, 350001, Fujian, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian, China
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian, China
| | - Yuxiang Lin
- Department of Breast Surgery, Fujian Medical University Union Hospital, No.29, Xin Quan Road, Gulou District, Fuzhou, 350001, Fujian, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian, China.
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian, China.
| | - Chuan Wang
- Department of Breast Surgery, Fujian Medical University Union Hospital, No.29, Xin Quan Road, Gulou District, Fuzhou, 350001, Fujian, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian, China.
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian, China.
| | - Fangmeng Fu
- Department of Breast Surgery, Fujian Medical University Union Hospital, No.29, Xin Quan Road, Gulou District, Fuzhou, 350001, Fujian, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian, China.
- Breast Cancer Institute, Fujian Medical University, Fuzhou, Fujian, China.
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Generali D, Berardi R, Caruso M, Cazzaniga M, Garrone O, Minchella I, Paris I, Pinto C, De Placido S. Aromatase inhibitors: the journey from the state of the art to clinical open questions. Front Oncol 2023; 13:1249160. [PMID: 38188305 PMCID: PMC10770835 DOI: 10.3389/fonc.2023.1249160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024] Open
Abstract
Breast cancer is a major cause of death among females. Great advances have been made in treating this disease, and aromatase inhibitors (AIs) have been recognized as the cornerstone. They are characterized by high efficacy and low toxicity. The authors reviewed the available literature and defined state-of-the-art AI management. This study was designed to assist clinicians in addressing the need to equally weigh patients' needs and disease control rates in their everyday clinical practice. Today, AIs play a central role in the treatment of hormone receptor-positive breast cancer. In this study, an expert panel reviewed the literature on the use of AIs, discussing the evolution of their use in various aspects of breast cancer, from pre- and postmenopausal early breast cancer to metastatic breast cancer, along with their management regarding efficacy and toxicity. Given the brilliant results that have been achieved in improving survival in everyday clinical practice, clinicians need to address their concerns about therapy duration and the adverse effects they exert on bone health, the cardiovascular system, and metabolism. Currently, in addition to cancer treatment, patient engagement is crucial for improving adherence to therapy and supporting patients' quality of life, especially in a selected subset of patients, such as those receiving an extended adjuvant or combination with targeted therapies. A description of modern technologies that contribute to this important goal is provided.
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Affiliation(s)
- Daniele Generali
- Breast Cancer Unit, Azienda Socio Sanitaria Territoriale di Cremona, Cremona, Italy
- Department of Medical, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Rossana Berardi
- Medical Oncology, Azienda Ospedaliera Universitaria (AOU) delle Marche, University Politecnica delle Marche, Ancona, Italy
| | - Michele Caruso
- Humanitas Istituto Clinico Catanese, Breast Centre Humanitas Catania, Catania, Italy
| | - Marina Cazzaniga
- School of Medicine and Surgery University of Milano Bicocca, Milan, Italy
- Phase 1 Research Unit, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Ornella Garrone
- Medical Oncology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ida Minchella
- Division of Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
| | - Ida Paris
- Department of Woman and Child Health and Public Health, Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Carmine Pinto
- Medical Oncology Unit, Comprehensive Cancer Centre, Azienda Unità Sanitaria Locale - Istituto di Ricerca e Cura a Carattere Scientifico (AUSL-IRCCS) di Reggio Emilia, Reggio Emilia, Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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Petrelli F, Cavallone M, Dottorini L. 10 years or less of extended adjuvant endocrine therapy for postmenopausal breast cancer patients: A systematic review and network meta-analysis. Eur J Cancer 2023; 193:113322. [PMID: 37769477 DOI: 10.1016/j.ejca.2023.113322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 09/30/2023]
Abstract
INTRODUCTION Adjuvant hormonal therapy, with or without prior chemotherapy, has been widely recognised as the preferred treatment strategy for resected breast cancer (BC) for a minimum duration of 5 years. If the effectiveness of therapy beyond a 5-year period has been established, there is still ongoing debate regarding the optimal duration for this prolonged period. A network meta-analysis (NMA) was conducted to ascertain the optimal duration of extended therapy for resected BC in postmenopausal women. MATERIAL AND METHODS A comprehensive search was conducted on online databases, including MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials, to identify all randomised trials on extended duration of endocrine therapy. The search was limited to trials that had been published before 30th April 2023. The study focused on evaluating disease-free survival (DFS) as the primary outcome, with overall survival (OS) as the secondary endpoint. Under the Bayesian framework, NMA was performed using the GeMTC package. The relative rankings of the treatments were determined by utilising surface under the cumulative ranking curve (SUCRA) p scores. A network meta-regression analysis was employed to ascertain the impact of the baseline characteristics of the disease and the initial treatments administered. RESULTS In the overall population, increasing the duration by 5 years did not result in a significantly better DFS compared to durations of 2-3 and 3-4 more years (hazard ratio [HR] = 0.97, 95% confidence interval [CI] [0.88-1.08] and HR = 0.87, 95% CI [0.72-1.06]). This effect was independent of adjuvant chemotherapy and nodal status. However, the effect of 5 more years of AI was significantly better in node-positive BC and in those who received some years of tamoxifen instead of aromatase inhibitors (AIs) as initial adjuvant therapy. OS was not affected by the administration of extended endocrine therapy. CONCLUSIONS We conclude that an extended course of AI lasting 2-3 years, following an initial 5-year treatment, may be considered an appropriate regimen for achieving DFS benefits. In node-positive BC cases, it has been observed that a duration of 10 years provides a greater advantage compared to shorter durations, especially when tamoxifen is administered initially. Therefore, it is suggested that a longer duration is a potential standard of care in these cases.
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Xie M, Zhong Y, Yang Y, Shen F, Nie Y. Extended adjuvant endocrine therapy for women with hormone receptor-positive early breast cancer: A meta-analysis with trial sequential analysis of randomized controlled trials. Front Oncol 2022; 12:1039320. [PMID: 36387136 PMCID: PMC9647050 DOI: 10.3389/fonc.2022.1039320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/12/2022] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVES The aim of the current study is to explore the association between extended adjuvant endocrine treatment and prognosis of women with hormone receptor-positive (HR+) early breast cancer. METHODS Databases including PubMed, Web of Science, Embase and the Cochrane Library databases were electronically searched to identify randomized controlled trials (RCTs) that reported extended endocrine therapy for women with HR+ early breast cancer. The retrieval time was limited from inception to September 2022. Two reviewers independently screened literature, extracted data, and assessed risk bias of included studies. Meta-analysis was performed by using R software Version 4.1.2 and STATA Version 12.0. RESULTS A total of 15 RCTs involving 29497 cases were included. The overall analysis showed that compared with the control, extended adjuvant endocrine therapy increased disease-free survival (DFS) (HR=0.814, 95% CI: 0.720-0.922, 95% PI: 0.556-1.194), overall survival (OS) (HR=0.885, 95% CI: 0.822-0.953, 95% PI: 0.771-1.035), relapse-free survival (RFS) (HR=0.833, 95% CI: 0.747-0.927, 95% PI: 0.575-1.159), distant metastatic-free survival (DMFS) (HR=0.824, 95% CI: 0.694-0.979, 95% PI: 0.300-2.089) and reduced new breast cancer cumulative incidence (NBCCI) (HR=0.484, 95% CI: 0.403-0.583, 95% PI: 0.359-0.654). For adverse events, extended adjuvant endocrine treatment was associated with a significantly higher risk of bone fracture (RR=1.446, 95% CI: 1.208-1.730, 95% PI: 1.154-1.854) and osteoporosis (RR=1.377, 95% CI: 1.018-1.862, 95% PI: 0.347-5.456). CONCLUSION Our study showed that extended adjuvant endocrine therapy increased DFS, OS, RFS, DMFS, the incidence of bone fracture and osteoporosis, and reduced NBCCI. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero, identifier (CRD42022351295).
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Affiliation(s)
- Ming Xie
- Department of Science and Education, The Third Hospital of Changsha, Changsha, China
| | - Yan Zhong
- Department of Preventive Medicine, School of Medicine, Hunan Normal University, Changsha, China
| | - Yide Yang
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, China
| | - Fang Shen
- Department of Science and Education, The Third Hospital of Changsha, Changsha, China
| | - Yue Nie
- Department of Science and Education, The Third Hospital of Changsha, Changsha, China
- Department of Geriatrics, The Third Hospital of Changsha, Changsha, China
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Boszkiewicz K, Piwowar A, Petryszyn P. Aromatase Inhibitors and Risk of Metabolic and Cardiovascular Adverse Effects in Breast Cancer Patients-A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:3133. [PMID: 35683517 PMCID: PMC9181297 DOI: 10.3390/jcm11113133] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/14/2022] [Accepted: 05/25/2022] [Indexed: 02/01/2023] Open
Abstract
Aromatase inhibitors (AIs) have been considered first-line therapy for patients with hormone-dependent breast cancer due to their high efficacy and good tolerability. However, AIs are not free of adverse events, and studies show that therapy with AIs is associated with an increased risk of cardiovascular events and the development of insulin resistance and diabetes. We searched the Cochrane Central Register of Controlled Trials, PubMed and EMBASE up to 27 October 2020 for the prevalence of cardiovascular and/or metabolic adverse effects during treatment with AIs in postmenopausal women with breast cancer. A meta-analysis was performed using a random effects model. Odds ratios and 95% confidence intervals were calculated and illustrated using forest plot charts. We performed separate analyses depending on trial design. Twenty two studies met the inclusion criteria. AIs were associated with a higher risk of cardiovascular events, especially when we compared study arms in which AIs were used (alone or in sequence with TAM) with the arms in which TAM was used alone (OR = 1.16; 95%CI 1.04-1.30) or when comparing patients taking AIs alone to patients taking TAM alone or in sequence with AIs (OR = 1.24; 95%CI 1.11-1.38). A pooled analysis of five trials comparing adjuvant AIs to TAM showed the odds for arterial hypertension being 1.31 times higher for patients taking AIs; however, this did not reach statistical significance (OR = 1.31; 95%CI 0.47-3.65). We have not shown an increased risk of dyslipidemia or weight gain with the use of AIs. Our results suggest that postmenopausal women with breast cancer treated with AIs have an increased risk of cardiovascular events in comparison with TAM, potentially due more to a cardioprotective effect of the latter than the cardiotoxicity of AIs. We were unable to prove a similar association for hypertension, dyslipidemia, hyperglycemia or weight gain. Further high-quality RCTs and post-marketing safety observational studies are needed to definitively evaluate the impact of AIs on metabolic disorders in breast cancer patients.
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Affiliation(s)
- Kamila Boszkiewicz
- Department of Toxicology, Wroclaw Medical University, Borowska Street 211, 50-556 Wroclaw, Poland;
| | - Agnieszka Piwowar
- Department of Toxicology, Wroclaw Medical University, Borowska Street 211, 50-556 Wroclaw, Poland;
| | - Paweł Petryszyn
- Department of Clinical Pharmacology, Wroclaw Medical University, Borowska Street 211a, 50-556 Wroclaw, Poland;
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Moloney C, Shiely F. Under-served groups remain underserved as eligibility criteria routinely exclude them from breast cancer trials. J Clin Epidemiol 2022; 147:132-141. [PMID: 35341945 DOI: 10.1016/j.jclinepi.2022.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/08/2022] [Accepted: 03/21/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Under-served groups are populations unrepresented or disengaged from medical research or services despite a disproportionately high healthcare burden. Under-served groups may be directly (age, pregnancy as examples) or indirectly excluded (provision of written information in one language only as example) from trial enrolment by strict eligibility exclusions. The purpose of our study was to assess eligibility criteria in published phase III breast cancer clinical trials to determine whether they excluded under-served groups either directly, or indirectly. STUDY DESIGN AND SETTING Medline was searched for phase III randomised controlled trials evaluating interventional drugs for breast cancer in high-impact journals published between January 1st, 2010 and December 31st, 2020. 5133 eligible trials were returned and 40 selected, by simple randomization, for inclusion. RESULTS All 40 trials had multiple exclusions that affected recruitment of under-served groups. Clinical or scientific rationale for the recorded inclusion and exclusion criteria was under-reported in 39 of 40 trials. CONCLUSIONS Clinical trial eligibility criteria exclude under-served groups from breast cancer trials. Trialists should provide a justification for each eligibility criterion and funders, reviewers, ethics committees, and others should demand one. Without this under-served groups will remain just that: under-served.
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Affiliation(s)
- Carolyn Moloney
- TRAMS (Trials Research and Methodologies Unit), Trial Forge, HRB Clinical Research Facility, University College Cork
| | - Frances Shiely
- TRAMS (Trials Research and Methodologies Unit), Trial Forge, HRB Clinical Research Facility, University College Cork; School of Public Health, University College Cork.
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Chen J, Zhang X, Lu Y, Zhang T, Ouyang Z, Sun Q. Optimal duration of endocrine therapy with extended aromatase inhibitors for postmenopausal patients with hormone receptor-positive breast cancer: a meta-analysis. Breast Cancer 2021; 28:630-643. [PMID: 33387283 DOI: 10.1007/s12282-020-01196-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/25/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal duration of endocrine therapy for patients with hormone receptor-positive (HR-positive) breast cancer is still unclear. This meta-analysis aims to determine the optimal duration of endocrine therapy with extended aromatase inhibitors (AI) for postmenopausal patients with HR-positive early breast cancer who have finished 5 years of endocrine therapy. METHODS Eligible randomized controlled trials were classified into three categories according to the whole duration of endocrine therapy (10 years versus 5 years, 7-8 years versus 5 years, and 10 years versus 7-8 years). For each category, hazard ratio (HR) for disease-free survival (DFS) and overall survival (OS), and risk ratio (RR) for the incidence of adverse events were pooled. RESULTS Altogether 9 RCTs enrolling a total of 22,313 postmenopausal women with HR-positive breast cancer were included. Pooled data showed an improvement in DFS when extending endocrine therapy from 5 to 7-8 years (HR = 0.79 [0.69, 0.91]), specifically among those who had been treated with only tamoxifen (HR = 0.40 [0.22, 0.73]) or sequential tamoxifen followed by AI (HR = 0.82 [0.71, 0.95]), with tumors that were node-positive (HR = 0.72 [0.56, 0.93]), estrogen receptor (ER) and progesterone receptor (PR) positive (HR = 0.61 [0.47, 0.78]), or ≥ 2 cm in size (HR = 0.72 [0.51, 0.98]). However, no improvement in DFS was obtained when extending from 7-8 to 10 years (HR = 0.98 [0.87, 1.11]). In addition, the extension of endocrine therapy was not associated with an improvement in OS, but was associated with an increased risk of bone fracture and osteopenia/osteoporosis. CONCLUSION Patients who have been treated with AI for 5 years, with tumors that are node-negative, ER+/PR- or ER-/PR+, and < 2 cm in size do not need to receive extended AI therapy. For those who have been treated with only tamoxifen or sequential tamoxifen followed by an AI for a total of 5 years, with tumors that are node-positive, ER+/PR+ or ≥ 2 cm in size, 2-3 years of extended AI is necessary and maybe enough.
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Affiliation(s)
- Juan Chen
- Institute of Medical Information/Medical Library, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohui Zhang
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Lu
- Institute of Medical Information/Medical Library, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ting Zhang
- Institute of Medical Information/Medical Library, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhaolian Ouyang
- Institute of Medical Information/Medical Library, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Qiang Sun
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Moreau-Bachelard C, Campion L, Robert M, Kerdraon O, Renaudeau C, Aumont M, Classe JM, Campone M, Frénel JS. Development of a Prognostic Tool to Guide the Decision to Extend Adjuvant Aromatase Inhibitors for up to Ten Years in Postmenopausal Early Breast Cancer Patients. Cancers (Basel) 2020; 12:E3725. [PMID: 33322473 PMCID: PMC7763581 DOI: 10.3390/cancers12123725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/03/2020] [Accepted: 12/10/2020] [Indexed: 11/17/2022] Open
Abstract
Background: The selection of women with hormone receptor-positive (HR+) early breast cancer (EBC) at high risk of relapse after five years (yrs.) of adjuvant aromatase inhibitors (AIs) is crucial, as the benefit of extending AIs is counterbalanced by toxicity. We developed a clinicopathological tool to estimate the residual risk of relapse after five years of adjuvant AIs. Methods: The Institut de Cancérologie de l'Ouest (ICO) database was used to determine a prognostic score of post-five-year AI relapse. Cox regression models estimated our score's prognostic performance. Results: In total, 1105 women were included. Median follow-up was 44 months (IQR = 21-70) post-AI treatment. From the Cox models, we designed a dichotomous prognostic score including the number of macrometastases, age (>70 yrs. vs. ≤70 yrs.), tumor size (≥T2 vs. not), and mitotic activity (≥2 vs. not). Overall, 77.5% of patients were classified as being at low risk and 22.5% at high risk of late recurrence. Low-risk patients had a five- to ten-year local or distant recurrence risk of 7.6% (95% CI, 5.4% to 10.6%) as compared with 26.9% (95% CI, 19.9% to 35.7%) for the high-risk roup. Conclusion: In this study, we developed a simple tool to identify women at high risk of relapse despite completing five years of AIs.
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Affiliation(s)
- Camille Moreau-Bachelard
- Department of Medical Oncology, Institut de Cancérologie de l’Ouest, Boulevard Professeur Jacques Monod, 44800 Saint-Herblain, France; (C.M.-B.); (M.R.); (M.C.)
| | - Loïc Campion
- Department of Biometrics, Institut de Cancérologie de l’Ouest, Boulevard Professeur Jacques Monod, 44800 Saint-Herblain, France;
- CRCINA, University of Nantes, INSERM UMR1232, CNRS-ERL6001, 44000 Nantes, France
| | - Marie Robert
- Department of Medical Oncology, Institut de Cancérologie de l’Ouest, Boulevard Professeur Jacques Monod, 44800 Saint-Herblain, France; (C.M.-B.); (M.R.); (M.C.)
| | - Olivier Kerdraon
- Department of Pathology, Institut de Cancérologie de l’Ouest, Boulevard Professeur Jacques Monod, 44800 Saint-Herblain, France;
| | - Céline Renaudeau
- Department of Surgery, Institut de Cancérologie de l’Ouest, Boulevard Professeur Jacques Monod, 44800 Saint-Herblain, France; (C.R.); (J.-M.C.)
| | - Maud Aumont
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest, Boulevard Professeur Jacques Monod, 44800 Saint-Herblain, France;
| | - Jean-Marc Classe
- Department of Surgery, Institut de Cancérologie de l’Ouest, Boulevard Professeur Jacques Monod, 44800 Saint-Herblain, France; (C.R.); (J.-M.C.)
| | - Mario Campone
- Department of Medical Oncology, Institut de Cancérologie de l’Ouest, Boulevard Professeur Jacques Monod, 44800 Saint-Herblain, France; (C.M.-B.); (M.R.); (M.C.)
| | - Jean-Sébastien Frénel
- Department of Medical Oncology, Institut de Cancérologie de l’Ouest, Boulevard Professeur Jacques Monod, 44800 Saint-Herblain, France; (C.M.-B.); (M.R.); (M.C.)
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Komorowski AS, MacKay HJ, Pezo RC. Quality of adverse event reporting in phase III randomized controlled trials of breast and colorectal cancer: A systematic review. Cancer Med 2020; 9:5035-5050. [PMID: 32452660 PMCID: PMC7367648 DOI: 10.1002/cam4.3095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Clinical trial reports often emphasize efficacy over harms, leading to misinterpretation of the risk-to-benefit ratio of new therapies. Clear and sufficiently detailed reporting of methods and results is especially important in the abstracts of trial reports, as readers often base their assessment of a trial on such information. In this study, we evaluated the quality of adverse event (AE) reporting and abstract quality in phase III randomized controlled trials (RCTs) of systemic therapies in breast and colorectal cancer. METHODS Medline, EMBASE, Cochrane Database of RCTs, and Cochrane Database of Systematic Reviews were searched from November 2005 to September 2018. Phase III RCTs evaluating systemic therapies in breast or colorectal cancer were included. Each article was independently reviewed by two investigators using a standardized data extraction form based on guidelines developed by the Consolidated Standards of Reporting Trials (CONSORT) group. Descriptive statistics, bivariate analysis, and multivariable linear regression were used to analyze data. All statistical tests were two-sided. RESULTS Of 166 RCTs identified, 99.4% reported harms in the manuscript body, and 59.6% reported harms in the abstract. Reporting was restricted to severe harms in 15.6% of RCTs. Statistical comparison of AE rates went unreported in 59.0% of studies. Information regarding AEs leading to dose reductions, treatment discontinuations, or study withdrawals went unreported in 59.3%, 18.7%, and 86.8% of studies, respectively. Recently published RCTs (P = .009) and those sponsored at least partially by for-profit companies (P = .003) had higher abstract quality scores. CONCLUSIONS Breast and colorectal cancer phase III RCTs inadequately report CONSORT-compliant AE data. Improved guideline adherence and abstract reporting is required to properly weigh benefits and harms of new oncologic therapies. SYSTEMATIC REVIEW REGISTRATION NUMBER CRD42019140673.
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Affiliation(s)
- Adam S. Komorowski
- Division of Medical MicrobiologyMcMaster UniversityHamiltonONCanada
- Sunnybrook Research InstituteSunnybrook Health Sciences CentreTorontoONCanada
| | - Helen J. MacKay
- Division of Medical OncologySunnybrook Health Sciences CentreTorontoONCanada
- Department of MedicineUniversity of TorontoTorontoONCanada
| | - Rossanna C. Pezo
- Division of Medical OncologySunnybrook Health Sciences CentreTorontoONCanada
- Department of MedicineUniversity of TorontoTorontoONCanada
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Efficacy and toxicity of extended aromatase inhibitors after adjuvant aromatase inhibitors-containing therapy for hormone-receptor-positive breast cancer: a literature-based meta-analysis of randomized trials. Breast Cancer Res Treat 2019; 179:275-285. [DOI: 10.1007/s10549-019-05464-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 09/30/2019] [Indexed: 02/05/2023]
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12
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Clement Z, Kollias J, Bingham J, Whitfield R, Bochner M. Extended duration of adjuvant aromatase inhibitor in breast cancer: a meta-analysis of randomized controlled trials. Gland Surg 2018; 7:449-457. [PMID: 30505766 DOI: 10.21037/gs.2018.08.03] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background The risk of hormone positive breast cancer extends beyond 5 years. Extended duration of tamoxifen to 10 years has been shown to improve overall survival (OS) and disease-free survival (DFS). In post-menopausal women aromatase inhibitor (AI) is the gold standard for adjuvant endocrine therapy. Several randomized controlled trials (RCTs) showed benefit with extending the duration of AIs in post-menopausal women. However, the duration and the overall benefit is still controversial. Methods Eligible 8 RCTs comprising of 17,190 participants were included in this meta-analysis. Results Extending the duration of AI did not show any statistically significant advantage in OS with OR of 1.033 (95% CI: 0.925-1.154, P=0.56), DFS OR of 1.049 (95% CI: 0.930-1.185, P=0.435), recurrence-free survival (RFS) OR of 1.063 (95% CI: 0.952-1.187, P=0.276), and contralateral breast cancer (CBC) OR of 1.094 (95% CI: 0.920-1.301, P=0.311). Higher rates of side-effects of arthralgia, myalgia, hot flushes and bone toxicity was seen among the extended AI group. Conclusions Based on this meta-analysis and current literature review, extended use of AI after 5 years of endocrine therapy should be used in selected women with high risk tumour factors. Molecular markers and genomic profiling may assist in identifying the high-risk patients. It is important to consider quality of life and patient satisfaction when considering extending the duration of AI.
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Affiliation(s)
- Zackariah Clement
- Breast and Endocrine Surgery Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - James Kollias
- Breast and Endocrine Surgery Unit, Royal Adelaide Hospital, Adelaide, Australia.,Senior Clinical Lecturer, Department of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Janne Bingham
- Breast and Endocrine Surgery Unit, Royal Adelaide Hospital, Adelaide, Australia.,Senior Clinical Lecturer, Department of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Robert Whitfield
- Breast and Endocrine Surgery Unit, Royal Adelaide Hospital, Adelaide, Australia.,Senior Clinical Lecturer, Department of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Melissa Bochner
- Breast and Endocrine Surgery Unit, Royal Adelaide Hospital, Adelaide, Australia.,Senior Clinical Lecturer, Department of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, Australia
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13
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Brett J, Boulton M, Fenlon D, Hulbert-Williams NJ, Walter FM, Donnelly P, Lavery BA, Morgan A, Morris C, Watson EK. Adjuvant endocrine therapy after breast cancer: a qualitative study of factors associated with adherence. Patient Prefer Adherence 2018; 12:291-300. [PMID: 29497284 PMCID: PMC5819578 DOI: 10.2147/ppa.s145784] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Despite evidence of the efficacy of adjuvant endocrine therapy (AET) in reducing the risk of recurrence and mortality after treatment for primary breast cancer, adherence to AET is suboptimal. This study aimed to explore factors that influence adherence and nonadherence to AET following breast cancer to inform the development of supportive interventions. METHODS Interviews were conducted with 32 women who had been prescribed AET, 2-4 years following their diagnosis of breast cancer. Both adherers (n=19) and nonadherers (n=13) were recruited. The analysis was conducted using the Framework approach. RESULTS Factors associated with adherence were as follows: managing side effects including information and advice on side effects and taking control of side effects, supportive relationships, and personal influences. Factors associated with nonadherence were as follows: burden of side effects, feeling unsupported, concerns about long-term AET use, regaining normality, including valuing the quality of life over length of life, and risk perception. CONCLUSION Provision of timely information to prepare women for the potential side effects of AET and education on medication management strategies are needed, including provision of timely and accurate information on the efficacy of AET in reducing breast cancer recurrence and on potential side effects and ways to manage these should they arise. Trust in the doctor-patient relationship and clear patient pathways for bothersome side effects and concerns with AET are important. Training and education on AET for GPs should be considered alongside novel care pathways such as primary care nurse cancer care review and community pharmacist follow-up.
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Affiliation(s)
- Jo Brett
- Faculty of Health and Life Sciences, Oxford Brookes University, Oxford
- Correspondence: Jo Brett, Faculty of Health and Life Sciences, Oxford Brookes University, Jack Straws Lane, Marston, Oxford OX3 OFL, UK, Tel +44 1865 48 2696, Email
| | - Mary Boulton
- Faculty of Health and Life Sciences, Oxford Brookes University, Oxford
| | - Debbie Fenlon
- College of Human and Health Sciences, Swansea University, Swansea, Wales
| | - Nick J Hulbert-Williams
- Department of Psychology, Chester Research Unit for the Psychology of Health, University of Chester, Chester
| | - Fiona M Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Peter Donnelly
- South Devon Healthcare NHS Foundation Trust, Torbay Hospital, Torquay
| | | | | | | | - Eila K Watson
- Faculty of Health and Life Sciences, Oxford Brookes University, Oxford
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Extended adjuvant endocrine therapy in early breast cancer: a meta-analysis of published randomized trials. Med Oncol 2017. [DOI: 10.1007/s12032-017-0986-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Post-relapse survival in patients with the early and late distant recurrence in estrogen receptor-positive HER2-negative breast cancer. Breast Cancer 2016; 24:473-482. [PMID: 27628678 DOI: 10.1007/s12282-016-0730-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/07/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Few studies have been performed on post-relapse survival in patients with the early and late distant recurrence in estrogen receptor (ER)-positive, HER2-negative breast cancer. METHODS A total of 205 patients with the early distant recurrence and 134 patients with the late distant recurrence of ER-positive, HER2-negative breast cancer who had undergone breast surgery or neoadjuvant chemotherapy between January 2000 and December 2004 were registered from nine institutions. Prognostic factors for post-relapse survival in patients with the early and late recurrence were analyzed. RESULTS Post-relapse survival was significantly longer in patients with the late recurrence than in patients with the early recurrence. Predictive factors for post-relapse survival in patients with the early recurrence were lack of adjuvant chemotherapy, a long disease-free interval, and long durations of endocrine therapies and chemotherapies after relapse. In patients with the late recurrence, post-relapse survival was significantly improved for those individuals with one metastatic organ at relapse and individuals who were treated with the first-line and subsequent endocrine therapies for prolonged periods. Moreover, ER expression in primary breast tumors of late recurrence patients was significantly higher with a duration of the first-line endocrine therapy >6 months than in those with a duration ≤6 months. CONCLUSION Predictors for prognosis after relapse differed between patients with the early and late distant recurrence. Endocrine responsiveness after relapse is a key factor for improved post-relapse survival, and it is thus important to establish whether metastatic tumors are endocrine-resistant in ER-positive, HER2-negative recurrent breast cancer.
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