What additional therapy is appropriate for an 85-year-old woman with a 5 mm stage one, low-grade invasive tubular carcinoma, strongly ER positive, PR positive, with a history of osteoporosis treated with Reclast (zoledronic acid), and prior endometrial Stromal Sarcoma?

From the Guidelines

For this 85-year-old woman with a small, low-grade, hormone receptor-positive breast cancer, the recommended additional therapy would be endocrine therapy alone, specifically an aromatase inhibitor such as anastrozole 1 mg daily or letrozole 2.5 mg daily for 5 years. Given the patient's age and the tumor characteristics (small size, low grade, strongly ER/PR positive), endocrine therapy is likely to provide sufficient benefit while minimizing risks associated with more aggressive treatments. Aromatase inhibitors are preferred over tamoxifen in postmenopausal women due to their superior efficacy and different side effect profile, as supported by the 2019 study by the American Society of Clinical Oncology 1.

The patient's history of osteoporosis should be considered when initiating aromatase inhibitor therapy, as these medications can further decrease bone density. Regular bone density monitoring and continuation of osteoporosis management (e.g., calcium and vitamin D supplementation) is crucial, as recommended by the European Society for Medical Oncology in 2015 1. The prior Reclast treatment may provide some protection, but reassessment of bone health is warranted.

The history of endometrial stromal sarcoma does not directly impact the breast cancer treatment decision but emphasizes the importance of ongoing surveillance for both cancers. This approach balances the goal of reducing recurrence risk with the need to maintain quality of life in an older patient, considering her overall health status and prior medical history. The use of aromatase inhibitors has been shown to have a favorable quality of life profile, with minimal differences in symptoms such as hot flushes, musculoskeletal pain, and sleep disturbance compared to continuous therapy, as reported in the SOLE study 1.

Key considerations in the management of this patient include:

• Regular follow-up visits every 3-4 months in the first 2 years, every 6 months from years 3-5, and annually thereafter, as recommended by the European Society for Medical Oncology in 2015 1
• Annual ipsilateral and/or contralateral mammography with ultrasound
• Regular bone density evaluation and management of osteoporosis
• Ongoing surveillance for both breast cancer and endometrial stromal sarcoma
• Consideration of lifestyle factors, such as regular exercise and weight management, to improve prognosis and quality of life.

From the FDA Drug Label

Postmenopausal women with early breast cancer scheduled to be treated with anastrozole should have their bone status managed according to treatment guidelines already available for postmenopausal women at similar risk of fragility fracture Bisphosphonate treatment preserved bone density in most patients at risk of fracture

For an 85-year-old woman with a history of osteoporosis treated with Reclast (zoledronic acid), continuation of bisphosphonate therapy is appropriate to manage her bone status while being treated with an aromatase inhibitor like anastrozole for her breast cancer. Additionally, hormonal therapy with an aromatase inhibitor such as anastrozole is appropriate for her ER and PR positive breast cancer. However, given her history of endometrial stromal sarcoma, close monitoring for uterine malignancies is necessary if tamoxifen is considered as an alternative. 2 3 3

• Key considerations:
  • Bone health management with bisphosphonates
  • Hormonal therapy with an aromatase inhibitor
  • Close monitoring for uterine malignancies if tamoxifen is used

From the Research

Additional Therapy for 85-year-old Woman with Invasive Tubular Carcinoma

The patient's condition involves a 5 mm stage one, low-grade invasive tubular carcinoma that is strongly ER positive and PR positive, with a history of osteoporosis treated with Reclast (zoledronic acid) and prior endometrial Stromal Sarcoma. Considering the provided studies, the following points are relevant:

• The patient's tumor is small (5 mm) and low-grade, which suggests an indolent nature, similar to the tumors described in the studies 4, 5, 6.
• The tumor's strong ER and PR positivity indicates that hormone therapy may be effective, but this is not directly addressed in the provided studies.
• The patient's history of osteoporosis and treatment with Reclast (zoledronic acid) is not directly relevant to the management of the breast cancer, but it may be important to consider when evaluating the patient's overall health and potential treatment options.
• The prior endometrial Stromal Sarcoma is a significant aspect of the patient's medical history, but the provided studies do not address the management of breast cancer in patients with a history of other cancers.

Potential Treatment Options

Based on the provided studies, the following potential treatment options may be considered:

• Observation or expectant management, as described in study 7, may be appropriate for small, low-grade tumors, but this approach would require careful monitoring and regular follow-up.
• Surgical excision or biopsy may be necessary to confirm the diagnosis and evaluate the tumor's biology, as described in study 4.
• Hormone therapy may be effective for tumors that are ER and PR positive, but this is not directly addressed in the provided studies.

Key Considerations

When evaluating treatment options for this patient, the following factors should be considered:

• The patient's age (85 years) and overall health status, including the history of osteoporosis and prior endometrial Stromal Sarcoma.
• The tumor's small size (5 mm) and low-grade nature, which suggests an indolent course.
• The tumor's strong ER and PR positivity, which may indicate a response to hormone therapy.
• The potential risks and benefits of different treatment options, including observation, surgical excision, and hormone therapy.