The first question the panel had to answer on this topic was the ideal cut-off – in terms of percentage of ER-positive tumour cells – to prescribe endocrine therapy. There was no clear consensus on this topic: 30% of the panellists voted for >1%, 4% voted for >5%, 39% voted for >10%, while 25% took the view that there is no clear answer. Recently, updates were presented of the SOFT and TEXT trial  showing that among premenopausal women with breast cancer, the addition of ovarian suppression to tamoxifen resulted in significantly higher 8-year rates of both disease-free and overall survival than tamoxifen alone. The use of exemestane plus ovarian suppression resulted in even higher rates of freedom from recurrence. Based on these results, a majority of the panellists (68%) took the view that premenopausal patients with an ER-positive tumour who are getting adjuvant chemotherapy are candidate for ovarian function suppressive (OFS) therapy. Also in line with the SOFT and TEXT trials, 85% of the panellists agreed that an age <35 years should lower the threshold to prescribe OFS therapy. There was no consensus on the question whether premenopausal ER-positive patients with a moderate risk and no adjuvant chemotherapy are candidate for OFS: 46% voted “yes”, 42% voted “no.” A small majority of the panellists (60%) was of the opinion that an adverse result of a gene expression test should lower the threshold for OFS therapy in premenopausal ER-positive patients. Half of the panellists (52%) was of the opinion that Her2-positive status should not lower the threshold for OFS therapy. Asked for their opinion on the duration of OFS, a small majority of the panellists (55%) favoured 5 years of OFS, which was the duration of OFS in the SOFT and TEXT trial (24% voted for 2-3 years of OFS). A majority of the panellists endorsed OFS during chemotherapy for women who want a future pregnancy. This was the case for patients with HR-negative breast cancer (92% voted “yes”), and for patients with HR-positive breast cancer (80% voted “yes”).
With regard to preferred endocrine therapy for patients who remain premenopausal after 5 years of tamoxifen therapy, a small majority of the panellists recommended to stop further treatment with tamoxifen, while 37% of the panellists recommended to continue to 10 years of treatment with tamoxifen. However, in case the patient – who remained premenopausal after 5 years of tamoxifen – was at high risk at presentation (e.g. stage 2, node positivity), 80% of the panellists would recommend continuing tamoxifen treatment to 10 years.
- Francis PA, et al. N Engl J Med 2018; 379: 122-137.
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Table of Contents: BCC 2019
St. Gallen Consensus
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