Primary Endocrine Therapy vs Upfront Surgery for Older Women With Estrogen Receptor-Positive Breast Cancer: A Systematic Review and Meta-Analysis.
Neil Carleton, Jian Zou, Yangyang Mu et al.
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In 30 seconds
This systematic review and meta-analysis compared primary endocrine therapy (pET) with upfront surgery for operable, nonmetastatic, estrogen receptor-positive breast cancer in older women. It included 29 studies—6 randomised trials and 23 observational cohorts—with 22,821 patients and an overall median age of 83.1 years. In the randomised trials, pET was not associated with a statistically significant overall-survival difference versus surgery (HR, 1.14; 95% CI, 0.98-1.33), although the point estimate favored surgery. Observational findings linked more durable disease control under pET to favorable tumor biology.
Key findings
- Across randomised trials, overall survival did not differ significantly between pET and surgery (HR, 1.14; 95% CI, 0.98-1.33).
- Median time to progression ranged from 19.7 months (range, 13.5-26.0 months) in tumor biology-unselected, tamoxifen-era cohorts to more than 50 months in ER-selected, aromatase inhibitor-treated cohorts.
- Tumor biology was consistently associated with progression risk in observational cohorts.
Why it matters
The findings suggest that chronological age alone is an inadequate basis for considering pET. Although pooled trial evidence did not show a statistically significant overall-survival difference, the observational evidence indicates that disease control with pET varies with tumor biology. Assessing tumor characteristics alongside frailty may therefore help frame treatment discussions for older patients while acknowledging uncertainty in comparative outcomes.
What to keep in mind
The randomised trials spanned 5 decades and differed in tumor biology criteria. Observational cohorts were not pooled for comparative survival because of susceptibility to confounding by indication.