Breast Cancer Treatment in Postmenopausal WomenPurdue University School of Nursing

Rachel Noyes, Emily Gress, Kendra Merkel, and Julie Walton

Purpose Results

Conclusion/ Recommendations

Sample

Methods

PICO Question

In postmenopausal women, how does chemotherapy compared to hormone replacement therapy affect the treatment of breast

cancer?

Population: Postmenopausal womenIntervention: Chemotherapy/hormone replacement therapyComparison: Chemotherapy vs. hormone therapy as an

effective treatmentOutcome: Treatment of breast cancer

Our purpose is to determine whether chemotherapy or hormone replacement therapy is more effective in the treatment of breast

cancer in postmenopausal women.

Postmenopausal women receiving treatment for breast

cancer.

Method: review of literature Databases searched: PubMed

6 articles retained

ChemotherapyEndocrine Therapy

Combined Therapy

Citation Purpose Sample Design & Rank Measurement Results/ConclusionsGuth, U., Myrick M. E., Kilic N., Eppenberger-Castori, S., Schmid, S. M. (2011). Compliance and persistence of endocrine adjuvant breast cancer therapy, Breast Cancer Res Treat, 131, 491-499.

To evaluate compliance and persistence in adjuvant endocrine breast cancer therapy by clearly analyzing reasons of therapy cessation by differentiating clinical meaningful situations

N= 685Women who had HR-positive nonmetastatic invasive breast cancer who received surgical therapy divided into three age dependent groups: 30-49 years, 50-64 years, and 65-80 years

Multi-experimental group; VI

Follow up of the patients and a clear description of and discrimination between different reasons of therapy cessation to clearly define the frequency of non-persistence

42 patients refused endocrine therapy, patients younger than 50 years (P < 0.001) and those who received adjuvant chemotherapy and radiotherapy (each <0.001) were more likely to refuse therapy. 567 patients initiated endocrine therapy and at the 36 month follow up, 412 fully completed the targeted therapy. 82 patients discontinued therapy due to other health barriers. 73 patients were non-persistent to therapy.

Hashimoto, K., et. al. (2012) Immunohistochemical detection of breast cancer stem cells in hormone receptor-positive breast cancer and their role in response to endocrine therapy and clinical outcome. Oncology, 82, 168-174.

To clarify the role of stem cells in relation with endocrine therapy in hormone receptor-positive breast cancer

N=99histological confirmation of primary stage IV, female breast cancer, no history of chemotherapy or endocrine therapy before biopsy, endocrine therapy received between 1999 and 2008 as first-line treatment, availability of formalin-fixed paraffin-embedded biopsy samples, and estrogen receptor (ER) or progesterone receptor (PgR) positivity

Quasi-Experimental; VII Evaluation of the primary tumor was done at every visit at 2- to 4-month intervals. Imaging was done using the same modality used before treatment when tumor growth was suspected by physical examination, symptoms or tumor marker

The response rate to endocrine therapy for CD44+CD24– breast cancer was 29%, while that for other cancers was 30% (p = 0.56). The clinical benefit rate to endocrine therapy for CD44+CD24– breast cancer was 61.9%, compared with 63% (p = 0.58) for the others

Jones, E. L., Leak, A., & Muss, H. B. (2012). Adjuvant therapy of breast cancer in women 70 years of age and older: tough decisions, high stakes, Oncology, 26(9).

To decipher which adjuvant therapy is most effective in breast cancer treatment of women 70 years of age and older

N = 769Women age 50 and older with pathologic T1 or T2 invasive cancers, negative margins, and pathologically negative axillary lymph nodes       

N= 636Women age 70 and older with lumpectomy-treated T1, HR+, clinically or pathologically node-negative tumors

Randomized control trial; V            

Randomized control trial; V

Relapse rates among subjects            

Follow-up of the incidence of locoregional recurrence and survival

The 5-year local relapse rate was 0.6% in the radiation plus tamoxifen group and 7.7% for those receiving tamoxifen alone (P<.05). Tamoxifen in women 70 years and older dramatically lowers the annual risk of recurrence of breast cancer by 51% and the annual odds of dying of breast cancer 37%    

After median follow-up of 10.5 years, the incidence of locoregional recurrence was 2% in the tamoxifen and radiation group compared with 9% in the tamoxifen-alone group. Breast cancer-specific survival was 98% for the tamoxifen-alone goup and 96% for the tamoxifen and radiation group, and while all-cause mortality was 43%, the vast majority of deaths were due to non-breast cancer causes

Mieog, J. S. D., Morden, J. P., Bliss, J. M., Coombes, R. C., van de Velde, C. J. H. (2012). Carpal tunnel syndrome and musculoskeletal symptoms in postmenopausal women with early breast cancer treated with exemestane or tamoxifen after two to three years of tamoxifen: a retrospective analysis of the intergroup exemestane study, Lancet Oncol, 13, 420-432.

To assess risk factors and the prognostic value of musculoskeletal symptoms during treatment with the steroidal aromatase inhibitor exemestane or with tamoxifen after two to three years of tamoxifen.

N=4724Patients randomly assigned to exemestane or tamoxifen

Randomized control trial; V

Case report forms and questionnaires were distributed retrospectively to gain more details of cases

Patients that were treated with tamoxifen or exemestane after two or three years of tamoxifen for breast cancer showed an increased risk for carpal tunnel syndrome and musculoskeletal problems

Muss, H. B., et. al. (2009). Adjuvant chemotherapy in older women with early-stage breast cancer, The New England Journal of Medicine.

Studying the tolerance of chemotherapy vs. capecitabine in older women with breast cancer.

N=633 Eligible women were 65 years of age or older and had operable, histologically confirmed adenocarcinoma of the breast, with a performance status of 0 to 2 and a tumor diameter that was more than 1 cm

Experimental Design; VI Rates of relapse-free survival, relapse, overall survival, and death, as well as the causes of death Adverse events that were possibly, probably, or definitely related to treatment.

This trial shows that standard adjuvant chemotherapy with either CMF or doxorubicin plus cyclophosphamide is superior to capecitabine in older women with early-stage breast cancer. The benefit of standard chemotherapy was pronounced in women with hormone-receptor–negative tumors.

Tager, F. A., McKinley, P. S., Schnabel, F. R., El-Tamer, M., Cheung, Y. K. K., Fang, Y., Golden, C. R., Frosch, M. E., Habif, U., Mulligan, M. M., Chen, I. S., Hershman, D. L. (2009). The cognitive effects of chemotherapy in postmenopausal breast cancer patients; a controlled longitudinal study

To investigate cognitive effects of chemotherapy in postmenopausal women treated for early stage breast cancer as compared with women diagnosed with DCIS who are not treated with chemotherapy

N= 61Women ages 45-70 who were diagnosed with non-metastatic breast cancer who were receiving treatment at Columbia University Medical Center. Exclusion criteria included prior exposure to chemotherapy

Controlled longitudinal study; VII

Neuropsychological tests used before and after chemotherapy

Women who were not treated with chemotherapy improved more on motor tasks as compared with women receiving chemotherapy. There is no evidence supporting a cognitive decline.

From extensive research, findings support chemotherapy followed by endocrine therapy for breast cancer treatment in

postmenopausal women to be more effective than either treatment alone. The benefits of combined therapy outweigh the benefits of either chemotherapy or endocrine therapy as the only treatment.