Is adjuvant hormone therapy indicated for a patient with pTis (pathological Tis) N0 (lymph node 0) M0 (distant metastasis 0) Lvi (lymphovascular invasion) 0, estrogen receptor positive (ER+) and progesterone receptor positive (PR+)?

From the Guidelines

Adjuvant hormone therapy is not typically indicated for patients with pTisN0M0 (ductal carcinoma in situ, DCIS) breast cancer, even with positive estrogen and progesterone receptors, as the primary treatment approach includes surgical excision with clear margins, often followed by radiation therapy. The standard treatment for DCIS focuses on local therapy to reduce the risk of recurrence or progression to invasive disease. While DCIS is often hormone receptor positive, the benefit of endocrine therapy is small, and the potential side effects must be considered. According to the guidelines for hormone receptor-positive breast cancer, endocrine therapy is primarily recommended for patients with metastatic or invasive disease 1. In the context of DCIS, the guidelines do not support the routine use of adjuvant hormone therapy. However, in specific cases with high-risk features or strong patient preference, tamoxifen or an aromatase inhibitor could be considered after discussing the modest benefit-to-risk ratio. This decision should be individualized based on the patient's age, comorbidities, and personal preferences regarding the small absolute risk reduction versus potential side effects. Some key points to consider when making this decision include:

• The patient's menopausal status, as this may influence the choice of hormone therapy 1
• The presence of any high-risk features, such as large tumor size or high-grade disease
• The patient's overall health and potential for side effects from hormone therapy
• The patient's personal preferences and values regarding the potential benefits and risks of adjuvant hormone therapy.

From the FDA Drug Label

Anastrozole tablets are indicated for adjuvant treatment of postmenopausal women with hormone receptor-positive early breast cancer. Tamoxifen citrate tablets are indicated for the treatment of node-positive breast cancer in women following total mastectomy or segmental mastectomy, axillary dissection, and breast irradiation The estrogen and progesterone receptor values may help to predict whether adjuvant tamoxifen therapy is likely to be beneficial.

The patient has pTisN0M0 Lvi0 ER+ PR+, which indicates a non-invasive breast cancer (ductal carcinoma in situ) with positive estrogen and progesterone receptors.

• The patient's cancer is hormone receptor-positive, which suggests that adjuvant hormone therapy may be beneficial.
• However, the patient's cancer is non-invasive (pTis) and node-negative (N0), which may affect the decision to use adjuvant hormone therapy. Based on the information provided, adjuvant hormone therapy may be considered for this patient, but the decision should be made on an individual basis, taking into account the patient's specific clinical characteristics and preferences 2 3.

From the Research

Adjuvant Hormone Therapy Indication

• The patient has a diagnosis of pTisN0M0 Lvi0 ER+ PR+, indicating a non-invasive breast cancer with positive estrogen and progesterone receptors.
• According to the studies, adjuvant hormone therapy is beneficial for patients with hormone receptor-positive breast cancer 4, 5.
• Aromatase inhibitors, such as anastrozole, letrozole, and exemestane, have been shown to be effective in reducing the risk of recurrence in postmenopausal women with hormone receptor-positive breast cancer 4, 6, 5.
• The choice of adjuvant hormone therapy depends on various factors, including the patient's menopausal status, tumor characteristics, and medical history.
• For postmenopausal women, aromatase inhibitors are a viable option, with studies showing improved disease-free survival and overall survival compared to tamoxifen 5.
• The patient's specific situation, including their menopausal status and medical history, should be taken into account when deciding on adjuvant hormone therapy.

Treatment Options

• Aromatase inhibitors, such as anastrozole or letrozole, for 5 years 5.
• Tamoxifen for 5 years, although aromatase inhibitors have been shown to be more effective in reducing the risk of recurrence 4, 5.
• Sequential therapy with tamoxifen followed by an aromatase inhibitor, such as anastrozole or exemestane, for a total of 5 years 5.

Monitoring and Side Effects

• Patients receiving aromatase inhibitors should be monitored for changes in bone mineral density and cardiovascular disease risk factors and outcomes 5.
• The patient should be informed about the potential side effects of adjuvant hormone therapy, including hot flashes, osteoporosis, and cardiovascular disease.