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    • Twenty six of the patients had an early

    2019-05-13

    Twenty-six of the 98 patients had an early discontinuation due to recurrence: there were 14 patients with distant atr inhibitor and 12 with local recurrence. Most distant metastatic events (71.4%) occurred within the initial two years. Of the other 72 patients with early discontinuation of ET, only seven patients (9.7%) had well-documented ET-related adverse events in the medical records, 24 patients (33.3%) refused to take ET but remained in follow-up, 9 patients (12.5%) were attributed to other medical conditions, and 32 patients (44.4%) were lost in follow-up before a complete ET period (Table 3).
    The tolerance and choices of the initial endocrine agent Of the 197 patients who initiated ET with tamoxifen, the completion rate was 57.6%. Thirty-five patients (17.3%) switched to AI from six months to three years after tamoxifen initiation. Fifteen (44.1%) of the patients with switch were attributed to tamoxifen-related thromboembolic events (stroke, angina, or deep vein thrombosis) or endometrial thickening/vaginal spotting. When patients switched to AI, the completion rate was significantly higher, 79.4% vs. 53.3% for patients with upfront tamoxifen treatment (p = 0.005 by the Chi-square test). Among the patients taking aromatase inhibitor as the initial treatment, the completion rate was 57.6% (Table 3).
    Discussion The completion rate of adjuvant endocrine therapy in HR-positive breast cancer in our study was 49.4%, which was similar to previous studies. After patients were excluded for refusing to initiate ET, the overall completion rate further increased. We generally have observed that cancer patients with poor prognostic factors might exhibit improved medical compliance because of the awareness of a potentially poor outcome. To our surprise, this perception was not observed in our elderly patients. In fact, some of the elderly patients might be less concerned about a poor cancer-related outcome due to limited life expectancy; therefore, they were reluctant to adhere to a pill regimen for five years. Further, the completion rate among patients with known systemic disease was not significantly lower than those without such a disease. We can hypothesize that oral ET was tolerable to elderly patients with systemic comorbidities, so comorbidities were not a determinant factor to adherence of oral ET. What\'s more, the completion of chemotherapy did not correlate to an adherence with oral ET. As we had believed, the toxicity profile of chemotherapy, like fatigue, neutropenia, diarrhea or microsites, was less favored than that of oral ET. We can conclude that those patients that tolerated adjuvant chemotherapy but not oral ET should not be attributed to the adverse events of oral ET but were likely due to a poor insight of its survival benefits. On the contrary, patients who went through a five-week radiotherapy demonstrated a significant higher completion rate of oral ET. We suggested that the patients with a complete radiotherapy had a greater probability of continuing a “long but durable” treatment like oral ET. Therefore, for elderly patients who cannot complete or refuse adjuvant radiotherapy, we should undertake greater efforts to emphasize the importance and benefits of oral ET. The switch therapy in our study showed a significantly higher completion rate than upfront tamoxifen treatment. In the upfront group, we noted that some patients could undertake ET, even if ET-related adverse event occurred, while others could not. This can be explained by the wide variety of frailties and comorbidities among elderly patients. However, in the complete treatment group with switch therapy, the identified tamoxifen-related adverse events exceeded the upfront ones. Therefore, were elderly patients in the switch group healthier than their counterparts in the upfront tamoxifen group? Although we did not show such a similarity by way of the Charlson comorbidity index and performance status in this study, the higher completion rate could be explained by a kind of “mental comfort” with the switch therapy. Once tamoxifen-related adverse events occurred, Stringent response could recur again if patients continued taking the same drug. However, patients were willing to go on ET with another agent, like AI in this study, believing they would not encounter another tamoxifen-related adverse events yet still retain the survival benefits. This could explain why the completion rate was higher in the switch therapy than in the tamoxifen upfront group. According to the BIG 1–98 study, switch therapy presented similar survival benefits with letrozole upfront therapy, regardless of the nodal status. We can concluded that, since the switch therapy in our study showed a higher completion rate, elderly people would derive more survival benefits from switch therapy than upfront therapy.