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Breast Cancer Update for Surgeons 2007 (1)

DR MAURA N DICKLER: I tend to use an aromatase inhibitor up front with my postmenopausal patients. I believe the aromatase inhibitors are a little better than tamoxifen. You can prevent some of the earlier events with the aromatase inhibitors, and I like to use my best drug going forward.

I am still interested in studying a sequencing strategy and anxiously await the results of BIG 1-98 to see if the sequence of an aromatase inhibitor to tamoxifen may be better than an aromatase inhibitor alone for five years. But, until I know otherwise, I tend to start with an aromatase inhibitor up front.

Breast Cancer Update 2006 (7)

DR ROBERT W CARLSON: The vast majority of postmenopausal women would walk out of my office with a prescription for an adjuvant aromatase inhibitor — usually anastrozole — in my practice.

We have to establish a practice pattern, and mine is to lead with an aromatase inhibitor. It is interesting how expert panels interpreted the emerging aromatase inhibitor data differently.

Within 10 to 14 days of the initial ATAC presentation, the NCCN panel had modified the guidelines to allow anastrozole as an alternative to tamoxifen as initial hormonal therapy for postmenopausal patients with ER-positive disease.

The ASCO panel initially believed that tamoxifen should remain the standard hormonal therapy, but that guideline, over time, has also changed. Currently, the NCCN and the ASCO guidelines are essentially identical in terms of up-front hormonal therapy.

Breast Cancer Update for Surgeons 2007 (1)

DR JOHN MACKEY: The ATAC and BIG 1-98 trials show that if you start postmenopausal women on either anastrozole or letrozole, respectively, immediately after recovery from surgery, they do quite well and better than with tamoxifen.

However, we also have trials that suggest that if patients are halfway through their five-year course of tamoxifen, switching them to any one of the three aromatase inhibitors will provide a disease-free advantage.

Even after five years of tamoxifen, switching to an aromatase inhibitor will improve the disease-free survival. The remaining question is whether 15 years is better than 10 years of hormonal therapy.

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Premenopausal, Node-Positive

DR CLIFFORD HUDIS: In Figure 5, I don’t know what’s driving the shift in responses from “tamoxifen alone for five years, then no further therapy” to “tamoxifen plus ovarian suppression” in treating a 35-year-old patient with an ER-positive, PR-positive, HER2-negative, Grade II, node-positive breast cancer. No new data are available, and I don’t know of any direct evidence that says we know what to do for these patients beyond five years of tamoxifen. Although Cuzick’s presentation at the San Antonio meeting in 2006 on the impact of LHRH agonists is suggestive, it doesn’t give us the answer.

In my practice, I treat these patients with five years of tamoxifen or I enroll them on the SOFT study. In this study, women with functioning ovaries and ER-positive breast cancer are randomly assigned to five years of tamoxifen, which I consider standard therapy, versus ovarian ablation with tamoxifen versus ovarian suppression with exemestane. An important point, which I explain to patients all the time, is that, although doctors may have biases, the existence of SOFT speaks to the fact that nobody knows the answer. It would be unethical to conduct that trial if we already knew which therapy was best.

The prospective evidence in the adjuvant setting — and, for that matter, even in the metastatic setting — that shows an LHRH agonist can induce reliable ovarian suppression sufficient to allow aromatase inhibitors to do their job is pretty thin. The consistency of ovarian suppression with every three-month treatment is uncertain, especially, arguably, out toward the tail end of the three-month window.

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