Endocrine Treatments
Late diagnosis and substandard local and systemic therapies are common in elderly breast cancer patients, which is only partially and indirectly ‘compensated’ by more indolent tumour behaviour due to more favourable biological characteristics. Of these, the higher frequency of tumours expressing oestrogen or progesterone receptors (OR or PgR) makes endocrine treatment an ideal first choice for the majority of elderly breast cancer patients in the metastatic as well as adjuvant setting, assuming the high likelihood of potentially hormone-sensitive tumour status in this population.

The last update of the meta-analysis of the Early Breast Cancer Trialists’ Collaborative Group has recently validated these results in adjuvant setting with a high efficacy of tamoxifen preserved in the elderly contrary to chemotherapy. With the arrival of aromatase inhibitors challenging tamoxifen with 5% of extra absolute benefit in reducing the risk of cancer recurrence in post-menopausal women, one might have speculated that the prescription of aromatase inhibitors, upfront or sequentially following tamoxifen, would entirely replace the wellestablished schedule of an anti-oestrogen given for five years. It is clear that, unlike tamoxifen, aromatase inhibitors are not associated with an increased risk of thromboembolism or uterine cancer. The incidence of fractures and arthralgias is, however, increased among women taking these compounds, and some serious cardiac events have been reported more frequently, for example with letrozole. Unfortunately, data derived from published trials are limited for the elderly population, in whatever setting. Although most of the aromatase inhibitors adjuvant trials allowed inclusion of women without an age limit, the median age is usually around 65, below the ‘standard’ or ‘conventional’ 70-year-old threshold, and the proportion of patients over the age of 65–70 represent less than 25–30% of the population. In the largest trial ever conducted in such a post-menopausal population (ATAC), anastrozole was better tolerated than tamoxifen, with fewer serious adverse events. However, the analysis was not done according to age, and no conclusion can be easily drawn among the elderly as a specific subset. In another large trial (MA-17), the benefit conferred by the use of the aromatase inhibitor loses its significance beyond age 60. Although limited, some other data question the potential negative impact of aromatase inhibitors on cognitive functions in relation to the induction of a deep oestrogen deficiency. Thus, added to the challenge of compliance of oral treatments, the available literature precludes drawing any firm conclusions on the advantages and disadvantages of aromatase inhibitors over tamoxifen in the elderly, making longer follow-up with specific subgroup analysis necessary and eagerly awaited.