Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus).

While younger women with early-stage, oestrogen-sensitive breast cancer are almost invariably treated with surgery plus endocrine therapy, (which deprives the cancer of the hormonal stimulus that induces its growth), women over the age of 70 years are frequently offered endocrine therapy alone. This is known as primary endocrine therapy. Primary endocrine therapy using tamoxifen (a drug which blocks oestrogen receptors on the cancer cell, inhibiting its growth) was first suggested as a treatment for older women in the 1980s. Tamoxifen was given without surgery, radiotherapy or chemotherapy on the basis that older women are more likely to have cancers with oestrogen receptors and will therefore respond well to treatment. In addition they were thought less suitable for major surgery because of other existing health issues. However, a tumour will often only respond to this treatment for between 18 and 24 months, and those women who relapse will have to consider additional hormone treatment or opt for surgery or radiotherapy at a greater age. The long-term data suggest that, at 12 years of follow-up, more elderly women treated by primary tamoxifen alone will suffer a progression of their cancer than those who have had surgery. We undertook this review to assess the evidence for the clinical effectiveness of surgery (with or without endocrine therapy) compared with primary endocrine therapy in the treatment of operable breast cancer in women aged 70 years and over. Based on seven trials and an estimated 1081 deaths in 1571 women, the results of this review showed no benefit in respect to survival for either surgery or primary endocrine therapy. However, women who had surgery were less likely to relapse than women on primary endocrine therapy. The authors conclude that surgery controls breast cancer better than tamoxifen alone in older women but does not extend survival. Both interventions were associated with adverse events. Tamoxifen-related adverse effects included hot flushes, skin rash, vaginal discharge, indigestion, breast pain, sleepiness, headache, vertigo, itching, hair loss, cystitis, acute thrombophlebitis, nausea, and indigestion. Surgery-related adverse effects included tingling or numbness on the arm on the side of the surgery, and psychosocial problems. On this basis, primary endocrine therapy should only be offered to women with oestrogen receptor (ER)-positive tumours who are unfit for, or who refuse surgery. We need further trials to evaluate the clinical effectiveness of other agents such as aromatase inhibitors for use as primary endocrine therapy for an infirm older population with ER-positive tumours. - See more at: http://summaries.cochrane.org/CD004272/surgery-versus-primary-endocrine-therapy-for-elderly-women-with-operable-primary-breast-cancer#sthash.RRAt9B6f.dpu