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Recommendation
Initial adjuvant endocrine therapy – Postmenopausal women
Offer an aromatase inhibitor as the initial adjuvant endocrine therapy for postmenopausal women with lobular cancer or ER-positive breast cancer who are at intermediate or high risk of recurrence. Offer tamoxifen or aromatase inhibitors to postmenopausal women who are at low risk of recurrence. Offer tamoxifen if aromatase inhibitors are not tolerated or are contraindicated.
Offer an aromatase inhibitor as the initial adjuvant endocrine therapy for postmenopausal women with ER-positive invasive breast cancer who are at medium or high risk of disease recurrence. Offer tamoxifen to women who are at low risk of disease recurrence, or if aromatase inhibitors are not tolerated or are contraindicated
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How this guidance was developed
This recommendation was adapted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted to July 2008 and used wording (‘Offer’) indicative of a strong recommendation (using GRADE methods) by the source guideline authors. The source recommendation was adapted with the addition of ‘lobular cancer’. Also, there was some concern that the source recommendation does not reflect that many researchers and guidelines (e.g. CCO 2014; ASCO 2018) recommend that adjuvant endocrine therapy in postmenopausal women with ER-positive early breast cancer should include an aromatase inhibitor (AI). Studies consistently demonstrate the use of an AI alone or sequentially after tamoxifen therapy, compared with tamoxifen alone, reduces the risk of recurrence and improves disease-free survival rate. However, it is also noted that the absolute gain in breast cancer endpoints is generally small and that these gains are higher for patients with higher-risk cancer.
The guidelines also note that tamoxifen alone may be appropriate in some patients. It is generally recognised that the risk-to-benefit ratio of using tamoxifen and AIs must be taken into account.
The source recommendation was therefore adapted to incorporate the option for AIs as the initial therapy in postmenopausal women at low as well as intermediate or high risk of recurrence.
Initial adjuvant endocrine therapy – Postmenopausal women
Recommendation
Offer an aromatase inhibitor as the initial adjuvant endocrine therapy for postmenopausal women with lobular cancer or ER-positive breast cancer who are at intermediate or high risk of recurrence. Offer tamoxifen or aromatase inhibitors to postmenopausal women who are at low risk of recurrence. Offer tamoxifen if aromatase inhibitors are not tolerated or are contraindicated.
Principles in action
Patient-centred care
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Safe and quality care
Useful Links
This recommendation was adapted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted to July 2008 and used wording (‘Offer’) indicative of a strong recommendation (using GRADE methods) by the source guideline authors. The source recommendation was adapted with the addition of ‘lobular cancer’. Also, there was some concern that the source recommendation does not reflect that many researchers and guidelines (e.g. CCO 2014; ASCO 2018) recommend that adjuvant endocrine therapy in postmenopausal women with ER-positive early breast cancer should include an aromatase inhibitor (AI). Studies consistently demonstrate the use of an AI alone or sequentially after tamoxifen therapy, compared with tamoxifen alone, reduces the risk of recurrence and improves disease-free survival rate. However, it is also noted that the absolute gain in breast cancer endpoints is generally small and that these gains are higher for patients with higher-risk cancer.
The guidelines also note that tamoxifen alone may be appropriate in some patients. It is generally recognised that the risk-to-benefit ratio of using tamoxifen and AIs must be taken into account.
The source recommendation was therefore adapted to incorporate the option for AIs as the initial therapy in postmenopausal women at low as well as intermediate or high risk of recurrence.