Omission of Surgery among Postmenopausal Women with Breast Cancer

Omission of Surgery among Postmenopausal Women with Breast Cancer

Take-Home Message:

Using endocrine therapy alone to treat postmenopausal women with estrogen receptor (ER) positive breast cancer results in worse survival compared to treating with surgery.

Omission of surgery in older women with early breast cancer has an adverse impact on breast cancer-specific survival

Ward, S. E. et. al. BJS 2018;105:1454-1463

In the United Kingdom (UK), rates of surgery for women over 70 with operable breast cancer are lower than in the United States (US): rates are 60-88% in the UK versus over 90% in the US. The investigators noted that breast cancer related survival in the UK is lower than in other developed countries. This difference is more pronounced in older age groups. The reduced survival persists across cancer stages, leading the group to surmise that one cause of the discrepancy is suboptimal cancer treatment. They sought to determine if the reduced surgery and reduced survival rates were related.

Two national registries, which collected data over a 9-year period, were accessed. Over 18,000 cases of women aged 70 and older were reviewed. For women with ER-positive breast cancer, five-year breast cancer-specific survival was 69.4% for those treated with endocrine therapy alone and 89.9% for those who underwent surgery as well as endocrine therapy. This significant difference persisted regardless of breast cancer stage. The group did note that the underlying health status of each woman was unknown. This means that mortality rates may have been influenced by factors other than breast cancer or breast cancer treatment. However, as the evaluation was for breast cancer-specific (and not overall) survival, it is expected that the results would be the same as if the health status of each woman were known.

This study’s results support the idea that older women with operable ER-positive breast cancer will do better with surgery than with endocrine therapy alone. Some older women (and their providers) may believe that their life expectancies are so low that surgery will not benefit them. This data challenges that thinking. This study adds to the understanding that surgery for early stage breast cancer should be considered as first-line therapy, balancing its risks and benefits against a woman’s overall health status and priorities.