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Recommendation
Ovarian function suppression – Use of GnRH agonist #1
For premenopausal women with ER-positive breast cancer at higher risk of recurrence, consider ovarian function suppression with a gonadotrophin releasing hormone (GnRH) agonist in addition to endocrine therapy (tamoxifen or aromatase inhibitors), noting that a GnRH agonist must be used with aromatase inhibitors.
- Consider ovarian function suppression in addition to endocrine therapy for premenopausal women with ER-positive invasive breast cancer
- Discuss the benefits and risks of ovarian function suppression in addition to endocrine therapy with premenopausal women with ER-positive invasive breast cancer. Explain to women that ovarian function suppression may be most beneficial for those women who are at sufficient risk of disease recurrence to have been offered chemotherapy
- The addition of a GnRH agonist (or ovarian ablation) to tamoxifen or an aromatase inhibitor is indicated in patients at higher risk of relapse. (Level of evidence – I)
- AIs without ovarian function suppression contraindicated in premenopausal women. (Level of evidence – I)
Strong evidence for efficacy with a substantial clinical benefit, strongly recommended
A "moderate" rating was assigned if the consensus was less than 90%
How this guidance was developed
This recommendation was adapted from the NICE 2018 guidelines (UK). Two source recommendations were merged and simplified by omitting ‘explain to women that ovarian function suppression may be most beneficial for those women who are at sufficient risk of disease recurrence to have been offered chemotherapy’. Both source recommendations were based on a systematic review conducted to September 2017 and used wording ('Consider') indicative of a conditional recommendation (using GRADE methods). This recommendation was further adapted by merging with the ESO-ESMO 2017/2020 recommendation (graded 'A' using ACCP methods) that aromatase inhibitors without ovarian function suppression are contraindicated in young women.
The recently released ASCO 2020 guideline on the management of male breast cancer is noted. This guideline, based on a systematic review of the evidence to 20 September 2019, indicates that ‘Men with hormone receptor-positive breast cancer who are candidates for adjuvant endocrine therapy but have a contraindication to tamoxifen may be offered GnRH and an aromatase inhibitor’ (Type: formal consensus; Evidence quality: low; Strength of recommendation: moderate).
Related guidance by topic
Ovarian function suppression – Use of GnRH agonist #1
Recommendation
For premenopausal women with ER-positive breast cancer at higher risk of recurrence, consider ovarian function suppression with a gonadotrophin releasing hormone (GnRH) agonist in addition to endocrine therapy (tamoxifen or aromatase inhibitors), noting that a GnRH agonist must be used with aromatase inhibitors.
Principles in action
Patient-centred care
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Safe and quality care
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Multidisciplinary care
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Care coordination
This recommendation was adapted from the NICE 2018 guidelines (UK). Two source recommendations were merged and simplified by omitting ‘explain to women that ovarian function suppression may be most beneficial for those women who are at sufficient risk of disease recurrence to have been offered chemotherapy’. Both source recommendations were based on a systematic review conducted to September 2017 and used wording ('Consider') indicative of a conditional recommendation (using GRADE methods). This recommendation was further adapted by merging with the ESO-ESMO 2017/2020 recommendation (graded 'A' using ACCP methods) that aromatase inhibitors without ovarian function suppression are contraindicated in young women.
The recently released ASCO 2020 guideline on the management of male breast cancer is noted. This guideline, based on a systematic review of the evidence to 20 September 2019, indicates that ‘Men with hormone receptor-positive breast cancer who are candidates for adjuvant endocrine therapy but have a contraindication to tamoxifen may be offered GnRH and an aromatase inhibitor’ (Type: formal consensus; Evidence quality: low; Strength of recommendation: moderate).
Related guidance by topic
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