Current medical treatment of estrogen receptor-positive breast cancer

Approximately 80% of breast cancers (BC) are estrogen receptor (ER)-positive and thus endocrine therapy (ET) should be considered complementary to surgery in the majority of patients. The advantages of oophorectomy, adrenalectomy and hypophysectomy in women with advanced BC have been demonstrated many years ago, and currently ET consist of (1) ovarian function suppression (OFS), usually obtained using gonadotropin-releasing hormone agonists (GnRHa); (2) selective estrogen receptor modulators or down-regulators (SERMs or SERDs); and (3) aromatase inhibitors (AIs), or a combination of two or more drugs. For patients aged less than 50 years and ER+ BC, there is no conclusive evidence that the combination of OFS and SERMs (i.e., tamoxifen) or chemotherapy is superior to OFS alone. Tamoxifen users exhibit a reduced risk of BC, both invasive and in situ, especially during the first 5 years of therapy, and extending the treatment to 10 years further reduced the risk of recurrences. SERDs (i.e., fulvestrant) are especially useful in the neoadjuvant treatment of advanced BC, alone or in combination with either cytotoxic agents or AIs. There are two types of AIs: type I are permanent steroidal inhibitors of aromatase, while type II are reversible nonsteroidal inhibitors. Several studies demonstrated the superiority of the third-generation AIs (i.e., anastrozole and letrozole) compared with tamoxifen, and adjuvant therapy with AIs reduces the recurrence risk especially in patients with advanced BC. Unfortunately, some cancers are or became ET-resistant, and thus other drugs have been suggested in combination with SERMs or AIs, including cyclin-dependent kinase 4/6 inhibitors (palbociclib) and mammalian target of rapamycin (mTOR) inhibitors, such as everolimus. Further studies are required to confirm their real usefulness.

Endocrine Therapy in Early Breast Cancer

Background

Endocrine therapy with a standard duration of 5 years is well known as an effective treatment for endocrine-sensitive breast cancer.

Summary

In the adjuvant setting this treatment reduces the 15-year mortality rates by about 30 and 40% with tamoxifen and aromatase inhibitor, respectively. The well-known long-term recurrence risk of luminal cancers led to multiple trials examining the benefit of extended endocrine treatment for up to 15 years. Additional benefit with extended therapy was seen for patients with high recurrence risk. Also, additional ovarian suppression for premenopausal women exhibited a significant benefit for patients at higher risk.

Key Messages

The data of the last years will be summarized and discussed, also considering the side effects of the different treatment options.

Predictive value and clinical utility of centrally assessed ER, PgR, and Ki-67 to select adjuvant endocrine therapy for premenopausal women with hormone receptor-positive, HER2-negative early breast cancer: TEXT and SOFT trials

The SOFT and TEXT randomized phase III trials investigated adjuvant endocrine therapies for premenopausal women with hormone receptor-positive (HR+) early breast cancer. We investigated the prognostic and predictive value of centrally assessed levels of estrogen receptor (ER), progesterone receptor (PgR), and Ki-67 expression in women with HER2-negative disease. Of 5707 women enrolled, 4115 with HER2-negative (HR+/HER2-) disease had ER, PgR, and Ki-67 centrally assessed by immunohistochemistry. Breast cancer-free interval (BCFI) was defined from randomization to first invasive local, regional, or distant recurrence or contralateral breast cancer. The prognostic and predictive values of ER, PgR and Ki-67 expression levels were assessed using Cox modeling and STEPP methodology. In this HR+/HER2- population, the median ER, PgR, and Ki-67 expressions were 95, 90, and 18 % immunostained cells. As most patients had strongly ER-positive tumors, the predictive value of ER levels could not be investigated. Lower PgR and higher Ki-67 expression were associated with reduced BCFI. There was no consistent evidence of heterogeneity of the relative treatment effects according to PgR or Ki-67 expression levels, though there was a greater 5-year absolute benefit of exemestane + ovarian function suppression (OFS) versus tamoxifen with or without OFS at lower levels of PgR and higher levels of Ki-67. Women with poor prognostic features of low PgR and/or high Ki-67 have greater absolute benefit from exemestane + OFS versus tamoxifen + OFS or tamoxifen alone, but individually PgR and Ki-67 are of limited predictive value for selecting adjuvant endocrine therapy for premenopausal women with HR+/HER2- early breast cancer.

The role of the addition of ovarian suppression to tamoxifen in young women with hormone-sensitive breast cancer who remain premenopausal or regain menstruation after chemotherapy (ASTRRA): study protocol for a randomized controlled trial and progress

Background

Ovarian function suppression (OFS) has been shown to be effective as adjuvant endocrine therapy in premenopausal women with hormone receptor-positive breast cancer. However, it is currently unclear if addition of OFS to standard tamoxifen therapy after completion of adjuvant chemotherapy results in a survival benefit. In 2008, the Korean Breast Cancer Society Study Group initiated the ASTRRA randomized phase III trial to evaluate the efficacy of OFS in addition to standard tamoxifen treatment in hormone receptor-positive breast cancer patients who remain or regain premenopausal status after chemotherapy.

Methods

Premenopausal women with estrogen receptor-positive breast cancer treated with definitive surgery were enrolled after completion of neoadjuvant or adjuvant chemotherapy. Ovarian function was assessed at the time of enrollment and every 6 months for 2 years by follicular-stimulating hormone levels and bleeding history. If ovarian function was confirmed as premenopausal status, the patient was randomized to receive 2 years of goserelin plus 5 years of tamoxifen treatment or 5 years of tamoxifen alone. The primary end point will be the comparison of the 5-year disease-free survival rates between the OFS and tamoxifen alone groups. Patient recruitment was finished on March 2014 with the inclusion of a total of 1483 patients. The interim analysis will be performed at the time of the observation of the 187th event.

Discussion

This study will provide evidence of the benefit of OFS plus tamoxifen compared with tamoxifen only in premenopausal patients with estrogen receptor-positive breast cancer treated with chemotherapy.

Trial registration

ClinicalTrials.gov Identifier NCT00912548. Registered May 31 2009. Korean Breast Cancer Society Study Group Register KBCSG005. Registered October 26 2009.

Efficacy and safety of leuprorelin acetate 6-month depot, TAP-144-SR (6M), in combination with tamoxifen in postoperative, premenopausal patients with hormone receptor-positive breast cancer: a phase III, randomized, open-label, parallel-group comparative study

Background

Leuprorelin acetate, a luteinizing hormone-releasing hormone agonist, is used worldwide in premenopausal women with hormone receptor-positive breast cancer. This study was conducted to assess the non-inferiority of the 6-month depot formulation, TAP-144-SR (6M) 22.5 mg to the 3-month depot formulation, TAP-144-SR (3M) 11.25 mg in postoperative, premenopausal patients with hormone receptor-positive breast cancer.

Methods

This was a 96-week phase III, randomized, open-label, parallel-group comparative study. All patients concomitantly received oral tamoxifen (20 mg daily). The primary endpoint was the suppression rate of serum estradiol (E₂) to the menopausal level (≤30 pg/mL) from Week 4 through Week 48.

Results

In total, 167 patients were randomized to receive TAP-144-SR (6M) (n = 83) or TAP-144-SR (3M) (n = 84) and the E₂ suppression rate was 97.6 and 96.4 %, respectively. The estimated between-group difference was 1.2 % (95 % confidence interval −5.2 to 7.8). The non-inferiority of TAP-144-SR (6M) to TAP-144-SR (3M) for E₂ suppression was confirmed. As for safety, common adverse events were hot flush and injection site reactions including induration, pain, and erythema in both treatment groups, which were of ≤Grade 2 in severity and not serious. No significant between-group differences in safety profiles and tolerability were observed.

Conclusions

TAP-144-SR (6M) was not inferior to TAP-144-SR (3M) for its suppressive effect on serum E₂. TAP-144-SR (6M) was also as well tolerated as TAP-144-SR (3M).

Ovarian Suppression: Early Menopause, Late Effects

PURPOSE OF REVIEW

Pre-menopausal women diagnosed with hormone receptor (HR) breast cancer are candidates for prolonged hypoestrogenism to improve cancer outcomes. However, the disease benefit eclipses the toxicities associated with ovarian function suppression (OFS), which are often under-reported.

RECENT FINDINGS

Increased risk of mortality from cardiovascular disease, bone disorders, and metabolic disorders is well reported in women with no history of cancer, after surgical oophorectomy or premature ovarian failure. Vasomotor symptoms, urogenital atrophy, weight gain, sexual dysfunction, cognitive decline, and sleep disturbances contribute to the increased non-compliance associated with OFS, especially in younger women. Balancing the toxicities of prolonged OFS with its benefits should be critically analyzed by providers when making recommendations for their patients. Supportive care to manage multi-system toxicities and to counteract the long-term impact on all-cause mortality should be emphasized by every cancer program. Future studies with OFS should incorporate patient outcomes and strategies for symptom management in addition to focusing on improving disease outcomes.

Managing Menopausal Symptoms in Young Women With Breast Cancer: When Medicine Is Not All. The Take Care Project

In the last decade, endocrine therapy strategies in perimenopausal women with hormone-responsive early breast cancer (BC) have changed and now ovarian function suppression (OFS) is recommended for the majority of patients. Side effects of OFS mimic menopausal symptoms, including hot flushes, sweats, weight gain, and sexual dysfunction, which may negatively impact quality of life (QoL). Aims of the Take Care Project are the education of physicians and patients to have all the information (medical and nonmedical) they need to manage menopausal symptoms by distributing educational materials useful to face menopause. Four different areas have been identified by surveys conducted among physicians and young patients: for each area, interventions and tools have been elaborated by a doctor and nonphysician professionals of these identified areas, to offer the widest information available. Clinical and practical suggestions have been provided. Based on the evidence given, we strongly suggest setting up a multidisciplinary team for the treatment planning of young patients with BC, which could help patients to face and manage their new menopause condition. The reduction of side effects and the improvement in QoL should be the best ally to treat young patients with BC.

An Italian Delphi study to evaluate consensus on adjuvant endocrine therapy in premenopausal patients with breast cancer: the ERA project

BACKGROUND

Several trials evaluated the role of ovarian function suppression for the adjuvant treatment of premenopausal patients with hormone receptor-positive early breast cancer. Based on the results of the SOFT and TEXT trials, international guidelines recommend the addition of ovarian function suppression to standard adjuvant endocrine therapy for patients at higher risk of relapse.

METHODS

The ERA project (Evaluation of Risk factors in the Adjuvant treatment of breast cancer in premenopausal patients) was devised with the objective of obtaining a consensus on the identification of risk factors and the use of ovarian function suppression in the adjuvant treatment of these women. To this aim, a panel of 31 Italian oncologists with expertise in breast cancer participated in a Delphi consensus study in June 2017.

RESULTS

A total of 29 statements related to prognostic factors, therapeutic strategies and ovarian function suppression were defined and voted to gain final consensus. For each topic we report data supporting the acquired consensus and the relevant issues discussed.

CONCLUSIONS

The SOFT and TEXT trials have changed the standard adjuvant treatment of premenopausal patients with hormone receptor-positive early breast cancer, but the available treatment options require a careful risk assessment and toxicities evaluation to ensure the greatest clinical benefit for each patient.

OFS plus AI or SERM vs. SERM alone in premenopausal women with hormone receptor-positive breast cancer: a prospective cohort study using the real-world database

BACKGROUND

Ovarian function suppression (OFS) plus other endocrine treatment was recommended to hormone receptor (HR)-positive breast cancer by some guidelines recently. We performed this study to validate the survival benefits of OFS plus aromatase inhibitors (AI) or selective estrogen receptor modulators (SERM) in the real world.

METHODS

All premenopausal, HR-positive breast cancer patients diagnosed between 1996 and 2017 were identified. Eligible patients were classified into three groups according to their adjuvant endocrine treatment, including OFS plus AI, OFS plus SERM and SERM alone. The primary outcome is invasive disease-free survival (iDFS), whereas the secondary outcome is overall survival (OS). Cox proportional hazards models and propensity score adjusted models were used to compare the survival benefits in three groups.

RESULTS

We included 2838 patients, of which 246 received OFS plus AI, 175 received OFS plus SERM, and 2417 received SERM alone. Compared with SERM alone, OFS plus AI was associated with an improved iDFS (HR 0.59, 95% CI 0.36-0.96) and OS (HR 0.26, 95% CI 0.08-0.85). OFS plus SERM, however, was not significantly associated with extended iDFS or OS. Among patients older than 40 years old, OFS plus AI was more effective than OFS plus SERM (HR 0.38, 95% CI 0.17-0.88) or SERM alone (HR 0.44, 95% CI 0.23-0.84) in terms of iDFS.

CONCLUSIONS

Our findings suggest that OFS plus AI treatment may extend both iDFS and OS among premenopausal patients with hormone receptor-positive breast cancer in the real world.

[LHRH analogs in adjuvant endocrine therapy for pre-menopausal localized breast cancers: Ending the controversy for novel guidelines?]

Endocrine treatment represents the cornerstone of endocrine-sensitive pre-menopausal early breast cancer. The estrogen blockade plays a leading role in the therapeutic management with surgery, radiotherapy and selective antiestrogen treatment. For several years, selective estrogen receptor modulators, such as tamoxifen, have revolutionized medical care of hormone receptors-positive breast cancer and have conquered the therapeutic arsenal while becoming the gold standard of treatment. Other combinations associating the ovarian function suppression using LHRH agonists with tamoxifen or aromatase inhibitors have been recently investigated, leading to mitigated opinions regarding the clinical benefit of these associations. We propose here a comprehensive overview on existing data and their actualization concerning LHRH analogues, whilst emphasizing benefit-risk balance for this targeted population.

Impact on disease-free survival of the duration of ovarian function suppression, as postoperative adjuvant therapy, in premenopausal women with hormone receptor-positive breast cancer: a retrospective single-institution study

Introduction

Although tamoxifen (TAM) plus ovarian function suppression (OFS) is considered as a standard adjuvant treatment for premenopausal women with hormone receptor-positive breast cancer, the optimal duration of OFS has not yet been established. This retrospective study was designed to assess the duration of OFS and the impact of the duration of OFS on the DFS in these patients.

Methods

We retrospectively reviewed the data of premenopausal patients with breast cancer who received TAM + OFS (goserelin or leuprorelin) as adjuvant therapy between February 2004 and June 2015. The primary analysis was a comparison of the disease-free survival (DFS) between patients who received OFS for 3 years or less (OFS ≤ 3 years group) and those who received OFS for longer than 3 years (OFS > 3 years group).

Results

We analyzed the data of 215 premenopausal patients diagnosed as having hormone receptor-positive breast cancer. A propensity score-matched model showed the absence of any significant difference in the DFS between the OFS ≤ 3 years group and OFS > 3 years group (6-year DFS rate, 93.2 vs. 94.0%; log-rank test p = 0.767).

Conclusions

Our data showed that among premenopausal women with hormone receptor-positive breast cancer who received TAM + OFS as adjuvant endocrine therapy, there was no significant difference in the DFS between the OFS ≤ 3-year group and OFS > 3-year group. A randomized trial is needed to establish the optimal duration of OFS for these patients.

Effectiveness of gonadotropin-releasing hormone agonists for ovarian function suppression in premenopausal patients with hormone receptor-positive breast cancer: a retrospective single-center real-world study

PURPOSE

This study evaluated the effectiveness of ovarian function suppression (OFS) of various gonadotropin-releasing hormone agonists (GnRHa) combined with aromatase inhibitors (AI) in premenopausal patients with hormone receptor-positive (HR-positive) breast cancer. Potential risk factors associated with insufficient OFS were analyzed.

PATIENTS AND METHODS

Premenopausal HR-positive breast cancer patients who had received AI with GnRHa were studied retrospectively. Patients were divided into different groups according to monthly or trimonthly GnRHa schedules they received, and the effectiveness of OFS was compared between groups. Insufficient OFS was defined as at least one instance of estradiol ≥ 30 pg/ml. Patient data was gathered from medical records for this comparison.

RESULTS

Of the 264 patients enrolled in this study, 117 were administered 3.6 mg of goserelin monthly (goserelin 1 M group), 63 received 3.75 mg of leuprorelin monthly (leuprorelin 1 M group) and 84 were given 11.25 mg of leuprorelin every three months (leuprorelin 3 M group). Overall, 7.20% experienced insufficient OFS. The incidence rates in the three GnRHa depot groups were 7.69%, 6.35%, and 7.14%, respectively, without a significant statistical difference (P = 0.900). Notably, younger patients exhibited a higher likelihood of insufficient OFS [OR = 0.900, 95%CI (0.824-0.982), P = 0.018].

CONCLUSION

Insufficient OFS remains a concern during GnRHa and AI treatment. The effectiveness of the three GnRHa depots commonly used in China seems comparable. Younger patients face a heightened risk of insufficient OFS.

Serum Cholesterol Level Changes during Gonadotropin-Releasing Hormone-Agonist Therapy in Premenopausal Female Patients with Breast Cancer

OBJECTIVES

To investigate the changes in cholesterol levels during medical ovarian suppression.

METHODS

We reviewed the medical records and blood test results of 187 female patients with breast cancer who underwent gonadotropin-releasing hormone (GnRH)-agonist therapy for > 24 weeks at our hospital between 1 January 2018 and 31 December 2020. The study excluded patients in this cohort who had previously been diagnosed with dyslipidemia, diabetes, or had recently received lipid-lowering agents, resulting in a final sample size of 152 participants. The age at diagnosis and preoperative body mass index (BMI) were included as baseline demographics. A generalized additive mixed model was applied to analyze the relationship between the duration of GnRH-agonist treatment and changes in cholesterol levels.

RESULTS

The study participants had a mean age of 42.5 ± 5.2 years and a mean preoperative BMI of 23.0 ± 3.6 kg/m²; the mean GnRH-agonist therapy duration was 19.3 months (range: 5.6-37.7 months); and the total cholesterol level before GnRH-agonist treatment was 171 mg/dL that was significantly higher at 181 mg/dL (P = 0.03) during the most recent measurement. The total cholesterol level was unaffected by the GnRH-agonist therapy until 19.3 months after which it significantly increased by 1.28 mg/dL per month (P = 0.011). There was no significant effect of age, preoperative BMI, or the glomerular filtration rate on the total cholesterol levels.

CONCLUSIONS

Long-term GnRH agonist therapy for > 19 months can cause a significant increase in the serum cholesterol levels. To prevent complications, patients receiving the treatment should be informed and monitored for the possible progression of dyslipidemia.

Adjuvant endocrine therapy choices in premenopausal patients with hormone receptor-positive early breast cancer: Insights from the prospective GIM23-POSTER study

BACKGROUND

Most premenopausal patients with early breast cancer (eBC) are diagnosed with hormone receptor-positive disease and therefore candidate for adjuvant endocrine therapy (ET).

PATIENTS AND METHODS

The Gruppo Italiano Mammella (GIM) 23-POSTER (GIM23) is a multicenter, prospective, observational study conducted in 26 Italian institutions, aiming to evaluate ET choices for premenopausal patients affected by hormone receptor-positive eBC in a real-world setting. Here we report also the results in terms of type of ET prescribed according to the definition of high-risk patients by monarchE and NATALEE trials.

RESULTS

Between October 2019 and June 2022, 600 premenopausal patients were included, with a median age of 46 years. Almost half (271, 45.2 %) of the patients had stage I disease, while 254 (42.3 %) and 60 (10.0 %) patients had stage II and III, respectively. Overall, 149 (25.1 %) patients received tamoxifen alone, 83 (14.0 %) tamoxifen with ovarian function suppression (OFS), while 361 (60.9 %) received aromatase inhibitor (AI) with OFS. Patients treated with AI and OFS had higher number of metastatic axillary nodes, higher grade and more often received chemotherapy (all p < 0.001). According to the inclusion criteria of the monarchE and NATALEE trials, 81 patients (15.6 %) were considered high-risk for the monarchE and received AI with OFS in 88.9 % of the cases, while 231 patients (44.4 %) were considered high-risk for the NATALEE trial and received AI with OFS in 74.5 % of cases.

CONCLUSIONS

AI with OFS is the most prescribed adjuvant ET among premenopausal patients, especially in the presence of high-risk features.

Cost-Effectiveness Analysis of Adjuvant Endocrine Therapy With Ovarian Suppression in Premenopausal Patients With Hormone Receptor-Positive Early Breast Cancer in China

PURPOSE

Endocrine therapy combined with ovarian function suppression (OFS) is recommended in intermediate- or high-risk patients among premenopausal women with hormone receptor-positive early breast cancer. However, in China, the cost-effectiveness of this strategy compared with endocrine therapy alone is unclear. This study aimed to evaluate the long-term cost-effectiveness of tamoxifen (TAM), TAM+OFS, and exemestane plus OFS (EXE+OFS).

METHODS

On the basis of prognostic data from the Suppression of Ovarian Function Trial (SOFT), cost data from the Hospital Information System of the West China Hospital of Sichuan University, and health utility values from the published literature, a Markov model was established. The incremental cost-effectiveness ratio (ICER) was used to compare the treatment strategies.

RESULTS

In a 25-year simulation of adjuvant therapy in Chinese women with early breast cancer, the total costs of TAM, TAM+OFS, and EXE+OFS were $7821, $9318, and $9445, respectively. The quality-adjusted life-years (QALYs) were 11.615, 11.896, and 11.734 years, respectively. Compared with TAM, the ICERs of TAM+OFS and EXE+OFS were $5,327.4021/QALY and $13,647.0588/QALY, respectively. The ICERs of TAM+OFS and EXE+OFS were below the threshold of $32,517/QALY. The reliability and stability of the simulation results were verified using Monte Carlo simulation and sensitivity analysis.

CONCLUSION

In the context of limited resources in China, TAM+OFS and EXE+OFS are cost-effective options compared with TAM.

A follow-up study of a randomized controlled study evaluating safety and efficacy of leuprorelin acetate every-3-month depot for 2 versus 3 or more years with tamoxifen for 5 years as adjuvant treatment in premenopausal patients with endocrine-responsive breast cancer

Background

Previously, we conducted the 5-year open-label, randomized controlled trial (RCT) of leuprorelin adjuvant therapy in post-operative premenopausal patients with endocrine-responsive breast cancer, which was a pilot study to investigate the optimal duration of leuprorelin treatment. Since, however, long-term outcomes became required for the adjuvant endocrine therapy, we performed this follow-up observation study.

Methods

Follow-up observation study was performed up to 10th year after randomization, continuing RCT to evaluate the efficacy and safety of leuprorelin every 3 months for ≥ 3 versus 2 years, with daily tamoxifen for 5 years. Primary endpoints were disease-free survival (DFS) and 2-year landmark DFS.

Results

Eligible patients (N = 222) were randomly assigned to receive leuprorelin for either 2 years (N = 112) or ≥ 3 years (N = 110) with tamoxifen. Leuprorelin treatment for ≥ 3 years versus 2 years provided no significant difference in DFS (HR 0.944, 95% CI 0.486–1.8392) or 2-year landmark DFS (N = 99 and 102 in 2-year and ≥ 3-year groups, HR 0.834, 0.397–1.753). In small, higher-risk subgroup (n = 17); however, 2-year landmark DFS in ≥ 3-year group was significantly longer (HR 0.095, 0.011–0.850) than that in 2-year group. The incidence of bone-related adverse events was around 5% in both groups.

Conclusions

Adjuvant leuprorelin treatment for ≥ 3 years with tamoxifen only showed similar efficacy and safety profiles to those for 2 years in analyses among all patients but suggested greater benefit in higher-risk patients. No new safety signal was identified for long-term leuprorelin treatment.

Trial registration number

Not applicable. This was an observational study.

Adjuvant Endocrine Therapy in Premenopausal Women With Hormone Receptor-Positive Early-Stage Breast Cancer: Risk Stratification in a Real-World Setting

BACKGROUND

Ovarian function suppression (OFS) and hormone therapy (HT) represent an adjuvant option in premenopausal hormone receptor-positive early breast cancer (HR+EBC). The SOFT-TEXT trials showed improved outcomes upon receiving aromatase inhibitors (AIs)/OFS.

METHODS

In order to estimate the magnitude of absolute improvements, we conducted a retrospective study applying composite risk (CR) to 237 premenopausal HR+EBC patients.

RESULTS

Overall, 119 of these received tamoxifen (T)/OFS and 118 received AIs/OFS. The median age was 45 years (ys). After a median follow up of 65 months, recurrence was 6.7% in T patients and 10.2% in AI ones. CR (cutoff: 2.67) and ET duration (five-year cutoff) was found to have a significant impact on DFS. Invasive disease-free survival (IDFS) at 5 ys amounted to 82.9% for a CR>2.67 and 95% with CR

CONCLUSION

In a real-world setting, treatment options for premenopausal patients who are candidates for HT and OFS should take risk status into account. Therefore, every effort should be made to maintain patient adherence to treatment in order to manage toxicities and improve outcomes.

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Key Words

• Adjuvant hormone therapy
• Aromatase inhibitors
• Breast cancer
• Ovarian function suppression
• Tamoxifen

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Comparison of oncological outcomes of premenopausal with ovarian function suppression versus postmenopausal women in ER+/HER2- breast cancer

BACKGROUND

The Rx for positive node endocrine-responsive breast cancer trial highlighted that premenopausal (PRE) women who underwent chemotherapy exhibited superior survival rates compared to postmenopausal (POST) counterparts, but showed worse survival without chemotherapy. This raises the question whether application of ovarian function suppression (OFS) in PRE women aligns with their cancer biology, treatment response, and outcomes observed in POST women.

METHODS

Data from the Seoul National University Hospital breast cancer cohort focusing on patients with stage pT1-3, pN0-1, estrogen receptor-positive (ER+), and HER2-negative breast cancer were analyzed. Survival outcomes, including invasive disease-free survival (iDFS) and distant relapse-free survival (DRFS), were compared between PRE women receiving OFS and POST women, with chemotherapy usage as a stratification factor. Propensity score matching was performed.

RESULT

We analyzed 3483 patients, comprising 2901 POST and 582 PRE women with OFS. In the cohort without chemotherapy, the 10-year iDFS rates were 90.3 % and 88.3 % (hazard ratio [HR], 1.32; p = 0.16), and 10-year DRFS rates were 94.3 % and 96.1 % (HR, 0.78; p = 0.41) for POST and PRE women with OFS, respectively. Among women treated with chemotherapy, 10-year iDFS rates were 83.0 % and 79.5 % (HR, 1.21; p = 0.37), and DRFS rates were 86.7 % and 85.7 % (HR, 1.14; p = 0.58) for POST and PRE women with OFS, respectively. These results remained consistent after PSM.

CONCLUSION

Oncological outcomes of PRE women receiving OFS were comparable to those of POST women with ER+ and HER2-early breast cancer, irrespective of chemotherapy administration.

Empowerment-Led Guided Self-Help Intervention for Symptom Burden in Breast Cancer Women Treated With Ovarian Function Suppression: A Randomized Trial Protocol

Background

Ovarian function suppression (OFS) treatment causes breast cancer patients' estrogens to fall rapidly to postmenopausal levels, and the 5-year treatment duration and 28-day treatment cycles place a heavy physical and psychological symptom burden on them, which in turn directly or indirectly affects the survival benefit. Managing symptom burden early in treatment is critical, but OFS-related studies have yet to be seen. Self-management is essential for patients' symptom burden. However, self-help management is hampered by patients' lack of knowledge, skills, motivation, etc. Guided self-help intervention (GSH) provides a feasible approach. Empowerment theory is a promising theoretical framework to guide self-management.

Methods

A prospective two-arm parallel randomized controlled single-blind clinical trial will be conducted to investigate the effect of symptom burden GSH based on empowerment theory in breast cancer patients in the early stages of OFS treatment. A block randomization method is used to allocate 144 patients to either the control or intervention group. The program is conducted according to the OFS return-to-hospital treatment cycle. The intervention group will receive a total of two rounds and five sessions of empowering GSH, lasting at least 15 weeks in total; the control group will receive only usual nursing care. Symptom burden and related metrics will be assessed at baseline and 1, 3, and 6 months after OFS treatment, and changes between and within groups will be explored. This paper adhered to the SPIRIT and CONSORT guidelines.

Conclusion

These results will help to validate the GSH in symptom burden management for breast cancer patients in OFS treatment early stages. It enriches its symptom burden management research and may provide implications for the whole cycle of OFS treatment patients.

[The effect of ovarian function suppression on the psychological status of breast cancer patients under 35 years old in China]

Objective: To explore whether the addition of ovarian function suppression in endocrine therapy of Chinese breast cancer patients under 35 years old will affect the psychological state. Methods: This cross-sectional study enrolled 91 Chinese postoperative breast cancer patients aged 35 years or younger. The depression and anxiety state of patients were assessed by Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7), and their sociodemographic characteristics were collected. Results: Among the 91 patients, 61 were receiving ovarian function suppression (OFS) treatment, 30 were not. Among the 30 patients with out OFS treatment, 2 had PHQ-9 score ≥8, 28 had PHQ-9 score < 8, 1 had GAD-7 score ≥10, and 29 had GAD-7 score < 10. Among the 61 patients with OFS, 19 had PHQ-9 score ≥8, 42 had PHQ-9 score < 8, 8 had GAD-7 score ≥10, and 53 had GAD-7 score <10. The incidence of depression was 6.7% and 31.1% in the non-OFS group and OFS group, respectively (P=0.018). The incidence of anxiety in the two groups was 3.3% and 13.1%, respectively (P=0.174). Univariate analysis showed that the incidence of depression was significantly higher in patients with OFS (P=0.018). After taking into account the sociodemographic factors, pathological stage and treatment of the patients, multivariate analysis showed that the administration of OFS was still significantly related to the incidence of depression (OR=9.14, 95% CI=1.52~55.16, P=0.016). There was no significant difference in the incidence of anxiety (P=0.174). Conclusions: For Chinese young breast cancer patients under 35 years old, the use of OFS in the adjuvant endocrine therapy may lead to a significant increase in the incidence of depression. We should pay attention to the evaluation and monitoring of the psychological state of this population.

Adjuvant ovarian function suppression in premenopausal women with hormone receptor-positive, human epidermal growth factor receptor 2-negative early breast cancer: a multi-center retrospective study

PURPOSE

Based on SOFT and TEXT trials data, a composite recurrence risk score (CR-score) model was developed for early premenopausal women with hormone receptor -positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) breast cancer using the subgroup treatment effect map (STEPP) method to guide ovarian function suppression (OFS) application. However, the CR-score model has yet to be validate in real-world settings.

METHODS

Our study included patients diagnosed between January 1, 2013, and December 31, 2021, from 42 breast centers in China. We utilized restricted cubic splines (RCS) to visualize continuous CR-score and hazard ratios for breast cancer recurrence. After adjusting for confounding factors via propensity score matching (PSM), Kaplan-Meier curves were used to compare disease-free survival (DFS) among premenopausal patients between the OFS and non-OFS groups.

RESULTS

The hazard ratio of recurrence consistently increased with higher CR-scores. Notably, 87.68% of patients who received OFS had a CR-score above 1.42. Following PSM, adjuvant OFS significantly improved DFS in the high CR-score group (CR-score above 1.42)(HR 0.571; 95% CI 0.403-0.809; p = 0.001). Among patients younger than 35 years old, those receiving OFS had significantly better DFS compared to those without OFS. After matching for age, grade, ER, PR, and lymph node status, OFS can significantly improve the DFS of those chemotherapy-treated patients with CR-score above 1.42 (p = 0.006). Furthermore, the group with high CR-score but ER expression below 50% did not benefit from OFS.

CONCLUSION

The CR-score model can effectively guide clinicians in making decisions regarding OFS for premenopausal patients with HR+/HER2- breast cancer.