Cost-effectiveness analysis of endocrine therapy alone versus partial-breast irradiation alone versus combined treatment for low-risk hormone-positive early-stage breast cancer in women aged 70 years or older

Ward, Matthew C.; Vicini, Frank A.; Al‐Hilli, Zahraa; Chadha, Manjeet; Pierce, Lori J.; Recht, Abram; Hayman, James A.; Thaker, Nikhil G.; Khan, Atif J.; Keisch, Martin; Shah, Chirag

doi:10.1007/s10549-020-05706-2

Cited by 19 publications

(41 citation statements)

References 74 publications

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“…Several studies, such as the Milan III (Milan Cancer Institute), have shown that older age portends more favorable breast cancer outcomes 35 . Moreover, with fewer remaining life‐years, an older patient has a shorter time horizon during which to manifest the benefit of adjuvant therapy for an indolent malignancy that may not yield a clinically significant recurrence for many years 36 . Thus, the option to omit either years of HT or the local toxicities of RT may offer appropriately selected patients a personalized approach that suits their goals and preferences.…”

Section: Discussionmentioning

confidence: 99%

“…These novel RT approaches may be opportune for older patients given potential advantages such as shorter treatment times, improved toxicity profiles, and cost reduction. From a cost‐effectiveness perspective, a recent analysis comparing HT alone for 5 years, accelerated PBI, and their combination, showed that both HT and RT monotherapy are appropriate options for patients aged 70 years or older with early‐stage breast cancer 36 . Thus, if RT monotherapy provides sufficient and comparable clinical benefit to RT + HT, omission of HT may be a reasonable consideration.…”

Section: Discussionmentioning

confidence: 99%

“…35 Moreover, with fewer remaining life-years, an older patient has a shorter time horizon during which to manifest the benefit of adjuvant therapy for an indolent malignancy that may not yield a clinically significant recurrence for many years. 36 Thus, the option to omit either years of HT or the local toxicities of RT may offer appropriately selected patients a personalized Cancer June 1, 2021 approach that suits their goals and preferences. The toxicities of HT, such as thromboembolic events, bone density issues, and hot flashes, should be carefully considered when weighing the clinical benefits of these medications.…”

Section: Discussionmentioning

confidence: 99%

“…From a cost-effectiveness perspective, a recent analysis comparing HT alone for 5 years, accelerated PBI, and their combination, showed that both HT and RT monotherapy are appropriate options for patients aged 70 years or older with early-stage breast cancer. 36 Thus, if RT monotherapy provides sufficient and comparable clinical benefit to RT + HT, omission of HT may be a reasonable consideration. Analogous to our investigation, this hypothesis is being evaluated by the EUROPA (Exclusive Endocrine Therapy or Partial Breast Irradiation for Women Aged ≥70 Years with Luminal A-Like Early-Stage Breast Cancer) study, a phase 3 trial comparing PBI alone versus HT alone after BCS in adults aged ≥70 years with early-stage breast cancer.…”

Section: Discussionmentioning

confidence: 99%

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Breast conservation among older patients with early‐stage breast cancer: Locoregional recurrence following adjuvant radiation or hormonal therapy

Tringale

Berger

Sevilimedu

et al. 2021

Cancer

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Background For patients with breast cancer undergoing breast‐conserving surgery (BCS), adjuvant radiation (RT) and hormonal therapy (HT) reduce the risk of locoregional recurrence (LRR). Although several studies have evaluated adjuvant HT ± RT, the outcomes of HT versus RT monotherapy remain less clear. In this study, the risk of LRR is characterized among older patients with early‐stage breast cancer following adjuvant RT alone, HT alone, neither, or both. Methods This study included female patients from the Memorial Sloan Kettering Cancer Center (New York, New York) who were aged ≥65 years with estrogen receptor–positive (ER+)/human epidermal growth factor receptor 2–negative (HER2–) T1N0 breast cancer treated with BCS. The primary endpoint was time to LRR evaluated by Cox regression analysis. Results There were 888 women evaluated with a median age of 71 years (range, 65‐100 years) and median follow‐up of 4.9 years (range, 0.0‐9.5 years). There were 27 LRR events (3.0%). Five‐year LRR was 11% for those receiving no adjuvant treatment, 3% for HT alone, 4% for RT alone, and 1% for HT and RT. LRR rates were significantly different between the groups (P < .001). Compared with neither HT nor RT, HT or RT monotherapy each yielded similar LRR reductions: HT alone (HR, 0.27; 95% CI, 0.10‐0.68; P = .006) and RT alone (HR, 0.32; 95% CI, 0.11‐0.92; P = .034). Distant recurrence and breast cancer–specific survival rates did not significantly differ between groups. Conclusions LRR risk following BCS is low among women aged ≥65 years with T1N0, ER+/HER2– breast cancer. Adjuvant RT and HT monotherapy each similarly reduce this risk; the combination yields a marginal improvement. Further study is needed to elucidate whether appropriate patients may feasibly receive adjuvant RT monotherapy versus the current standards of HT monotherapy or combined RT/HT.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Breast conservation among older patients with early‐stage breast cancer: Locoregional recurrence following adjuvant radiation or hormonal therapy

Tringale

Berger

Sevilimedu

et al. 2021

Cancer

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“…The phase II Triumph-T trial showed excellent local tumor control (albeit short median follow up) and breast cosmesis using a 3-fraction breast brachytherapy technique, and a similar 4-fraction regimen had excellent cosmesis with no locoregional recurrences at 6 years (37, 39). Furthermore, in elderly patients, single fraction regimens have also demonstrated excellent oncologic outcomes (40), and a recent study comparing PBI to PBI plus endocrine therapy or endocrine therapy alone in women over the age of 70 with low-risk, hormone-J o u r n a l P r e -p r o o f positive early-stage breast cancer demonstrated that PBI was superior when compliance with endocrine therapy was poor (41) and tested compliance interventions have demonstrated no improvement (42,43).…”

Section: Breast Brachytherapymentioning

confidence: 99%

The Case for Brachytherapy: Why It Deserves a Renaissance

Williams¹,

Kahn²,

Thaker³

et al. 2021

Advances in Radiation Oncology

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This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Is It Time to Reevaluate Radiotherapy Omission in Older Patients With Favorable Early-Stage Breast Cancer?

2021

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The role of adjuvant radiotherapy (RT) following breastconserving surgery in early-stage breast cancer has been well established based on several landmark clinical trials in the 1970s. 1,2 Subsequent studies 3,4 have suggested that in a subgroup of patients, particularly older women with smaller estrogen receptor (ER)-positive tumors receiving antihormonal therapy, irradiation may not provide as compelling a clinically meaningful benefit. More recently, significant technical 5 and practical 6,7 advances in breast RT have been made, and an emphasis on individual patient-centric care has become the norm. Taken together, these factors beg the question: Is it time to reevaluate the practice of omitting RT in patients 65 years or older with favorable early-stage breast cancer? Foundation for RT OmissionCancer and Leukemia Group (CALGB) 9343 3 and Postoperative Radiotherapy in Minimum-Risk Elderly II (PRIME II) 4 were landmark trials that served as the foundation for RT omission following breast-conserving surgery in older women with early-stage breast cancer. The CALGB 9343 trial included women 70 years or older with clinical stage I (T1N0M0), ER-positive invasive breast cancer. The PRIME II trial included women 65 years or older with clinical stage I (T1-2N0M0, <3 cm), ER-positive invasive breast cancer. Both studies randomized women to adjuvant long-term endocrine therapy (5 years of tamoxifen) with or without whole-breast RT. The 10-year results of both studies are very similar: the addition of whole-breast RT significantly reduced the risk of local and regional recurrence (10% to 1%-2%) with no differences seen in distant metastases or overall survival. It is important to note that CALGB 9343 was not powered to prove noninferiority in terms of survival. Based on these results, adjuvant endocrine therapy alone has been incorporated into the National Comprehensive Cancer Networks guideline (https://www.nccn.org/professionals/ physician_gls/pdf/breast.pdf) as a category 1 recommendation for women 70 years or older with early-stage, ER-positive breast cancer.

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Cost-effectiveness analysis of endocrine therapy alone versus partial-breast irradiation alone versus combined treatment for low-risk hormone-positive early-stage breast cancer in women aged 70 years or older

Cited by 19 publications

References 74 publications

Breast conservation among older patients with early‐stage breast cancer: Locoregional recurrence following adjuvant radiation or hormonal therapy

Breast conservation among older patients with early‐stage breast cancer: Locoregional recurrence following adjuvant radiation or hormonal therapy

The Case for Brachytherapy: Why It Deserves a Renaissance

Is It Time to Reevaluate Radiotherapy Omission in Older Patients With Favorable Early-Stage Breast Cancer?

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