Tumour grade on core biopsy and evidence of axillary involvement on ultrasound predicts response in elderly co-morbid patients treated with primary hormone therapy for oestrogen receptor positive breast carcinoma

IntroductionTreatment of women with oestrogen-receptor positive breast cancer who are high risk for general anaesthetic remains controversial. Current guidance is based on studies pre-dating aromatase inhibitors (AIs) which may have also included hormone-receptor negative patients. Such studies have demonstrated improved disease-free survival and local disease control following surgery when compared with primary hormone therapy (PHT) alone. However uncertainty persists regarding benefit of surgery over optimal hormone treatment in patients with significant co-morbidity.MethodRetrospective cohort study comparing efficacy of PHT in oestrogen-receptor positive breast cancer patients considered unsuitable for surgery. Co-morbidity was scored retrospectively using the Charlson Index. Overall survival and disease specific survival were noted and multivariate analysis performed to identify predictors of treatment failure.Results106 patients treated for breast cancer at Southampton University Hospital with PHT without surgery were identified (Mean age 84.1 years, range 48–101). 94.3% had a probability of 10 year survival of 2.25% or less according to the age-weighted Charlson score. Kaplan–Meier analysis demonstrated a four-year survival of 30% and breast cancer specific survival of 60%. Cox proportional hazards model demonstrated high-grade disease (grade III vs. grade I/II: HR = 2.007; 95% Confidence Interval (CI) = 1.004–4.014. P = 0.049) and ultrasound axillary staging (indeterminate/definite lymphatic involvement vs. no involvement: HR = 1.944; 95% CI = 1.010–3.742. P = 0.047) independently predicted early failure of PHT.ConclusionA high proportion of elderly and comorbid patients die with breast cancer rather than from breast cancer. Elderly comorbid patients who initially respond to primary hormone therapy have a less than 30% incidence of delayed treatment failure during their life time; however patients with grade III disease or an abnormal axillary ultrasound are twice as likely to fail first choice PHT.