Extended Adjuvant Aromatase Inhibitor Therapy

DR HUDIS: I believe that in the case of the 61-year-old patient in Figure 15 who just completed five years of anastrozole, I chose to continue the anastrozole. However, it’s important for me to stipulate that the evidence right now is not on my side. This is one of those situations in which the rationale for my decision is pulled from several places. The first is the long natural history of breast cancer and the fact that, at least with tamoxifen, there are more recurrences after the first five years than in the first five years. That motivates me to think about doing something that’s longer lasting.

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Second, we have evidence that we can change the natural history of breast cancer late in the game with active therapy. The third is that the choice of five years of therapy for both the up-front and the switching trials is completely arbitrary. It was driven by the toxicity and risk profile established by tamoxifen, not by some inherent understanding of breast cancer biology and what the optimal duration of therapy is.

In addition, most patients who experience intolerance or toxicities with aromatase inhibitors do so in the first few years. That doesn’t mean that patients who take aromatase inhibitors for a long period won’t develop some unexpected long-term toxicities, but we don’t have evidence of that yet.

Based on all of this, when I see a patient at high risk who is concerned about reducing her risk of recurrence and who has tolerated her aromatase inhibitor well, I have a long talk with her, explain what I don’t know and tell her that I would be comfortable with her remaining on the drug as long as she wishes.

I would like to add that if the MA17R trial is positive showing a benefit to an additional five years of therapy, I believe that’s going to blow the doors open to saying, “Once patients go on safe hormone therapy, they should stay on it.”

In the older patient, such as in the 81-year-old case scenario, at the risk of splitting a fine hair, I won’t say that I recommend it, but I will say that I encourage further therapy. I bring it up, lay it all out and tell the patient that this is what I would do if I were in her position. Age is an issue because of the competing causes of more morbidity and mortality, and I believe that the workup associated with a recurrence or a new breast cancer in the opposite breast is worth avoiding, even if survival is not being improved.

Therefore, with a nontoxic, well-tolerated therapy, I would tend to leave the 61-year-old and the 81-year-old patient on it, if they’re both relatively healthy. However, if the 81-year-old is sick with five other morbid conditions, I won’t push her to stay on the drug.

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