SlideShare a Scribd company logo
z
DR SUMIT KUMAR
Assistant professor
NEIGRIHMS, Shillong
z
Breast cancer is the most frequently diagnosed cancer and the
leading cause of death from cancer in women worldwide.
HR-positive (ie, estrogen [ER] and/or progesterone [PR] receptor-
positive) breast cancers comprise the most common types of
breast cancer, accounting for 75% of all cases.
This topic will review adjuvant endocrine therapy for non-
metastatic, hormone receptor- positive breast cancer occurring in
postmenopausal women.
z
Definitions of menopause used by the National Comprehensive
Cancer Network:
 Women 60 years and older are postmenopausal.
 Women less than 60 years are postmenopausal if one of the following conditions is met:
o They previously underwent a bilateral oophorectomy.
o They have not had any menstrual periods for 12 months or more in the absence of
tamoxifen, chemotherapy, or ovarian suppression, and the serum estradiol is in the
postmenopausal range.
o They are amenorrheic on tamoxifen, and follicle-stimulating hormone (FSH) and
serum estradiol are in the postmenopausal range.
z
 Endocrine therapy recommended for postmenopausal women with estrogen
receptor- or progesterone receptor-positive breast cancer.
 Benefits of endocrine therapy:
o Consistently reduces the risk of recurrence and second breast cancers.
o Improves overall survival.
 Greater benefit for those with higher-risk tumors.
 Nearly all postmenopausal women eligible for endocrine therapy, regardless of
age.
 Special consideration needed for patients with:
o Multiple comorbidities.
o History of thrombosis, cerebrovascular disease, or osteoporosis.
In such cases, the potential benefits of reducing recurrence and death from breast cancer
must be weighed against the possible side effects and risks associated with the therapy,
especially if the patient has comorbidities.
z
Preferred option:-
 Aromatase inhibitor
Anastrozole (1 mg daily)
Letrozole (2.5 mg daily)
Exemestane (25 mg daily)
Alternative option:
 Tamoxifen,
 Short course of tamoxifen
followed by an AI,
 Short course of AI
followed by tamoxifen,
Aromatase inhibitors (AIs) reduce plasma estrogen levels by inhibiting aromatase, the enzyme that
converts androgens to estrogens, and require ovarian suppression/ablation in premenopausal
women with intact ovarian function or therapy-induced amenorrhea.
z
Aspect Aromatase Inhibitors Tamoxifen
Mechanism of Action
Inhibit the peripheral conversion of
androgens to estrogen, reducing estrogen
levels in the body.
Selective estrogen receptor modulator
(SERM) that blocks estrogen from
binding to breast cancer cells.
Indications
1st-line therapy for postmenopausal
women with HR-positive breast cancer.
In pre-menopausal:-along with OFS
Used for both pre and postmenopausal
women with HR-positive breast cancer.
Clinical Trials
ATAC Trial (Arimidex, Tamoxifen, Alone
or in Combination):
BIG 1-98, and
TEAM Trial (Tamoxifen Exemestane
Adjuvant Multinational Trial):
MA.17 Trial (Maple Leaf):
Femara vs. Anastrozole Clinical
Evaluation (FACE) Trial
NSABP B-14,
NSABP B-20,
EBCTCG trials,
ATLAS Trial (Adjuvant Tamoxifen,
Longer Against Shorter.
IBIS-I Trial (International Breast Cancer
Intervention Study I&II)
SOFT Trial (Suppression of Ovarian
Function Trial)
ATTOM Trial
Adverse Effects
Common side effects include joint pain,
hot flashes, bone density loss, and
increased risk of osteoporosis.
Common side effects include hot flashes,
menstrual changes (in premenopausal
women), and an increased risk of uterine
cancer and blood clots.
z
Duration of Therapy
Typically prescribed for 5 years as
adjuvant therapy.
Typically prescribed for 5-10 years
as adjuvant therapy, depending on
the specific situation.
Bone Health
May lead to a decrease in bone
density, requiring monitoring and
potential use of bisphosphonates.
Has a positive effect on bone
density, reducing the risk of
osteoporosis.
Uterine Health
Generally does not affect the
uterus.
May increase the risk of
endometrial cancer and other
uterine issues.
Cardiovascular Effects
Generally considered safer for the
cardiovascular system compared
to tamoxifen.
May increase the risk of blood
clots, which can affect
cardiovascular health.
Hormone Levels
Lowers estrogen levels
significantly.
Blocks estrogen at breast tissue
but can have estrogen-like effects
in other tissues.
Combination Therapy
May be used in combination with
other therapies, such as CDK4/6
inhibitors.
Can be used in combination with
other hormone therapies or
chemotherapy.
z
 AI versus tamoxifen –
 Tamoxifen alone versus a short course of tamoxifen followed by an AI
Randomised trial
(n=9885)
5-yrs course of an AI or tamoxifen
AI resulted in :
Reduced breast cancer recurrence
Lower 10-yr breast cancer mortality
Randomised trial
(n=11,798)
5-yrs course of tamoxifen vs 2-3 yrs tam F/B AI for
5 yrs
Switch to AI resulted in :
Reduced breast cancer recurrence(during 2-4 yr)
Fewer death from BC
z
• AI alone versus a short course of tamoxifen followed by an AI
• AI alone versus short course of AI followed by tamoxifen –
BIG 1-98 trial
randomized over 8000 women
5-yrs of tamoxifen or letrozole monotherapy, or sequential treatment with
2yr of one of these drugs followed by 3 yrs of the other
Randomised trial
(n=12,799)
5-yrs course of an AI vs 2-3 yrs of tamoxifen F/B AI
for 5 yr
AI alone resulted in :
Lower recurrence rate during 0-1 yr
Similar recurrence rate during 2-4 yr
Reduced BC mortality
Outcomes better for letrozole compared with tamoxifen
monotherapy
no significant difference in either DFS or OS bet. the sequential
therapies and letrozole monotherapy
z
 Evidence suggests similar clinical outcomes and tolerability between the aromatase
inhibitors (AIs). As such, anastrozole, exemestane, and letrozole are all appropriate
options for those warranting adjuvant treatment with an AI. Individual patients may
tolerate one of these agents better than another, and it is reasonable to switch to an
alternative AI if the initial AI is poorly tolerated and other strategies of managing side
effects have been ineffective [6]. (See 'Side effects' below.)
 In the FATA-GIM3 trial, over 1800 women were randomly assigned to oral anastrozole
(1 mg per day), exemestane (25 mg per day), or letrozole (2.5 mg per day) for five
years [7]. Five-year disease-free survival (DFS) was 90 percent with anastrozole
(95% CI 87.9-91.7), 88 percent with exemestane (95% CI 85.8-89.9), and 89 percent
with letrozole (95% CI 87.3-91.1). Gastrointestinal side effects were more common
with exemestane than with letrozole, and hypercholesterolemia was more frequent
with anastrozole and letrozole than with exemestane. All other side effects were
similar between the agents. Treatment was interrupted due to toxicity in approximately
7 percent of patients on each of these treatment arms.
Trial: FATA-GIM3 Anastrozole Exemestane Letrozole
Drug Regimen 1 mg/day 25 mg/day 2.5 mg/day
Five-Year Disease-
Free Survival (DFS)
90% (95% CI 87.9-91.7) 88% (95% CI 85.8-89.9) 89% (95% CI 87.3-91.1)
Common Side Effects
- Gastrointestinal side
effects more common
with exemestane.
Hypercholesterolemia
more frequent
Hypercholesterolemia
more frequent
Treatment Interruption
due to Toxicity
Approximately 7% Approximately 7% Approximately 7%
table summarizing the key findings from the trial:
FATA-GIM3 Trial
1800 pt. compare 5-yr of different AI
z
 similar five-year DFS rates (85 vs 83 %)
 comparable side effect profiles.
NCIC-CTG MA.27Trial
7500 pt. compare 5-yr of Exemestane or anastrazole
Primary Finding
Similar efficacy in terms of DFS between the two groups. No statistically
significant difference in DFS.
Side Effects Generally well-tolerated with similar side effect profiles.
Additional Finding
Notable percentage discontinued both exemestane and anastrozole during the
study due to adverse events, concomitant illness, or study refusal (32% for
exemestane and 29% for anastrozole).
FACE Trial
compare 5-yr of Letrozole or anastrazole
z
Common side effect
1. Musculoskeletal Pains and Stiffness (AI-Associated Musculoskeletal
Syndrome - AIMSS)
2. Sexual Dysfunction:
3. Loss of Bone Density:
4. Osteoporosis and Fractures:
5. Cardiovascular Disease and Diabetes:
6. Hypercholesterolemia:
7. Hair Thinning:
8. Physical Health
9. Cognitive Problems
 AIMSS Symptoms may be severe in almost one- third of patients, and
may be responsible for treatment discontinuation in 10 to 20 percent of
patients
z
:
 Arthralgia
 Joint Stiffness
 Bone Pain
 Carpal Tunnel Syndrome
AI-associated musculoskeletal syndrome
(AIMSS) symptoms typically include:
Management:
a. Exercise: Exercise helps in reducing musculoskeletal symptoms associated with
AIs.
•HOPE Trial (Randomized Controlled Trial): 121 postmenopausal women with AI-
associated arthralgias were randomly assigned to an exercise regimen or usual care.
• The exercise regimen consisted of supervised resistance and strength training along
with moderate aerobic exercise for 150 minutes per week.
• Results: reduction in their worst pain score (20% reduction) and pain severity (21%
reduction) compared to the usual care group.
• A dose-response relationship between exercise and symptom severity was
identified, indicating that greater attendance at exercise sessions correlated with
more significant symptom reduction.
z
b. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):
c. Temporary Discontinuation of AI, followed by initiation of a different AI: some patients may benefit from
discontinuing the current AI for two to eight weeks and then starting a different AI.
This approach may improve symptoms and allow patients to continue with a different AI.
d. Duloxetine: an antidepressant, an option for AIMSS management.
SWOG S1202 Trial: 299 patients with stage I to III disease on AIs, those randomized to duloxetine experienced
improvement in joint pain over 12 weeks of treatment.
o Duloxetine dosing: 30 mg daily for 1 week, followed by 60 mg daily for 11 weeks, and then 30 mg daily for 1
week.
o Results: Patients on duloxetine showed improvements in joint pain compared to placebo, although results
between the groups were similar at 24 weeks.
o Duloxetine was relatively well-tolerated, with mostly grade 1 or 2 adverse events.
e. Acupuncture:
Acupuncture offers a nonpharmacological approach to AIMSS management.
One randomized trial showed a small benefit in joint symptoms for patients receiving acupuncture compared to
sham acupuncture or waitlist control.
F.Switch to tamoxifen, for those who are unable or unwilling to continue treatment with an AI.
z
Limitations of Tamoxifen
Compliance:
Resistance:
Drug Interactions: such as certain selective serotonin reuptake inhibitors,
Side Effects of Tamoxifen:
 Thromboembolic Disease: 2- to 3 fold increased relative risk
 Strokes:.
 Uterine Cancer:
 Fatty Liver Disease: Tamoxifen is associated with fatty liver disease.
 Hot Flashes: Hot flashes are a common side effect of tamoxifen use.
 Vaginal Discharge: Some women may experience vaginal discharge while
taking tamoxifen.
 Sexual Dysfunction: Tamoxifen may lead to sexual dysfunction in some
individuals.
 Menstrual Irregularities: Changes in menstrual patterns can occur during
tamoxifen therapy.
 Increased Risk of Diabetes:
z
Patient selection –high-risk, node-positive, ER-positive, HER2- negative breast cancer].
NCCN define high-risk as either :
 ≥4 positive lymph nodes; or
 1 to 3 positive lymph nodes with one or more of the following:
o Grade 3 disease,
o Tumor size ≥5 cm, or
o Ki-67 score of ≥20 percent
Duration –Adjuvant abemaciclib therapy, the duration is for two years, typically concurrently with the start of endocrine
treatment.
CDK 4/6 inhibitors
high-risk, node-positive disease
Abemaciclib
Palbociclib
PARP inhibitors
high risk, BRCA-mutated cancers
Olaparib
CDK 4/6 inhibitors, high-risk, node-positive disease
(AMEMACICLIB)
z
5600 patients HR+ve,HER2-negative high risk EBC
(compare Abemaciclib+endo vs endocrine therapy)
•Timing of Randomization:
• Patients could receive up to 12 weeks of endocrine therapy.
• Randomization occurred within 16 months of definitive breast cancer surgery.
•Definition of High Risk:
• High risk was defined as meeting one of the following criteria:
• ≥4 positive lymph nodes
• 1-3 positive lymph nodes and at least one of:
• Tumor size ≥5 cm
• Histologic grade 3
• Central Ki-67 ≥20 percent
•Efficacy Results:
• Patients receiving abemaciclib and endocrine therapy had improved outcomes compared to
those on endocrine therapy alone.
• Three-year Invasive Disease-Free Survival (IDFS) rates: 89% vs. 83%
• Hazard Ratio (HR) for IDFS: 0.70 (95% CI 0.59-0.82)
• Three-year Distant Recurrence-Free Survival rates: 90% vs. 86%
• HR for Distant Recurrence-Free Survival: 0.69 (95% CI 0.57-0.83)
• Benefit was sustained at four years..
z
• Subgroup Analysis:
• Improvements with abemaciclib were statistically significant in the premenopausal subset.
• No statistically significant improvement among postmenopausal women.
• Ki-67 Benefit:
• The absolute IDFS benefit was more pronounced in the Ki-67 ≥20 percent group.
• 7.1 percent benefit in this group compared to 4.5 percent in the Ki-67 <20 percent group.
• FDA Approval:
• FDA approval for abemaciclib is specifically for tumors with Ki-67 ≥20 percent.
 TOXICITY
The most frequent AEs were diarrhea, neutropenia, and fatigue in the abemaciclib arm and arthralgia,
hot flush, and fatigue in the control arm. A higher incidence of grade ≥3 AEs was observed with versus
without abemaciclib (50 vs 16 %, respectively).
5600 patients HR+ve,HER2-negative high risk EBC
(compare Abemaciclib + endo vs endocrine therapy)
z
 Olaparib for select high risk, BRCA-mutated cancers —
Olaparib has regulatory approval by the FDA for the adjuvant treatment of adult
patients with deleterious or suspected deleterious germline BRCA-mutated, HER2-
negative, high-risk early breast cancer who have been treated with neoadjuvant or
adjuvant chemotherapy
Pallas study
Addition of 2 yr Palbociclib to adj endocrine
No improve IDFS
PENELOPE-B trial
Addition of 1 yr Palbociclib to adj endocrine
No improve IDFS
z
 Women treated with adjuvant endocrine therapy are treated for a minimum duration of five
years, with extended therapy offered to some with higher-risk features.
 Rationale for extended treatment in some patients Observational data suggests that the risk of
distant recurrence in ER-positive breast cancer patients after five years of adjuvant endocrine therapy
continues steadily for at least the subsequent 20 years. This provides a rationale for considering extended
endocrine treatment in some patients.
Meta-analysis of 88 trials
62,923 women with ER+VE
disease free after 5 years of scheduled
endocrine therapy
Danish Breast Cancer Group database
20,000 patients who were survivors 10 years after
diagnosis
riginal Lymph Node Status
Annual Risk of Distant
Recurrence
Many positive nodes Nearly 3% per year
One to three positive nodes Approx. 2% per year
Negative nodes but T2 or
greater lesions
Approx. 1% per year
Node-negative and smaller
tumors
Approx. 0.5 to 1.0% per year
Time After Diagnosis
(Years)
Cumulative Incidence
of Late Recurrence
15 years 8.5%
20 years 12.5%
25 years 15.2%
32 years 16.6%
z
 Extended adjuvant ET beyond 5-yrs is an option for all patients with a prior history of invasive,
ER+VE BC.
 Some data suggest that longer durations of ET improve DFS, if not OS .
 Larger tumors or node-positive disease, extended ET has clear cut benefit.
 Smaller, node-negative tumors, the benefits are less clear and, for some, may not outweigh the
risk of toxicities.
 Patient selection is crucial for balancing benefits and risks.
 RISK of recurrence may be assess by ;
o PAM50 and Endopredict (Effective at identifying node-positive patients at low risk for late
recurrence).
o Oncotype DX Recurrence Score or Breast Cancer Index (Genomics-only assays).
o Clinical Treatment Score post-5 years (CTS5):.
(CTS5):Not recommended by ASCO Tumor Marker Guidelines for Early Breast Cancer Panel.
z
 Women treated with tamoxifen –
 After 5 yrs of tamoxifen, either continuing tamoxifen or switching to an AI for an additional 5
yrs.
 No head to head comparision between tamoxifen and AI in extended ET.
z
OUTCOME EXTENDED ARM CONTROL ARM
Breast cancer recurrence 617(3428) 711(3418)
Breast cancer mortality 331 397
Reduced overall mortality 639 722
Cumulative risk of recurrence
during yr 5–14
21.4% 25.1%
Breast cancer mortality during
years 5–14
12.2% 15.0%
Cumulative risk of endometrial
cancer during years 5–14
3.1% 1.6%
TOXICITY
 STROKE
 PULMONARY
EMBOLUS
 IHD
 BONE FRACTURE
130
41
126
62
119
21
163
70
continuing adjuvant tamoxifen to 10 years versus stopping at 5 years
outcomes among the 6846 women
(absolute mortality reduction 2·8%).
z
z
Outcome Extended arm Control arm
breast cancer recurrence 580/3468 672/3485
breast cancer mortality deaths
after recurrence
392 443
overall mortality (deaths) 849 910
endometrial cancers 102 45
endometrial cancers deaths 37 (1.1%) 20(0.6%)
6,953 women with early breast cancer.
continuing adjuvant tamoxifen to 10 years versus stopping at 5 years
z
MA.17, 5000 postmenopausal
patients who had completed a 5-year
course of tamoxifen were randomly
assigned to a 5-year course of
letrozole or placebo.
• Letrozole was associated with an
improvement in DFS compared with
placebo and an improvement in OS
National Surgical Adjuvant Breast
and Bowel Project (NSABP) B-33,
exemestane as extended endocrine
treatment after 5 years of tamoxifen
• resulted in improvement in
recurrence-free survival.
In a separate trial, postmenopausal
women who remained recurrence
free after a two- to three-year course
of tamoxifen subsequent five years of
letrozole versus letrozole for two to
three years
• experienced modestly improved 12-
year DFS (67 vs 62 %).
z
 Some data suggest that for women completing 5 yrs of an AI, an additional five years of AI
improves recurrence-free survival; however, OS is not improved.
 For women who complete a five-year course of AI after any duration of prior tamoxifen.
MA.17R trial
Approx 1900 post menopausal women
compare the efficacy of extended adjuvant therapy with
letrozole vs. placebo after completing 5 yr of AI
Aspect Extended Letrozole Placebo
5-Year Disease-Free Survival
(DFS)
95% (95% CI 93-96%) 91% (95% CI 89-93%)
Contralateral Breast Cancer
Rate
Reduced with letrozole
(0.21%
0.49%
Bone-Related Toxic Effects
Bone pain
Fracture
New-onset osteoporosis
18%
14%
11%
14%
9%
6%
 NSABP-B42, the DATA trial, and the IDEAL trial have not confirmed any improved DFS .
z
 If extended endocrine therapy is chosen in patients with low-risk cancers, an
additional 2 years of treatment is appropriate (for a total of 7 years of
treatment).
 The benefits of a total of 10 versus 7 years of endocrine therapy are small, if
any, in women with low-risk cancers, and the risks of adverse events persist..
SOLE trial(Study of Letrozole Extension)
Evaluate continuous vs intermittent AI(nine months each year, followed by
a three-month break)
Key Findings
No significant difference in DFS between the two treatment schedules.
Intermittent schedule, better tolerated by patients.
z
Challenges in Adjuvant Therapy Continuation:
 A significant percentage of women discontinue adjuvant endocrine therapy.
 Restarting adjuvant therapy has shown promise in improving disease-free survival (DFS).
Observations Supporting Restarting Adjuvant Therapy:.
Swedish Registry Study (2005-2008):Among 3071 women on adjuvant endocrine therapy, 48%
discontinued treatment for at least 3 months.
 65% of those who discontinued restarted adjuvant therapy, while 35% did not.
 Women who restarted adjuvant therapy had significantly improved DFS (eight-year DFS,
89.8% vs. 82.0%).
SOLE Trial (Aromatase Inhibition):
Women reaching five years on adjuvant aromatase inhibition without recurrence were assigned to
continuous extended AI therapy vs. AI for nine months/year.
 No difference in event-free survival or overall survival.
 Alternating arm reported superior quality of life.
Implications:
Restarting adjuvant therapy can offer improved outcomes in terms of DFS.
z
 Adjuvant chemotherapy plus trastuzumab followed by endocrine therapy (plus maintenance
trastuzumab) should be administered to these women. The use of endocrine therapy plus
trastuzumab (without chemotherapy) remains investigational and should be done only as part of a
clinical trial.
z
 Some studies suggest a potential association between higher BMI and worse breast cancer outcomes.
 Evidence from Post-Hoc Analyses:
1. ATAC Trial Analysis (Postmenopausal Women):
1. 4900 postmenopausal women.
2. BMI >35 kg/m² Compare with <23 kg/m2 at baseline associated with:
1. Greater risk of recurrence (21% vs. 14%)
2. BIG 1-98 Trial Analysis (Postmenopausal Women):
1. 4700 women assigned to tamoxifen or letrozole.
2. Obesity associated with compared with :
1. Trends toward increased recurrence (30% vs. 25%)
2. Trends toward increased all-cause mortality (21% vs. 15%)
z
Patients with cardiac risk factors
 AIs appear to be associated with a long-term increased risk of cardiovascular disease compared
with tamoxifen .
Patients with mucinous or tubular/cribriform histologies —
• Mucinous or tubular/cribriform histotypes have a better prognosis and therefore may derive a
smaller absolute risk reduction from endocrine therapy compared with patients with other breast
cancer histologies, though they would still benefit a similar chemoprotective effect against a
second breast cancer.
 tamoxifen was associated with nonsignificant trends towards improved
disease-free survival and overall survival compared with letrozole
Subset analysis of the BIG 1-98 trial
including 183 women with mucinous or tubular/cribriform histologies
z
Estrogen receptor (ER)- and/or progesterone receptor (PR)-positive breast cancers comprise
the most common type of breast cancer, accounting for 75 percent of all breast cancers.
For patients with hormone receptor-positive breast cancer, adjuvant endocrine therapy
An aromatase inhibitor (AI) rather than tamoxifen as adjuvant endocrine treatment
For women who wish to discontinue an AI, it would be reasonable to switch to tamoxifen.
Incorporation of abemaciclib For patients with hormone receptor-positive, human epidermal
growth factor receptor 2 (HER2)-negative, node- positive breast cancer at high risk of
recurrence,
z
Duration of endocrine treatment –at least a five-year course of treatment (Grade 1A
• For women with higher-risk disease (eg, stage II or stage III disease),extended endocrine treatment
(Grade 2B),
For patients with high-risk disease, a total duration between 7 and 10 years is appropriate.
For women with smaller, node-negative tumors (ie, stage I disease), it is not clear that there is a sufficiently
high risk of late recurrence to justify the side effects and risks of extended endocrine therapy.
Initiate endocrine therapy after chemotherapy has completed (ie, sequentially) rather than concurrently
with chemotherapy.
Adjuvant radiation therapy (RT) for breast cancer, endocrine therapy may be initiated concurrently with RT
or sequentially, following the completion of RT.
z

More Related Content

Similar to Breast cancer: Post menopausal endocrine therapy

Hormone therapy for carcinoma breast
Hormone therapy for carcinoma breastHormone therapy for carcinoma breast
Hormone therapy for carcinoma breast
Parag Roy
 
Endocrine treatment in metastatic breast cancer
Endocrine treatment in metastatic breast cancerEndocrine treatment in metastatic breast cancer
Endocrine treatment in metastatic breast cancer
Venkata pradeep babu koyyala
 
Hormonal therapy in breast cancer
Hormonal therapy in breast cancerHormonal therapy in breast cancer
Hormonal therapy in breast cancer
DrAyush Garg
 
Hormone therapy in breast cancer
Hormone therapy in breast cancerHormone therapy in breast cancer
Hormone therapy in breast cancer
Rajib Bhattacharjee
 
Soft & text trial- an overview
Soft & text trial- an overview Soft & text trial- an overview
Soft & text trial- an overview
Kundan Singh
 
Harmonal therapy IN BREASAT CANCER dr.kiran
Harmonal therapy IN BREASAT CANCER dr.kiranHarmonal therapy IN BREASAT CANCER dr.kiran
Harmonal therapy IN BREASAT CANCER dr.kiran
Kiran Ramakrishna
 
Tamoxifen
TamoxifenTamoxifen
Tamoxifen
ketan kalariya
 
Fertility, Pregnancy, Contraception, Lactation And Endocrine Therapy In Breas...
Fertility, Pregnancy, Contraception, Lactation And Endocrine Therapy In Breas...Fertility, Pregnancy, Contraception, Lactation And Endocrine Therapy In Breas...
Fertility, Pregnancy, Contraception, Lactation And Endocrine Therapy In Breas...
Mamdouh Sabry
 
Adjuvant Endocrine Therapy For Postmenopausal Breast Cancer
Adjuvant Endocrine Therapy For  Postmenopausal Breast CancerAdjuvant Endocrine Therapy For  Postmenopausal Breast Cancer
Adjuvant Endocrine Therapy For Postmenopausal Breast Cancer
Emad Shash
 
Role and Side effects of Ovarian Function Suppression in Breast Cancer
Role  and Side effects of Ovarian Function Suppression in Breast CancerRole  and Side effects of Ovarian Function Suppression in Breast Cancer
Role and Side effects of Ovarian Function Suppression in Breast Cancer
Ajeet Gandhi
 
journal dr. pratik copy.pptx
journal dr. pratik copy.pptxjournal dr. pratik copy.pptx
journal dr. pratik copy.pptx
PratikJugnake1
 
Satyajeet rath chemotherapy and hormone therapy in breast cancer
Satyajeet rath chemotherapy and hormone therapy in breast cancerSatyajeet rath chemotherapy and hormone therapy in breast cancer
Satyajeet rath chemotherapy and hormone therapy in breast cancer
Satyajeet Rath
 
The renaissance of_endocrine_therapy_in_breast.9
The renaissance of_endocrine_therapy_in_breast.9The renaissance of_endocrine_therapy_in_breast.9
The renaissance of_endocrine_therapy_in_breast.9
Luis Carlos Murillo Valencia
 
Hr+ mbc
Hr+ mbc Hr+ mbc
Endocrine Therapy In Advanced Breast Cancer
Endocrine Therapy In Advanced Breast CancerEndocrine Therapy In Advanced Breast Cancer
Endocrine Therapy In Advanced Breast Cancer
guest8887a7
 
Hormone therapy in beast cancer
Hormone therapy in beast cancerHormone therapy in beast cancer
Hormone therapy in beast cancer
Ashutosh Mukherji
 
Hormonal treatment of metastatic breast cancer dr. abeer elsayed
Hormonal treatment of metastatic breast cancer  dr. abeer elsayedHormonal treatment of metastatic breast cancer  dr. abeer elsayed
Hormonal treatment of metastatic breast cancer dr. abeer elsayed
Abeer Ibrahim
 
BALKAN MCO 2011 - F. Cardoso - Hormone therapy: best options for pre and post...
BALKAN MCO 2011 - F. Cardoso - Hormone therapy: best options for pre and post...BALKAN MCO 2011 - F. Cardoso - Hormone therapy: best options for pre and post...
BALKAN MCO 2011 - F. Cardoso - Hormone therapy: best options for pre and post...
European School of Oncology
 
CALGB 9343 -Lumpectomy without Radiation in women >70 years
CALGB 9343 -Lumpectomy without Radiation in women >70 yearsCALGB 9343 -Lumpectomy without Radiation in women >70 years
CALGB 9343 -Lumpectomy without Radiation in women >70 years
Dr.Bhavin Vadodariya
 
oncology Hormonal agents.pptx
oncology Hormonal agents.pptxoncology Hormonal agents.pptx
oncology Hormonal agents.pptx
parnianboroonsara1
 

Similar to Breast cancer: Post menopausal endocrine therapy (20)

Hormone therapy for carcinoma breast
Hormone therapy for carcinoma breastHormone therapy for carcinoma breast
Hormone therapy for carcinoma breast
 
Endocrine treatment in metastatic breast cancer
Endocrine treatment in metastatic breast cancerEndocrine treatment in metastatic breast cancer
Endocrine treatment in metastatic breast cancer
 
Hormonal therapy in breast cancer
Hormonal therapy in breast cancerHormonal therapy in breast cancer
Hormonal therapy in breast cancer
 
Hormone therapy in breast cancer
Hormone therapy in breast cancerHormone therapy in breast cancer
Hormone therapy in breast cancer
 
Soft & text trial- an overview
Soft & text trial- an overview Soft & text trial- an overview
Soft & text trial- an overview
 
Harmonal therapy IN BREASAT CANCER dr.kiran
Harmonal therapy IN BREASAT CANCER dr.kiranHarmonal therapy IN BREASAT CANCER dr.kiran
Harmonal therapy IN BREASAT CANCER dr.kiran
 
Tamoxifen
TamoxifenTamoxifen
Tamoxifen
 
Fertility, Pregnancy, Contraception, Lactation And Endocrine Therapy In Breas...
Fertility, Pregnancy, Contraception, Lactation And Endocrine Therapy In Breas...Fertility, Pregnancy, Contraception, Lactation And Endocrine Therapy In Breas...
Fertility, Pregnancy, Contraception, Lactation And Endocrine Therapy In Breas...
 
Adjuvant Endocrine Therapy For Postmenopausal Breast Cancer
Adjuvant Endocrine Therapy For  Postmenopausal Breast CancerAdjuvant Endocrine Therapy For  Postmenopausal Breast Cancer
Adjuvant Endocrine Therapy For Postmenopausal Breast Cancer
 
Role and Side effects of Ovarian Function Suppression in Breast Cancer
Role  and Side effects of Ovarian Function Suppression in Breast CancerRole  and Side effects of Ovarian Function Suppression in Breast Cancer
Role and Side effects of Ovarian Function Suppression in Breast Cancer
 
journal dr. pratik copy.pptx
journal dr. pratik copy.pptxjournal dr. pratik copy.pptx
journal dr. pratik copy.pptx
 
Satyajeet rath chemotherapy and hormone therapy in breast cancer
Satyajeet rath chemotherapy and hormone therapy in breast cancerSatyajeet rath chemotherapy and hormone therapy in breast cancer
Satyajeet rath chemotherapy and hormone therapy in breast cancer
 
The renaissance of_endocrine_therapy_in_breast.9
The renaissance of_endocrine_therapy_in_breast.9The renaissance of_endocrine_therapy_in_breast.9
The renaissance of_endocrine_therapy_in_breast.9
 
Hr+ mbc
Hr+ mbc Hr+ mbc
Hr+ mbc
 
Endocrine Therapy In Advanced Breast Cancer
Endocrine Therapy In Advanced Breast CancerEndocrine Therapy In Advanced Breast Cancer
Endocrine Therapy In Advanced Breast Cancer
 
Hormone therapy in beast cancer
Hormone therapy in beast cancerHormone therapy in beast cancer
Hormone therapy in beast cancer
 
Hormonal treatment of metastatic breast cancer dr. abeer elsayed
Hormonal treatment of metastatic breast cancer  dr. abeer elsayedHormonal treatment of metastatic breast cancer  dr. abeer elsayed
Hormonal treatment of metastatic breast cancer dr. abeer elsayed
 
BALKAN MCO 2011 - F. Cardoso - Hormone therapy: best options for pre and post...
BALKAN MCO 2011 - F. Cardoso - Hormone therapy: best options for pre and post...BALKAN MCO 2011 - F. Cardoso - Hormone therapy: best options for pre and post...
BALKAN MCO 2011 - F. Cardoso - Hormone therapy: best options for pre and post...
 
CALGB 9343 -Lumpectomy without Radiation in women >70 years
CALGB 9343 -Lumpectomy without Radiation in women >70 yearsCALGB 9343 -Lumpectomy without Radiation in women >70 years
CALGB 9343 -Lumpectomy without Radiation in women >70 years
 
oncology Hormonal agents.pptx
oncology Hormonal agents.pptxoncology Hormonal agents.pptx
oncology Hormonal agents.pptx
 

More from Dr. Sumit KUMAR

Breast cancer :Receptor (ER/PR/HER2 NEU) Discordance.pptx
Breast cancer :Receptor (ER/PR/HER2 NEU) Discordance.pptxBreast cancer :Receptor (ER/PR/HER2 NEU) Discordance.pptx
Breast cancer :Receptor (ER/PR/HER2 NEU) Discordance.pptx
Dr. Sumit KUMAR
 
EUTHANASIA: WORLD AND INDIAN PERSPECTIVEpptx
EUTHANASIA: WORLD AND INDIAN PERSPECTIVEpptxEUTHANASIA: WORLD AND INDIAN PERSPECTIVEpptx
EUTHANASIA: WORLD AND INDIAN PERSPECTIVEpptx
Dr. Sumit KUMAR
 
advanced stage ovary tumor.pptx
advanced stage ovary tumor.pptxadvanced stage ovary tumor.pptx
advanced stage ovary tumor.pptx
Dr. Sumit KUMAR
 
BREAST CANCER: systemic treatment HER 2 Neu pptx
BREAST CANCER: systemic treatment HER 2 Neu pptxBREAST CANCER: systemic treatment HER 2 Neu pptx
BREAST CANCER: systemic treatment HER 2 Neu pptx
Dr. Sumit KUMAR
 
ovarian cancer: NACT
ovarian cancer: NACTovarian cancer: NACT
ovarian cancer: NACT
Dr. Sumit KUMAR
 
Renal cell carcinoma
Renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma
Dr. Sumit KUMAR
 
Renal cell carcinoma: clinical feature
Renal cell carcinoma: clinical featureRenal cell carcinoma: clinical feature
Renal cell carcinoma: clinical feature
Dr. Sumit KUMAR
 
OSTEORADIONECROSIS.pptx
OSTEORADIONECROSIS.pptxOSTEORADIONECROSIS.pptx
OSTEORADIONECROSIS.pptx
Dr. Sumit KUMAR
 
OVARY CANCER: BORDERLINE
OVARY CANCER: BORDERLINEOVARY CANCER: BORDERLINE
OVARY CANCER: BORDERLINE
Dr. Sumit KUMAR
 
lung cancer: sclc uPTODATE.pptx
 lung cancer: sclc uPTODATE.pptx lung cancer: sclc uPTODATE.pptx
lung cancer: sclc uPTODATE.pptx
Dr. Sumit KUMAR
 
mesothelioma peritoneal.pptx
mesothelioma peritoneal.pptxmesothelioma peritoneal.pptx
mesothelioma peritoneal.pptx
Dr. Sumit KUMAR
 
MESOTHELIOMA (pleural) Management.pptx
MESOTHELIOMA (pleural) Management.pptxMESOTHELIOMA (pleural) Management.pptx
MESOTHELIOMA (pleural) Management.pptx
Dr. Sumit KUMAR
 
Hepatocellular Carcinoma(HCC): Treatment option
Hepatocellular Carcinoma(HCC): Treatment optionHepatocellular Carcinoma(HCC): Treatment option
Hepatocellular Carcinoma(HCC): Treatment option
Dr. Sumit KUMAR
 
Hepatocellular carcinoma: clinical feature.pptx
Hepatocellular carcinoma: clinical feature.pptxHepatocellular carcinoma: clinical feature.pptx
Hepatocellular carcinoma: clinical feature.pptx
Dr. Sumit KUMAR
 
Hepatocellular Carcinoma (HCC): Updated Treatment Approaches in advanced case
 Hepatocellular Carcinoma (HCC): Updated Treatment Approaches in advanced case Hepatocellular Carcinoma (HCC): Updated Treatment Approaches in advanced case
Hepatocellular Carcinoma (HCC): Updated Treatment Approaches in advanced case
Dr. Sumit KUMAR
 

More from Dr. Sumit KUMAR (15)

Breast cancer :Receptor (ER/PR/HER2 NEU) Discordance.pptx
Breast cancer :Receptor (ER/PR/HER2 NEU) Discordance.pptxBreast cancer :Receptor (ER/PR/HER2 NEU) Discordance.pptx
Breast cancer :Receptor (ER/PR/HER2 NEU) Discordance.pptx
 
EUTHANASIA: WORLD AND INDIAN PERSPECTIVEpptx
EUTHANASIA: WORLD AND INDIAN PERSPECTIVEpptxEUTHANASIA: WORLD AND INDIAN PERSPECTIVEpptx
EUTHANASIA: WORLD AND INDIAN PERSPECTIVEpptx
 
advanced stage ovary tumor.pptx
advanced stage ovary tumor.pptxadvanced stage ovary tumor.pptx
advanced stage ovary tumor.pptx
 
BREAST CANCER: systemic treatment HER 2 Neu pptx
BREAST CANCER: systemic treatment HER 2 Neu pptxBREAST CANCER: systemic treatment HER 2 Neu pptx
BREAST CANCER: systemic treatment HER 2 Neu pptx
 
ovarian cancer: NACT
ovarian cancer: NACTovarian cancer: NACT
ovarian cancer: NACT
 
Renal cell carcinoma
Renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma
 
Renal cell carcinoma: clinical feature
Renal cell carcinoma: clinical featureRenal cell carcinoma: clinical feature
Renal cell carcinoma: clinical feature
 
OSTEORADIONECROSIS.pptx
OSTEORADIONECROSIS.pptxOSTEORADIONECROSIS.pptx
OSTEORADIONECROSIS.pptx
 
OVARY CANCER: BORDERLINE
OVARY CANCER: BORDERLINEOVARY CANCER: BORDERLINE
OVARY CANCER: BORDERLINE
 
lung cancer: sclc uPTODATE.pptx
 lung cancer: sclc uPTODATE.pptx lung cancer: sclc uPTODATE.pptx
lung cancer: sclc uPTODATE.pptx
 
mesothelioma peritoneal.pptx
mesothelioma peritoneal.pptxmesothelioma peritoneal.pptx
mesothelioma peritoneal.pptx
 
MESOTHELIOMA (pleural) Management.pptx
MESOTHELIOMA (pleural) Management.pptxMESOTHELIOMA (pleural) Management.pptx
MESOTHELIOMA (pleural) Management.pptx
 
Hepatocellular Carcinoma(HCC): Treatment option
Hepatocellular Carcinoma(HCC): Treatment optionHepatocellular Carcinoma(HCC): Treatment option
Hepatocellular Carcinoma(HCC): Treatment option
 
Hepatocellular carcinoma: clinical feature.pptx
Hepatocellular carcinoma: clinical feature.pptxHepatocellular carcinoma: clinical feature.pptx
Hepatocellular carcinoma: clinical feature.pptx
 
Hepatocellular Carcinoma (HCC): Updated Treatment Approaches in advanced case
 Hepatocellular Carcinoma (HCC): Updated Treatment Approaches in advanced case Hepatocellular Carcinoma (HCC): Updated Treatment Approaches in advanced case
Hepatocellular Carcinoma (HCC): Updated Treatment Approaches in advanced case
 

Recently uploaded

Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
paridubey2024#G05
 
ONYDA XR clonidine liquid preparation by Dr. Amrutha
ONYDA XR clonidine liquid preparation by Dr. AmruthaONYDA XR clonidine liquid preparation by Dr. Amrutha
ONYDA XR clonidine liquid preparation by Dr. Amrutha
Amrutha Gudimetla
 
Prevention of Cruelty to animals act 1960
Prevention of Cruelty to animals act 1960Prevention of Cruelty to animals act 1960
Prevention of Cruelty to animals act 1960
PratibhaSonawane5
 
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptxHow to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
AmandaChou9
 
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Anindya Das Adhikary
 
THE MANAGEMENT OF PROSTATE CANCER . pptx
THE MANAGEMENT OF PROSTATE CANCER . pptxTHE MANAGEMENT OF PROSTATE CANCER . pptx
THE MANAGEMENT OF PROSTATE CANCER . pptx
Bright Chipili
 
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptxPICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
Aloy Okechukwu Ugwu
 
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
ED PIllsForever
 
TEST BANK For Katzung's Basic and Clinical Pharmacology, 16th Edition.docx
TEST BANK For Katzung's Basic and Clinical Pharmacology, 16th Edition.docxTEST BANK For Katzung's Basic and Clinical Pharmacology, 16th Edition.docx
TEST BANK For Katzung's Basic and Clinical Pharmacology, 16th Edition.docx
kevinkariuki227
 
PCD Pharma Franchise For Gynae Products | Infertility Range - Sarthi Life Sci...
PCD Pharma Franchise For Gynae Products | Infertility Range - Sarthi Life Sci...PCD Pharma Franchise For Gynae Products | Infertility Range - Sarthi Life Sci...
PCD Pharma Franchise For Gynae Products | Infertility Range - Sarthi Life Sci...
Sarthi Life Sciences
 
The impact of CD160 deficiency on alloreactive CD8 T cell responses and allog...
The impact of CD160 deficiency on alloreactive CD8 T cell responses and allog...The impact of CD160 deficiency on alloreactive CD8 T cell responses and allog...
The impact of CD160 deficiency on alloreactive CD8 T cell responses and allog...
MARIALUISADELROGONZL
 
Lymphoma Made Easy , New Teaching Lectures
Lymphoma Made Easy , New Teaching LecturesLymphoma Made Easy , New Teaching Lectures
Lymphoma Made Easy , New Teaching Lectures
MiadAlsulami
 
BCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotionsBCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotions
sathya swaroop patnaik
 
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdfYoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
Stuart McGill
 
Surat @Girls @ℂall 👄 XX000000XX 👄 With Cash Payment Home Delivery
Surat @Girls @ℂall 👄 XX000000XX 👄 With Cash Payment Home DeliverySurat @Girls @ℂall 👄 XX000000XX 👄 With Cash Payment Home Delivery
Surat @Girls @ℂall 👄 XX000000XX 👄 With Cash Payment Home Delivery
khandiya#G05
 
intermine.bio2rdf.org : A QLever SPARQL endpoint
intermine.bio2rdf.org : A QLever SPARQL endpointintermine.bio2rdf.org : A QLever SPARQL endpoint
intermine.bio2rdf.org : A QLever SPARQL endpoint
François Belleau
 
High Girls Call Ranchi 000XX00000 Provide Best And Top Girl Service And No1 i...
High Girls Call Ranchi 000XX00000 Provide Best And Top Girl Service And No1 i...High Girls Call Ranchi 000XX00000 Provide Best And Top Girl Service And No1 i...
High Girls Call Ranchi 000XX00000 Provide Best And Top Girl Service And No1 i...
hf66550
 
Pernacious Anamia. payhophysiology..pptx
Pernacious Anamia. payhophysiology..pptxPernacious Anamia. payhophysiology..pptx
Pernacious Anamia. payhophysiology..pptx
Dr. vaishali Kadam
 
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptxOBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
Niranjan Chavan
 
World Population Day 2024_Overview_Dr Bijan Das
World Population Day 2024_Overview_Dr Bijan DasWorld Population Day 2024_Overview_Dr Bijan Das
World Population Day 2024_Overview_Dr Bijan Das
srmnchatripura
 

Recently uploaded (20)

Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
 
ONYDA XR clonidine liquid preparation by Dr. Amrutha
ONYDA XR clonidine liquid preparation by Dr. AmruthaONYDA XR clonidine liquid preparation by Dr. Amrutha
ONYDA XR clonidine liquid preparation by Dr. Amrutha
 
Prevention of Cruelty to animals act 1960
Prevention of Cruelty to animals act 1960Prevention of Cruelty to animals act 1960
Prevention of Cruelty to animals act 1960
 
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptxHow to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
 
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
 
THE MANAGEMENT OF PROSTATE CANCER . pptx
THE MANAGEMENT OF PROSTATE CANCER . pptxTHE MANAGEMENT OF PROSTATE CANCER . pptx
THE MANAGEMENT OF PROSTATE CANCER . pptx
 
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptxPICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
 
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
 
TEST BANK For Katzung's Basic and Clinical Pharmacology, 16th Edition.docx
TEST BANK For Katzung's Basic and Clinical Pharmacology, 16th Edition.docxTEST BANK For Katzung's Basic and Clinical Pharmacology, 16th Edition.docx
TEST BANK For Katzung's Basic and Clinical Pharmacology, 16th Edition.docx
 
PCD Pharma Franchise For Gynae Products | Infertility Range - Sarthi Life Sci...
PCD Pharma Franchise For Gynae Products | Infertility Range - Sarthi Life Sci...PCD Pharma Franchise For Gynae Products | Infertility Range - Sarthi Life Sci...
PCD Pharma Franchise For Gynae Products | Infertility Range - Sarthi Life Sci...
 
The impact of CD160 deficiency on alloreactive CD8 T cell responses and allog...
The impact of CD160 deficiency on alloreactive CD8 T cell responses and allog...The impact of CD160 deficiency on alloreactive CD8 T cell responses and allog...
The impact of CD160 deficiency on alloreactive CD8 T cell responses and allog...
 
Lymphoma Made Easy , New Teaching Lectures
Lymphoma Made Easy , New Teaching LecturesLymphoma Made Easy , New Teaching Lectures
Lymphoma Made Easy , New Teaching Lectures
 
BCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotionsBCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotions
 
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdfYoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
 
Surat @Girls @ℂall 👄 XX000000XX 👄 With Cash Payment Home Delivery
Surat @Girls @ℂall 👄 XX000000XX 👄 With Cash Payment Home DeliverySurat @Girls @ℂall 👄 XX000000XX 👄 With Cash Payment Home Delivery
Surat @Girls @ℂall 👄 XX000000XX 👄 With Cash Payment Home Delivery
 
intermine.bio2rdf.org : A QLever SPARQL endpoint
intermine.bio2rdf.org : A QLever SPARQL endpointintermine.bio2rdf.org : A QLever SPARQL endpoint
intermine.bio2rdf.org : A QLever SPARQL endpoint
 
High Girls Call Ranchi 000XX00000 Provide Best And Top Girl Service And No1 i...
High Girls Call Ranchi 000XX00000 Provide Best And Top Girl Service And No1 i...High Girls Call Ranchi 000XX00000 Provide Best And Top Girl Service And No1 i...
High Girls Call Ranchi 000XX00000 Provide Best And Top Girl Service And No1 i...
 
Pernacious Anamia. payhophysiology..pptx
Pernacious Anamia. payhophysiology..pptxPernacious Anamia. payhophysiology..pptx
Pernacious Anamia. payhophysiology..pptx
 
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptxOBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
 
World Population Day 2024_Overview_Dr Bijan Das
World Population Day 2024_Overview_Dr Bijan DasWorld Population Day 2024_Overview_Dr Bijan Das
World Population Day 2024_Overview_Dr Bijan Das
 

Breast cancer: Post menopausal endocrine therapy

  • 1. z DR SUMIT KUMAR Assistant professor NEIGRIHMS, Shillong
  • 2. z Breast cancer is the most frequently diagnosed cancer and the leading cause of death from cancer in women worldwide. HR-positive (ie, estrogen [ER] and/or progesterone [PR] receptor- positive) breast cancers comprise the most common types of breast cancer, accounting for 75% of all cases. This topic will review adjuvant endocrine therapy for non- metastatic, hormone receptor- positive breast cancer occurring in postmenopausal women.
  • 3. z Definitions of menopause used by the National Comprehensive Cancer Network:  Women 60 years and older are postmenopausal.  Women less than 60 years are postmenopausal if one of the following conditions is met: o They previously underwent a bilateral oophorectomy. o They have not had any menstrual periods for 12 months or more in the absence of tamoxifen, chemotherapy, or ovarian suppression, and the serum estradiol is in the postmenopausal range. o They are amenorrheic on tamoxifen, and follicle-stimulating hormone (FSH) and serum estradiol are in the postmenopausal range.
  • 4. z  Endocrine therapy recommended for postmenopausal women with estrogen receptor- or progesterone receptor-positive breast cancer.  Benefits of endocrine therapy: o Consistently reduces the risk of recurrence and second breast cancers. o Improves overall survival.  Greater benefit for those with higher-risk tumors.  Nearly all postmenopausal women eligible for endocrine therapy, regardless of age.  Special consideration needed for patients with: o Multiple comorbidities. o History of thrombosis, cerebrovascular disease, or osteoporosis. In such cases, the potential benefits of reducing recurrence and death from breast cancer must be weighed against the possible side effects and risks associated with the therapy, especially if the patient has comorbidities.
  • 5. z Preferred option:-  Aromatase inhibitor Anastrozole (1 mg daily) Letrozole (2.5 mg daily) Exemestane (25 mg daily) Alternative option:  Tamoxifen,  Short course of tamoxifen followed by an AI,  Short course of AI followed by tamoxifen, Aromatase inhibitors (AIs) reduce plasma estrogen levels by inhibiting aromatase, the enzyme that converts androgens to estrogens, and require ovarian suppression/ablation in premenopausal women with intact ovarian function or therapy-induced amenorrhea.
  • 6. z Aspect Aromatase Inhibitors Tamoxifen Mechanism of Action Inhibit the peripheral conversion of androgens to estrogen, reducing estrogen levels in the body. Selective estrogen receptor modulator (SERM) that blocks estrogen from binding to breast cancer cells. Indications 1st-line therapy for postmenopausal women with HR-positive breast cancer. In pre-menopausal:-along with OFS Used for both pre and postmenopausal women with HR-positive breast cancer. Clinical Trials ATAC Trial (Arimidex, Tamoxifen, Alone or in Combination): BIG 1-98, and TEAM Trial (Tamoxifen Exemestane Adjuvant Multinational Trial): MA.17 Trial (Maple Leaf): Femara vs. Anastrozole Clinical Evaluation (FACE) Trial NSABP B-14, NSABP B-20, EBCTCG trials, ATLAS Trial (Adjuvant Tamoxifen, Longer Against Shorter. IBIS-I Trial (International Breast Cancer Intervention Study I&II) SOFT Trial (Suppression of Ovarian Function Trial) ATTOM Trial Adverse Effects Common side effects include joint pain, hot flashes, bone density loss, and increased risk of osteoporosis. Common side effects include hot flashes, menstrual changes (in premenopausal women), and an increased risk of uterine cancer and blood clots.
  • 7. z Duration of Therapy Typically prescribed for 5 years as adjuvant therapy. Typically prescribed for 5-10 years as adjuvant therapy, depending on the specific situation. Bone Health May lead to a decrease in bone density, requiring monitoring and potential use of bisphosphonates. Has a positive effect on bone density, reducing the risk of osteoporosis. Uterine Health Generally does not affect the uterus. May increase the risk of endometrial cancer and other uterine issues. Cardiovascular Effects Generally considered safer for the cardiovascular system compared to tamoxifen. May increase the risk of blood clots, which can affect cardiovascular health. Hormone Levels Lowers estrogen levels significantly. Blocks estrogen at breast tissue but can have estrogen-like effects in other tissues. Combination Therapy May be used in combination with other therapies, such as CDK4/6 inhibitors. Can be used in combination with other hormone therapies or chemotherapy.
  • 8. z  AI versus tamoxifen –  Tamoxifen alone versus a short course of tamoxifen followed by an AI Randomised trial (n=9885) 5-yrs course of an AI or tamoxifen AI resulted in : Reduced breast cancer recurrence Lower 10-yr breast cancer mortality Randomised trial (n=11,798) 5-yrs course of tamoxifen vs 2-3 yrs tam F/B AI for 5 yrs Switch to AI resulted in : Reduced breast cancer recurrence(during 2-4 yr) Fewer death from BC
  • 9. z • AI alone versus a short course of tamoxifen followed by an AI • AI alone versus short course of AI followed by tamoxifen – BIG 1-98 trial randomized over 8000 women 5-yrs of tamoxifen or letrozole monotherapy, or sequential treatment with 2yr of one of these drugs followed by 3 yrs of the other Randomised trial (n=12,799) 5-yrs course of an AI vs 2-3 yrs of tamoxifen F/B AI for 5 yr AI alone resulted in : Lower recurrence rate during 0-1 yr Similar recurrence rate during 2-4 yr Reduced BC mortality Outcomes better for letrozole compared with tamoxifen monotherapy no significant difference in either DFS or OS bet. the sequential therapies and letrozole monotherapy
  • 10. z  Evidence suggests similar clinical outcomes and tolerability between the aromatase inhibitors (AIs). As such, anastrozole, exemestane, and letrozole are all appropriate options for those warranting adjuvant treatment with an AI. Individual patients may tolerate one of these agents better than another, and it is reasonable to switch to an alternative AI if the initial AI is poorly tolerated and other strategies of managing side effects have been ineffective [6]. (See 'Side effects' below.)  In the FATA-GIM3 trial, over 1800 women were randomly assigned to oral anastrozole (1 mg per day), exemestane (25 mg per day), or letrozole (2.5 mg per day) for five years [7]. Five-year disease-free survival (DFS) was 90 percent with anastrozole (95% CI 87.9-91.7), 88 percent with exemestane (95% CI 85.8-89.9), and 89 percent with letrozole (95% CI 87.3-91.1). Gastrointestinal side effects were more common with exemestane than with letrozole, and hypercholesterolemia was more frequent with anastrozole and letrozole than with exemestane. All other side effects were similar between the agents. Treatment was interrupted due to toxicity in approximately 7 percent of patients on each of these treatment arms. Trial: FATA-GIM3 Anastrozole Exemestane Letrozole Drug Regimen 1 mg/day 25 mg/day 2.5 mg/day Five-Year Disease- Free Survival (DFS) 90% (95% CI 87.9-91.7) 88% (95% CI 85.8-89.9) 89% (95% CI 87.3-91.1) Common Side Effects - Gastrointestinal side effects more common with exemestane. Hypercholesterolemia more frequent Hypercholesterolemia more frequent Treatment Interruption due to Toxicity Approximately 7% Approximately 7% Approximately 7% table summarizing the key findings from the trial: FATA-GIM3 Trial 1800 pt. compare 5-yr of different AI
  • 11. z  similar five-year DFS rates (85 vs 83 %)  comparable side effect profiles. NCIC-CTG MA.27Trial 7500 pt. compare 5-yr of Exemestane or anastrazole Primary Finding Similar efficacy in terms of DFS between the two groups. No statistically significant difference in DFS. Side Effects Generally well-tolerated with similar side effect profiles. Additional Finding Notable percentage discontinued both exemestane and anastrozole during the study due to adverse events, concomitant illness, or study refusal (32% for exemestane and 29% for anastrozole). FACE Trial compare 5-yr of Letrozole or anastrazole
  • 12. z Common side effect 1. Musculoskeletal Pains and Stiffness (AI-Associated Musculoskeletal Syndrome - AIMSS) 2. Sexual Dysfunction: 3. Loss of Bone Density: 4. Osteoporosis and Fractures: 5. Cardiovascular Disease and Diabetes: 6. Hypercholesterolemia: 7. Hair Thinning: 8. Physical Health 9. Cognitive Problems  AIMSS Symptoms may be severe in almost one- third of patients, and may be responsible for treatment discontinuation in 10 to 20 percent of patients
  • 13. z :  Arthralgia  Joint Stiffness  Bone Pain  Carpal Tunnel Syndrome AI-associated musculoskeletal syndrome (AIMSS) symptoms typically include: Management: a. Exercise: Exercise helps in reducing musculoskeletal symptoms associated with AIs. •HOPE Trial (Randomized Controlled Trial): 121 postmenopausal women with AI- associated arthralgias were randomly assigned to an exercise regimen or usual care. • The exercise regimen consisted of supervised resistance and strength training along with moderate aerobic exercise for 150 minutes per week. • Results: reduction in their worst pain score (20% reduction) and pain severity (21% reduction) compared to the usual care group. • A dose-response relationship between exercise and symptom severity was identified, indicating that greater attendance at exercise sessions correlated with more significant symptom reduction.
  • 14. z b. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): c. Temporary Discontinuation of AI, followed by initiation of a different AI: some patients may benefit from discontinuing the current AI for two to eight weeks and then starting a different AI. This approach may improve symptoms and allow patients to continue with a different AI. d. Duloxetine: an antidepressant, an option for AIMSS management. SWOG S1202 Trial: 299 patients with stage I to III disease on AIs, those randomized to duloxetine experienced improvement in joint pain over 12 weeks of treatment. o Duloxetine dosing: 30 mg daily for 1 week, followed by 60 mg daily for 11 weeks, and then 30 mg daily for 1 week. o Results: Patients on duloxetine showed improvements in joint pain compared to placebo, although results between the groups were similar at 24 weeks. o Duloxetine was relatively well-tolerated, with mostly grade 1 or 2 adverse events. e. Acupuncture: Acupuncture offers a nonpharmacological approach to AIMSS management. One randomized trial showed a small benefit in joint symptoms for patients receiving acupuncture compared to sham acupuncture or waitlist control. F.Switch to tamoxifen, for those who are unable or unwilling to continue treatment with an AI.
  • 15. z Limitations of Tamoxifen Compliance: Resistance: Drug Interactions: such as certain selective serotonin reuptake inhibitors, Side Effects of Tamoxifen:  Thromboembolic Disease: 2- to 3 fold increased relative risk  Strokes:.  Uterine Cancer:  Fatty Liver Disease: Tamoxifen is associated with fatty liver disease.  Hot Flashes: Hot flashes are a common side effect of tamoxifen use.  Vaginal Discharge: Some women may experience vaginal discharge while taking tamoxifen.  Sexual Dysfunction: Tamoxifen may lead to sexual dysfunction in some individuals.  Menstrual Irregularities: Changes in menstrual patterns can occur during tamoxifen therapy.  Increased Risk of Diabetes:
  • 16. z Patient selection –high-risk, node-positive, ER-positive, HER2- negative breast cancer]. NCCN define high-risk as either :  ≥4 positive lymph nodes; or  1 to 3 positive lymph nodes with one or more of the following: o Grade 3 disease, o Tumor size ≥5 cm, or o Ki-67 score of ≥20 percent Duration –Adjuvant abemaciclib therapy, the duration is for two years, typically concurrently with the start of endocrine treatment. CDK 4/6 inhibitors high-risk, node-positive disease Abemaciclib Palbociclib PARP inhibitors high risk, BRCA-mutated cancers Olaparib CDK 4/6 inhibitors, high-risk, node-positive disease (AMEMACICLIB)
  • 17. z 5600 patients HR+ve,HER2-negative high risk EBC (compare Abemaciclib+endo vs endocrine therapy) •Timing of Randomization: • Patients could receive up to 12 weeks of endocrine therapy. • Randomization occurred within 16 months of definitive breast cancer surgery. •Definition of High Risk: • High risk was defined as meeting one of the following criteria: • ≥4 positive lymph nodes • 1-3 positive lymph nodes and at least one of: • Tumor size ≥5 cm • Histologic grade 3 • Central Ki-67 ≥20 percent •Efficacy Results: • Patients receiving abemaciclib and endocrine therapy had improved outcomes compared to those on endocrine therapy alone. • Three-year Invasive Disease-Free Survival (IDFS) rates: 89% vs. 83% • Hazard Ratio (HR) for IDFS: 0.70 (95% CI 0.59-0.82) • Three-year Distant Recurrence-Free Survival rates: 90% vs. 86% • HR for Distant Recurrence-Free Survival: 0.69 (95% CI 0.57-0.83) • Benefit was sustained at four years..
  • 18. z • Subgroup Analysis: • Improvements with abemaciclib were statistically significant in the premenopausal subset. • No statistically significant improvement among postmenopausal women. • Ki-67 Benefit: • The absolute IDFS benefit was more pronounced in the Ki-67 ≥20 percent group. • 7.1 percent benefit in this group compared to 4.5 percent in the Ki-67 <20 percent group. • FDA Approval: • FDA approval for abemaciclib is specifically for tumors with Ki-67 ≥20 percent.  TOXICITY The most frequent AEs were diarrhea, neutropenia, and fatigue in the abemaciclib arm and arthralgia, hot flush, and fatigue in the control arm. A higher incidence of grade ≥3 AEs was observed with versus without abemaciclib (50 vs 16 %, respectively). 5600 patients HR+ve,HER2-negative high risk EBC (compare Abemaciclib + endo vs endocrine therapy)
  • 19. z  Olaparib for select high risk, BRCA-mutated cancers — Olaparib has regulatory approval by the FDA for the adjuvant treatment of adult patients with deleterious or suspected deleterious germline BRCA-mutated, HER2- negative, high-risk early breast cancer who have been treated with neoadjuvant or adjuvant chemotherapy Pallas study Addition of 2 yr Palbociclib to adj endocrine No improve IDFS PENELOPE-B trial Addition of 1 yr Palbociclib to adj endocrine No improve IDFS
  • 20. z  Women treated with adjuvant endocrine therapy are treated for a minimum duration of five years, with extended therapy offered to some with higher-risk features.  Rationale for extended treatment in some patients Observational data suggests that the risk of distant recurrence in ER-positive breast cancer patients after five years of adjuvant endocrine therapy continues steadily for at least the subsequent 20 years. This provides a rationale for considering extended endocrine treatment in some patients. Meta-analysis of 88 trials 62,923 women with ER+VE disease free after 5 years of scheduled endocrine therapy Danish Breast Cancer Group database 20,000 patients who were survivors 10 years after diagnosis riginal Lymph Node Status Annual Risk of Distant Recurrence Many positive nodes Nearly 3% per year One to three positive nodes Approx. 2% per year Negative nodes but T2 or greater lesions Approx. 1% per year Node-negative and smaller tumors Approx. 0.5 to 1.0% per year Time After Diagnosis (Years) Cumulative Incidence of Late Recurrence 15 years 8.5% 20 years 12.5% 25 years 15.2% 32 years 16.6%
  • 21. z  Extended adjuvant ET beyond 5-yrs is an option for all patients with a prior history of invasive, ER+VE BC.  Some data suggest that longer durations of ET improve DFS, if not OS .  Larger tumors or node-positive disease, extended ET has clear cut benefit.  Smaller, node-negative tumors, the benefits are less clear and, for some, may not outweigh the risk of toxicities.  Patient selection is crucial for balancing benefits and risks.  RISK of recurrence may be assess by ; o PAM50 and Endopredict (Effective at identifying node-positive patients at low risk for late recurrence). o Oncotype DX Recurrence Score or Breast Cancer Index (Genomics-only assays). o Clinical Treatment Score post-5 years (CTS5):. (CTS5):Not recommended by ASCO Tumor Marker Guidelines for Early Breast Cancer Panel.
  • 22. z  Women treated with tamoxifen –  After 5 yrs of tamoxifen, either continuing tamoxifen or switching to an AI for an additional 5 yrs.  No head to head comparision between tamoxifen and AI in extended ET.
  • 23. z OUTCOME EXTENDED ARM CONTROL ARM Breast cancer recurrence 617(3428) 711(3418) Breast cancer mortality 331 397 Reduced overall mortality 639 722 Cumulative risk of recurrence during yr 5–14 21.4% 25.1% Breast cancer mortality during years 5–14 12.2% 15.0% Cumulative risk of endometrial cancer during years 5–14 3.1% 1.6% TOXICITY  STROKE  PULMONARY EMBOLUS  IHD  BONE FRACTURE 130 41 126 62 119 21 163 70 continuing adjuvant tamoxifen to 10 years versus stopping at 5 years outcomes among the 6846 women (absolute mortality reduction 2·8%).
  • 24. z
  • 25. z Outcome Extended arm Control arm breast cancer recurrence 580/3468 672/3485 breast cancer mortality deaths after recurrence 392 443 overall mortality (deaths) 849 910 endometrial cancers 102 45 endometrial cancers deaths 37 (1.1%) 20(0.6%) 6,953 women with early breast cancer. continuing adjuvant tamoxifen to 10 years versus stopping at 5 years
  • 26. z MA.17, 5000 postmenopausal patients who had completed a 5-year course of tamoxifen were randomly assigned to a 5-year course of letrozole or placebo. • Letrozole was associated with an improvement in DFS compared with placebo and an improvement in OS National Surgical Adjuvant Breast and Bowel Project (NSABP) B-33, exemestane as extended endocrine treatment after 5 years of tamoxifen • resulted in improvement in recurrence-free survival. In a separate trial, postmenopausal women who remained recurrence free after a two- to three-year course of tamoxifen subsequent five years of letrozole versus letrozole for two to three years • experienced modestly improved 12- year DFS (67 vs 62 %).
  • 27. z  Some data suggest that for women completing 5 yrs of an AI, an additional five years of AI improves recurrence-free survival; however, OS is not improved.  For women who complete a five-year course of AI after any duration of prior tamoxifen. MA.17R trial Approx 1900 post menopausal women compare the efficacy of extended adjuvant therapy with letrozole vs. placebo after completing 5 yr of AI Aspect Extended Letrozole Placebo 5-Year Disease-Free Survival (DFS) 95% (95% CI 93-96%) 91% (95% CI 89-93%) Contralateral Breast Cancer Rate Reduced with letrozole (0.21% 0.49% Bone-Related Toxic Effects Bone pain Fracture New-onset osteoporosis 18% 14% 11% 14% 9% 6%  NSABP-B42, the DATA trial, and the IDEAL trial have not confirmed any improved DFS .
  • 28. z  If extended endocrine therapy is chosen in patients with low-risk cancers, an additional 2 years of treatment is appropriate (for a total of 7 years of treatment).  The benefits of a total of 10 versus 7 years of endocrine therapy are small, if any, in women with low-risk cancers, and the risks of adverse events persist.. SOLE trial(Study of Letrozole Extension) Evaluate continuous vs intermittent AI(nine months each year, followed by a three-month break) Key Findings No significant difference in DFS between the two treatment schedules. Intermittent schedule, better tolerated by patients.
  • 29. z Challenges in Adjuvant Therapy Continuation:  A significant percentage of women discontinue adjuvant endocrine therapy.  Restarting adjuvant therapy has shown promise in improving disease-free survival (DFS). Observations Supporting Restarting Adjuvant Therapy:. Swedish Registry Study (2005-2008):Among 3071 women on adjuvant endocrine therapy, 48% discontinued treatment for at least 3 months.  65% of those who discontinued restarted adjuvant therapy, while 35% did not.  Women who restarted adjuvant therapy had significantly improved DFS (eight-year DFS, 89.8% vs. 82.0%). SOLE Trial (Aromatase Inhibition): Women reaching five years on adjuvant aromatase inhibition without recurrence were assigned to continuous extended AI therapy vs. AI for nine months/year.  No difference in event-free survival or overall survival.  Alternating arm reported superior quality of life. Implications: Restarting adjuvant therapy can offer improved outcomes in terms of DFS.
  • 30. z  Adjuvant chemotherapy plus trastuzumab followed by endocrine therapy (plus maintenance trastuzumab) should be administered to these women. The use of endocrine therapy plus trastuzumab (without chemotherapy) remains investigational and should be done only as part of a clinical trial.
  • 31. z  Some studies suggest a potential association between higher BMI and worse breast cancer outcomes.  Evidence from Post-Hoc Analyses: 1. ATAC Trial Analysis (Postmenopausal Women): 1. 4900 postmenopausal women. 2. BMI >35 kg/m² Compare with <23 kg/m2 at baseline associated with: 1. Greater risk of recurrence (21% vs. 14%) 2. BIG 1-98 Trial Analysis (Postmenopausal Women): 1. 4700 women assigned to tamoxifen or letrozole. 2. Obesity associated with compared with : 1. Trends toward increased recurrence (30% vs. 25%) 2. Trends toward increased all-cause mortality (21% vs. 15%)
  • 32. z Patients with cardiac risk factors  AIs appear to be associated with a long-term increased risk of cardiovascular disease compared with tamoxifen . Patients with mucinous or tubular/cribriform histologies — • Mucinous or tubular/cribriform histotypes have a better prognosis and therefore may derive a smaller absolute risk reduction from endocrine therapy compared with patients with other breast cancer histologies, though they would still benefit a similar chemoprotective effect against a second breast cancer.  tamoxifen was associated with nonsignificant trends towards improved disease-free survival and overall survival compared with letrozole Subset analysis of the BIG 1-98 trial including 183 women with mucinous or tubular/cribriform histologies
  • 33. z Estrogen receptor (ER)- and/or progesterone receptor (PR)-positive breast cancers comprise the most common type of breast cancer, accounting for 75 percent of all breast cancers. For patients with hormone receptor-positive breast cancer, adjuvant endocrine therapy An aromatase inhibitor (AI) rather than tamoxifen as adjuvant endocrine treatment For women who wish to discontinue an AI, it would be reasonable to switch to tamoxifen. Incorporation of abemaciclib For patients with hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative, node- positive breast cancer at high risk of recurrence,
  • 34. z Duration of endocrine treatment –at least a five-year course of treatment (Grade 1A • For women with higher-risk disease (eg, stage II or stage III disease),extended endocrine treatment (Grade 2B), For patients with high-risk disease, a total duration between 7 and 10 years is appropriate. For women with smaller, node-negative tumors (ie, stage I disease), it is not clear that there is a sufficiently high risk of late recurrence to justify the side effects and risks of extended endocrine therapy. Initiate endocrine therapy after chemotherapy has completed (ie, sequentially) rather than concurrently with chemotherapy. Adjuvant radiation therapy (RT) for breast cancer, endocrine therapy may be initiated concurrently with RT or sequentially, following the completion of RT.
  • 35. z