Should we treat our Chinese elderly breast cancer patients with surgery or primary hormonal therapy?

Abstract

Background/Objective: Primary hormonal therapy has been used as an alternative to primary surgery for elderly with estrogen receptor-positive breast tumors. Such practices are less commonly performed in Asian countries, and the response to primary hormonal therapy in Chinese cohort is still lacking. This study aims to evaluate the clinical outcome of primary hormonal therapy and compared that to those who received primary surgery in Chinese elderly patients. Methods: Chinese patients aged 70 and above with Stage I to III, estrogen receptor-positive breast cancer treated in a university-affiliated hospital from 2006 to 2015 were retrospectively reviewed. A 1:2 case match comparison of the overall survival of patients treated with primary hormonal therapy to those who were treated surgically was performed, using propensity score case-match analysis to adjust for confounding factors. The time to response and time to progression of primary hormonal therapy was also recorded. Results: There were 334 patients who fulfilled the inclusion criteria during the study period. Of these, 249 patients received primary operation followed by adjuvant therapy if indicated, whereas 85 patients were treated by primary hormonal therapy. The mean follow-up time was 56.5 months. Those patients treated with primary hormonal therapy were older (mean age 84.22 vs 75.87, p=0.000) and presented with larger tumors (T1 32.5% vs 62.3%, T2 52.0% vs 31.7%, T3 9.1% vs 2.4%, T4 6.5% vs 3.6%, p=0.000) than the operated group. There is no difference in terms of N stage, grading, and HER2 status. A 1:2 case match analysis was performed adjusting the confounding effect of age and T stage. In the first 2 years after treatment, the 2 groups had similar survival (p=0.367). The survival curves diverged after 3 years. Those patients with operation performed had a significantly better outcome than those treated with primary hormonal therapy (p=0.002) [Figure]. Among the 85 patients treated with primary hormonal therapy, 7 patients (8.2%) had clinical complete response. Twenty-nine patients (34.1%) had partial response, and 45 patients (52.9%) had stable disease. The median time to response is 4 months (range 1-15 months). A total of 41 patients (48.2%), with or without prior response, eventually had progression of disease. The median time to progression is 24 months (range 3-68 months). There was no significant difference in time to response and time to progression between patients on tamoxifen or aromatase inhibitor. Conclusions: For frail elderly patients with limited life expectancy of less than 2 years, primary hormonal therapy alone may be appropriate since equivalent survival can be achieved for primary hormonal therapy with or without surgery. Those patients with longer life expectancy may gain survival benefits from local treatment. A comprehensive geriatric assessment is useful to predict the survival probability and guide the optimal treatment.