A case of advanced breast cancer successfully treated with primary endocrine therapy

We present a case of a premenopausal woman with advanced hormone-sensitive breast cancer who was successfully treated with primary endocrine therapy consisting of ovarian ablation followed by a combined endocrine regimen of the aromatase inhibitor fadrozole 2 mg daily and tamoxifen 20 mg daily. During the 5 months treatment period, PR evaluation of the loco-regional lesions was performed The patient then underwent mastectomy with axillary lymph node dissection followed by fadrozole and tamoxifen therapy. Throughout the treatment course, no adverse events were encountered and the patient has been enjoying a favorable quality of life. As shown by this case, primary endocrine therapy is a promising treatment option for hormonesensitive breast cancer. However, this modality should be continued to be regarded as experimental.     

Neoadjuvant hormonal therapy for endocrine sensitive breast cancer: A systematic review

In recent years, studies investigating neoadjuvant therapies have been emerging, because of the additional benefits it provides in terms of facilitating less extensive surgery and the possibility of investigating tumor biological features and response. Neoadjuvant hormonal therapy (NHT) is, in general, considered to be a suitable option for hormone receptor (HR)-positive patients who are unfit for chemotherapy or surgery, and is increasingly being utilized to achieve tumor downsizing before surgery in postmenopausal women. Studies investigating NHT were reviewed for tumor response data. NHT demonstrated similar efficacy to neoadjuvant chemotherapy (NCT) in HR-positive breast cancer patients. Clinical responses ranged from 13.5% to 100%, with treatment periods between 3 and 24 months. In studies comparing tamoxifen with aromatase inhibitors, the latter were superior in terms of tumor response and rates of breast-conserving surgery (BCS). In most studies with treatment durations longer than 3 months, tumor response rates increased. Therefore, longer durations of NHT are feasible and should be considered as an alternative to NCT in selected patients.     

Treatment strategies and survival outcomes in older women with breast cancer: A comparative study between the FOCUS cohort and Nottingham cohort

Objective

Clinical trials investigating breast cancer treatment often exclude or misrepresent older adults. This study compares treatment patterns and survival of older women diagnosed with breast cancer between a Dutch and a British observational cohort.

Breast conserving surgery after neoadjuvant therapy for large primary breast cancer

Aim

The aim of this study was to evaluate the safety of breast conserving surgery in patients with breast tumours satisfactorily downstaged after neoadjuvant therapy.

Methods

A retrospective cohort study was undertaken to analyze the loco-regional recurrence (LRR) after breast conserving surgery. We enrolled 88 patients with breast cancer subjected to neoadjuvant therapy (NAT group) who achieved an objective response due to neoadjuvant treatment and compared them with 191 patients with early breast cancer (EBC group) who were submitted to primary conserving surgery. Lumpectomy or quadrantectomy with axillary lymph node dissection was performed in all patients who received adjuvant radiotherapy. Systemic adjuvant therapy was offered to all patients. The mean periods of observation were 61.3 months in the NAT group and 67.5 months in the EBC group.

Results

The mean age was 53 years in the NAT group and 56 years in the EBC group (p = 0.04). There was no histological type and histological grade difference between groups. In the NAT group, the mean diameter of residual tumour was lower and the mean volume of breast tissue resection was higher than in the EBC group (p = 0.01 and p = 0.002, respectively). The ipsilateral recurrence rate was 7.9% in the NAT group and 7.8% in the EBC group (p = 0.9). The most important predictive factor of recurrence in the NAT group was the age of patient.

Conclusion

Breast conserving therapy is a safe procedure in satisfactorily downstaged breast cancer after neoadjuvant therapy.     

A systematic review of generic and breast cancer specific life expectancy models in the elderly

Introduction

The use of primary endocrine therapy (PET) in managing breast cancer in the elderly has become common practice. Whilst there appears to be no difference in overall survival in comparison with surgery, PET has been found to be inferior in local disease control with a limited duration of efficacy (2–3 years). The International Society of Geriatric Oncology (SIOG) state that PET may be considered in patients with a short life expectancy (<2 years) or considered unfit for surgery. Frequently, decision making for PET allocation is a subjective process by the clinician.

乳腺癌新辅助内分泌治疗的研究进展及展望

新辅助内分泌治疗（neoadjuvant endocrine therapy,NET）代替新辅助化疗（neoadjuvant chemotherapy therapy,NCT）对于雌激素受体（estrogen receptor,ER）阳性乳腺癌患者而言是一种有效的临床治疗策略,可以使肿瘤降期,从而接受乳腺癌保乳手术并减少术后的辅助化疗。本文旨在就NET的患者选择、NET效果对比、NET持续时间、NET与NCT效果对比及联合使用、NET联合靶向治疗、机会之窗试验、疗效评估预后指标及NET后辅助治疗决策等最新研究进展进行综述。     

老年乳腺癌患者新辅助内分泌治疗的临床应用

背景与目的:有研究表明,对于激素依赖性老年乳腺癌患者,内分泌治疗安全、有效.本研究探讨老年乳腺癌患者新辅助内分泌治疗的临床应用.方法:对本院45例ER和(或)PR阳性的老年乳腺痛患者进行新辅助内分泌治疗,方案为口服依西美坦,25 mg/d,治疗4个月后观察疗效.结果:45例患者中临床完全缓解2例,部分缓解32例,稳定11例,无进展病例,新辅助内分泌治疗总有效率为75.6%(34/45);ER和PR均为(+)及ER强阳性(+++)的有效率高;组织学低分级的有效率高(x2=10.06,P＜0.01).结论:对于ER和(或)PR阳性的老年乳腺癌患者,采用依西美坦新辅助内分泌治疗是安全、有效的方法.     

Age-specific nonpersistence of endocrine therapy in postmenopausal patients diagnosed with hormone receptor-positive breast cancer: a TEAM study analysis

Background.

Early discontinuation of adjuvant endocrine therapy may affect the outcome of treatment in breast cancer patients. The aim of this study was to assess age-specific persistence and age-specific survival outcome based on persistence status.

Methods.

Patients enrolled in the Tamoxifen Exemestane Adjuvant Multinational trial were included. Nonpersistence was defined as discontinuing the assigned endocrine treatment within 1 year of follow-up because of adverse events, intercurrent illness, patient refusal, or other reasons. Endpoints were the breast cancer–specific and overall survival times. Analyses were stratified by age at diagnosis (<65 years, 65–74 years, ≥75 years).

Results.

Overall, 3,142 postmenopausal breast cancer patients were included: 1,682 were aged <65 years, 951 were aged 65–74 years, and 509 were aged ≥75 years. Older age was associated with a higher proportion of nonpersistence within 1 year of follow-up. In patients aged <65 years, nonpersistent patients had lower breast cancer–specific and overall survival probabilities. In patients aged 65–74 years and patients aged ≥75 years, the survival times of persistent and nonpersistent patients were similar.

Conclusion.

Nonpersistence within 1 year of follow-up was associated with lower breast cancer–specific and overall survival probabilities in patients aged <65 years, but it was not associated with survival outcomes in patients aged 65–74 years or in patients aged ≥75 years. These results suggest that extrapolation of outcomes from a young to an elderly breast cancer population may be insufficient and urge age-specific breast cancer studies.     

Early primary breast cancer in the elderly - Pattern of presentation and treatment

Introduction

The incidence of primary breast cancer in elderly patients is increasing. However, little is known about their biological profile and most appropriate clinical management, as most studies have been conducted in the younger population. This study aimed to identify a profile of characteristics in elderly women with operable primary breast cancer and investigate the dynamics influencing the treatment decision-making process.

Methods

A review of 268 consecutive female patients >70 years of age, diagnosed with early operable primary breast cancer (<5 cm) over a 30-month period at the Nottingham Breast Institute, was conducted. Age, co-morbidity, cancer characteristics, treatment offered and undertaken, and reason for patient choice were recorded and analysed.

Results

The median age was 78 (range 70-100) years. In our study, 82% of the patients had one or more co-morbidities, with 34% of them having three or more co-morbidities. The commonest pathological diagnosis (from needle core biopsies) was invasive ductal carcinoma of no special type (76%) with histological grade 2 (64%). Majority of them were oestrogen receptor (ER)-positive (84%) and had a high histochemical (H)-score (83% with H-score >200).Most of the patients (60%) underwent primary surgical management, of which 45.4% received breast-conserving surgery. Among the patients who had breast-conserving surgery, 68% of them received adjuvant radiotherapy. When offered genuine choice in treatment options, most patients chose non-operative treatment. Patients who underwent non-operative treatment were on average seven years older and had significantly more co-morbidities than those who had surgery.

Conclusion

The elderly population evidently have demographic and cancer characteristics distinct from their younger counterparts, with less patients receiving surgical management. Further work is underway to correlate this with their clinical outcomes and to examine the factors behind the treatment decision-making process.     

乳腺癌患者应用内分泌药物治疗后合并脂肪肝的临床分析

目的：分析乳腺癌患者应用内分泌药物后发生脂肪肝的机理及预防。方法：收集住院及门诊服用内分泌药物治疗的乳腺癌患者,通过血脂、腹部CT或B超检查,探讨合并脂肪肝的机理。结果：107例患者均有不同程度的脂肪肝发生,轻度脂肪肝42例,中度脂肪肝37例,重度脂肪肝28例。中断内分泌治疗13例。最早发生脂肪肝服药3月,最晚服药近2年,平均13月。结论：乳腺癌服用内分泌治疗的患者应注意预防脂肪肝的发生并给予及早的干预治疗。     

再议乳腺癌内分泌治疗10项热点问题

近年来,乳腺癌的内分泌治疗数据更新较多,使临床工作中产生了新的问题,带来了新的思考。该文就绝经前乳腺癌患者内分泌治疗中卵巢功能抑制的适宜患者的选择,卵巢功能抑制联合口服内分泌药物方案的选择,内分泌治疗过程中不良反应管理,乳腺癌患者的生育问题和延长内分泌治疗等10项早期乳腺癌内分泌治疗中的热点问题,结合数据和笔者的临床经验进行再次阐述。     

Long-term clinical outcome of oestrogen receptor-positive operable primary breast cancer in older women: a large series from a single centre

Introduction:

A Cochrane review of seven randomised trials (N=1571) comparing surgery and primary endocrine therapy (PET) (oestrogen receptor (ER) unselected) shows no difference in overall survival (OS). We report outcome of a large series with ER-positive (ER+) early invasive primary breast cancer.

Methods:

Between 1973 and 2009, 1065 older (⩾70 years) women (median age 78 years (70–99)) had either surgery (N=449) or PET (N=616) as initial treatment.

Results:

At 49-month median follow-up (longest 230 months), the 5-year breast cancer-specific survival (BCSS) and OS were 90 and 62%, respectively. Majority (74.2%) died from causes other than breast cancer. The rates (per annum) of local/regional recurrence (<1%) (following surgery), contralateral tumour (<1%) and metastases (<3%) were low. For patients on PET, 97.9% achieved clinical benefit (CB) at 6 months, with median time to progression of 49 months (longest 132 months) and significantly longer BCSS when compared with those who progressed (P<0.001). All patients with strongly ER+ (H-score >250) tumours achieved CB and had better BCSS (P<0.01). Patients with tumours having an H-score >250 were found to have equivalent BCSS regardless of treatment (surgery or PET; P=0.175), whereas for those with H-score ⩽250, surgery produced better outcome (P<0.001).

Conclusion:

Older women with ER+ breast cancer appear to have excellent long-term outcome regardless of initial treatment. Majority also die from non-breast cancer causes. Although surgery remains the treatment of choice, patients with ER-rich (H-score >250) tumours tend to do equally well when treated by PET. This should be taken into account when therapies are considered.     

Predictors of response to second-line endocrine therapy for breast cancer

This study reports on factors predicting response tosecond-line endocrine therapy in 250 patients with breastcancer for which they were assessable for responseby the International Union Against Cancer (UICC) criteria.Clinical details relating to first-line endocrine therapy wereavailable for all patients. We have not includedin this study patients who received first-line endocrinetherapy but did not or have not yetproceeded to second-line hormone therapy – e.g. diedfrom rapidly progressive disease, started chemotherapy for rapidlyprogressive disease, or remained in long-term remission onfirst-line endocrine therapy.One hundred and fifty nine patients (72%) achievedremission (objective response and static disease [OR +SD]) on first-line endocrine therapy with a medianduration of 19 months. For second-line endocrine therapythe remission rate was 53% (132/225) with amedian duration of 15 months. Tumour grade andoestrogen receptor status of the primary tumour wereshown to be independent predictors of response tosecond-line endocrine therapy while response to first-line endocrinetherapy was a predictor of the duration ofresponse to second-line endocrine therapy. In the sub-groupof patients who showed OR or SD toboth first and second-line therapies, there was nocorrelation between the time to progression (TTP) onfirst and second-line therapies.     

Breast cancer subtypes and survival in Chinese women with operable primary breast cancer

Objective: To investigate the associations between the different breast cancer subtypes and survival in Chinese women with operable primary breast cancer. Methods: A total of 1538 Chinese women with operable primary breast cancer were analyzed in this study, the median follow-up was 77 months. Estrogen receptor (ER), progesterone receptor (PR), and HER2 status were available for these patients. Results: Luminal A (ER+ and/or PR+, HER2-) had a favorable disease-free survival (DFS) and overall survival (OS) c...     

Primary endocrine therapy in locally advanced breast cancers--the Nottingham experience

Introduction There are trials comparing different neoadjuvant chemotherapy regimens for locally advanced primary breast cancer (LAPC). Few studies have evaluated alternative therapeutic approaches towards LAPC. A previous trial from our institute in LAPC patients unselected for oestrogen receptor (ER) status, comparing primary endocrine therapy versus multimodal treatment, showed no difference in breast cancer related deaths or overall survival. We report our experience of primary endocrine therapy in ER+ LAPC. Methods Between 1988 and 2007, 195 ER+, non-inflammatory LAPC patients were treated with primary endocrine agents in our institute, due to patient choice, being unfit for chemotherapy, or recruitment into the above mentioned trial. All patients had disease assessable by UICC criteria. Results Median age was 69 years. The median follow-up was 61 months. 154 patients (79%) received endocrine treatment alone. 185 patients (95%) derived clinical benefit (complete response/ partial response/ stable disease) for ≥6 months from primary endocrine therapy. Overall 5-year survival was 76% and 5-year breast cancer specific survival was 86%. Conclusion In selected group of ER+ LAPC patients, primary endocrine treatment achieves excellent survival outcome and is a viable alternative to other modalities of treatment.     

The influence of age,comorbidity and frailty on treatment with surgery and systemic therapy in older women with operable triple negative breast cancer (TNBC) in England: A population-based cohort study

BackgroundSurgery and chemotherapy use were studied among older women with early stage triple negative breast cancer (TNBC) in a population-based cohort.MethodsWomen aged ≥50 years with unilateral early (stage 1-3a) TNBC diagnosed in 2014–2017 were identified from English cancer registration data. Information on surgery and chemotherapy was from linked Hospital Episode Statistics and Systemic Anti-Cancer Therapy datasets, respectively. Logistic regression was used to investigate the influences of patient age, comorbidity and frailty on uptake of surgery and chemotherapy.ResultsThere were 7094 women with early stage TNBC. Overall rate of surgery was 94%, which only decreased among women aged ≥85 years (74%) and among the most frail. Among the 6681 women receiving surgery, 16% had neoadjuvant and 42% had adjuvant chemotherapy; the use of both decreased with age. More comorbidities and greater frailty were associated with lower rates of chemotherapy. There were differences in the uptake of chemotherapy across geographical regions and in the neoadjuvant and adjuvant chemotherapy regimens between age groups.ConclusionMajority of older women with early TNBC had surgery, although some physically fit older women did not. Chemotherapy use varied by age and fitness.