PracticeUpdate: Haematology & Oncology

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EDITORIAL
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EMON121601
PracticeUpdate Oncology Advisory Board member Jeffrey
Kirshner MD, FACP, and breast cancer treatment expert and
advocate for breast cancer patients, Lillie Shockney RN, BS,
MAS, discuss their top stories in oncology for 2016, focusing on
breast cancer – aromatase inhibitors and survival rates.
Aromatase inhibitors in
breast cancer
By Jeffrey Kirshner MD, FACP
Although the increasing indications
and usage of checkpoint inhibitors
for multiple malignancies
continues to be a “top story,” I have
chosen another “story,” which arguably
may affect even more patients presently.
Oncologists are now offering an
additional 5 years of aromatase inhibitor
(AI) therapy (for a total of 10 years)
to patients receiving these drugs as
adjuvant therapy for early-stage breast
cancer. This recommendation is based
on the initial results of the MA.17R
study, which was the first presentation
at the ASCO Annual Meeting Plenary
Session in June 2016 (Goss PE et al,
MA.17R, Abstract LBA1). Study results
were immediately presented online in
The New England Journal of Medicine
and subsequently published as a lead
article the following month (N Engl
J Med 2016;375:209-219). In this
international, multi-institutional study,
over 1900 women were randomised
to an additional 5 years of letrozole
versus placebo (after completing an
initial 5 years of letrozole and remaining
disease-free). At a median follow-up of
over 6 years, letrozole-treated patients
had 67 “events” as opposed to 98 in
the placebo group. This translated to
an improvement in 5-year disease-
free survival from 91% to 95%. There
were fewer local–regional and distant
recurrences in the treatment group and
fewer cancers in the contralateral breast.
To date, there has been no difference in
overall survival. As expected, the patients
randomised to additional letrozole had a
slightly higher incidence of bone pain,
fractures, and new-onset osteoporosis.
There were no unexpected adverse
events in the treatment group.
This story is particularly important
because of the number of patients
that it affects. There are hundreds of
thousands of women receivingAI therapy
at the present time in the United States
(and many more worldwide!). Most
practicing general oncologists see these
patients on a daily basis and need to
present these data to their patients at
some point. They will have to discuss
the pros and cons of whether to extend
AI therapy to 10 years. It is not always
a straightforward decision. One must
take into account individual prognostic
factors, comorbidity, life expectancy,
bone health, and, of course, each
patient’s wishes. Even though extended
therapy has not affected overall survival
(yet!), decreasing recurrences and
fewer new breast cancers are obviously
important goals.
Is 10 years ofAI therapy the new standard
of care for postmenopausal women with
early-stage breast cancer? I would argue
that it should be considered, taking into
account the aforementioned factors;
but, ultimately, the decision should be
made by the patient with advice from
her oncologist.
Of course, many questions remain,
including: Do we consider restarting
AI in patients who had completed their
treatment several years earlier? Are there
certain high-risk patients who should
continue AI beyond 10 years? Do the
patients who have had tamoxifen prior
to their 5 years of AI benefit as much
as those who did not receive tamoxifen?
We all anxiously await results from the
NSABP B-42 study, which had a very
similar design. Further breakdown and
follow-up of these two studies will
enable us to make even better decisions
regarding the use of extendedAI therapy.
2016 Top Stories in Oncology