Selecting Adjuvant Endocrine Therapy for Breast Cancer
Selecting Adjuvant Endocrine Therapy for Breast Cancer
Our understanding of the biology
of breast cancer has undoubtedly
improved in the past
decade, and remarkable progress has
been achieved in its treatment. Those
caring for these patients have long
realized that breast cancer is a disease
with an extremely diverse natural history,
and much remains to be learned
about the interaction among known
predictive and prognostic factors. Not
long ago, the "more is better" strategy
exemplified by high-dose chemotherapy
(often resulting in high-dose toxicity)
dominated the research agenda
and clinical practices of many institutions.
Although a minimum chemotherapy dose intensity is required
and increasing the frequency of specific
regimens is advantageous, further
dose intensification with or
without stem cell rescue[4-6] offers
no meaningful benefit in the adjuvant
Pathologic response after preoperative
chemotherapy appears to be a
prognostic marker of outcome pending
the upcoming results of National
Surgical Adjuvant Breast and Bowel
Project (NSABP) B-27. Early studies
suggest that gene-expression profiling
of tumor samples at baseline
may predict those likely to respond to
specific chemotherapy regimens,[8,9]
but our ability to identify those likely
to benefit from different chemotherapy
options among patients with similar
clinicopathologic features is limited.
Still, chemotherapy has had a major
impact in reducing the odds of recurrence
and death in early-stage disease,[
10] and its role in patients with
moderate- and high-risk disease will
remain unchallenged for the foreseeable
Over the past 10 years, adjuvant
endocrine therapy has taken center
stage in this setting, and it is now accepted as effective therapy in patients
with hormone-receptor-positive disease,
regardless of age or nodal status.[
11] In this issue of ONCOLOGY,
Eneman et al present us with an extensive
review of available adjuvant
endocrine therapy options and remind
us of important ongoing clinical trials.
They also created four hypothetical
didactic clinical scenarios to illustrate
how to best integrate available
prognostic and predictive factors. Two
topics described in their review are
worth highlighting: the resurgence of
interest in ovarian ablation/suppression
for premenopausal women and
the growing body of evidence confirming
the clinical benefit offered by
aromatase inhibitors in postmenopausal
Long identified as an effective therapy in patients with advanced disease,[ 12] ovarian suppression was recently shown to be an effective riskreduction strategy in high-risk women carrying mutations in BRCA1 or BRCA2. Interest in its role in early-stage disease was rekindled by long-term follow-up data comparing ovarian suppression vs no therapy in premenopausal women. Several early-generation trials have since been reported. Some of these trials compared ovarian suppression with nonanthracycline regimens, while others examined the role of combining ovarian suppression with chemotherapy and tamoxifen. These data suggest that much of the chemotherapy benefit observed in premenopausal women is due to the suppressive effects on ovarian function. Surgical ablation (ie, bilateral oophorectomy) and chemical inhibition (ie, luteinizing hormone-releasing hormone [LHRH] analogs) are the most commonly used methods of ovarian suppression, and recent data suggest a possible direct antitumor effect of LHRH agonists in addition to their known endocrine effects. Ovarian irradiation is also feasible if careful attention is paid to its delivery and to monitoring of efficacy. The available evidence supports the statement from the 2000 National Institutes of Health Consensus Development Conference on adjuvant therapy indicating that ovarian suppression may be considered an alternative to chemotherapy in premenopausal women. Quality-of-life studies favor the adjuvant use of ovarian suppression over chemotherapy in pre-/perimenopausal patients with endocrineresponsive, node-positive breast cancer. Quality-of-life scores in the Zoladex Early Breast Cancer Research Association (ZEBRA) trial favored the LHRH agonist during the first 3 to 6 months of therapy due to side effects from CMF chemotherapy (cyclophosphamide [Cytoxan, Neosar], methotrexate, fluorouracil [5-FU]). No significant differences in overall quality of life were observed during and after the 2 years of goserelin (Zoladex), aside from worse scores for hormonal symptoms during the period of ovarian suppression. A similar survival outcome was seen among 1,063 patients with nodenegative disease treated in the International Breast Cancer Study Group (IBCSG) Trial VIII with goserelin for 24 months, classic CMF for six cycles, or both in sequence for 24 months. Perhaps of greater significance, most patients treated with ovarian suppression alone resumed menses once goserelin was discontinued, whereas most treated with CMF did not. This suggests that permanent induction of menopause is not necessary for the antitumor effect, an observation with a potential beneficial long-term impact on the overall health of these patients. Questions remain about the optimal use and duration of ovarian suppression (2 to 3 years vs longer), and on its beneficial effects in premenopausal women treated with anthracyclinecontaining regimens and tamoxifen.[ 11] The role of ovarian suppression in addition to tamoxifen in patients who remain premenopausal after chemotherapy is being addressed by the IBCSG 24-02 Suppression of Ovarian Function Trial (SOFT). Aromatase Inhibitors
In an ironic twist following the release of major trial results, patients and their doctors find themselves in a period of uncertainty regarding how to best use aromatase inhibitors in the adjuvant care of postmenopausal women. Since 2002, three large prospective randomized, placebo-controlled trials have been published examining the role of the commercially available third-generation aromatase inhibitors vs tamoxifen in postmenopausal women.[22-25] These data clearly show a disease-free survival benefit favoring those who received an aromatase inhibitor immediately after local therapy or after a few years of tamoxifen. In addition, a recent update of the MA.17 trial presented at the 2004 meeting of the American Society of Clinical Oncology demonstrated an overall survival benefit favoring aromatase inhibitors in patients with node-positive disease. Many questions remain, and some are the subject of ongoing or recently completed trials (Table 1).[23-27] Conclusions
It has taken a long time for endocrine therapy-arguably among the best examples of "targeted" therapy- to be fully accepted as one of the most important tools in the treatment of breast cancer. Many questions remain regarding its optimal use. In the notso- distant future, we hope to be able to integrate hallmark biologic markers of each patient's tumor to customize individual therapies. Specifically, characterization of multiple breast cancer phenotypes[28,29] may help identify tumors with specific natural histories that are likely to respond to a given therapy. Preliminary clinical data suggesting that aromatase inhibitors may have greater efficacy than tamoxifen in cancers expressing the growth factor receptor HER2 indicate that continued research is necessary to guide us in designing optimal therapies. Future research will focus on understanding the interactions among signal transduction pathways and the application of genetic and proteomic profiling techniques to better identify a responsive disease profile. Incorporating these markers into the selection of optimal therapy will push the concept of directed therapy to a new frontier.
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19. Jonat W, Kaufmann M, Sauerbrei W, et al: Goserelin versus cyclophosphamide, methotrexate, and fluorouracil as adjuvant therapy in premenopausal patients with node-positive breast cancer: The Zoladex Early Breast Cancer Research Association Study. J Clin Oncol 20:4628-4635, 2002.
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