Can De-Escalation of Adjuvant Therapy Be Considered for Older Adults with Breast Cancer?

AbstractThe trimodal approach of lumpectomy, radiotherapy, and endocrine therapy may represent overtreatment for certain older patients with early-stage breast cancer. Treatment guidelines permit adjuvant endocrine monotherapy, based on older randomized trials comparing adjuvant endocrine therapy with radiotherapy versus without radiotherapy. There are limited data on radiotherapy with endocrine therapy versus without endocrine therapy, and therefore, the incremental benefits versus burdens of endocrine therapy, specifically in older (≥70 years of age) women with favorable-risk breast cancer are unknown. With the routine use of molecular genomic assays that identify low-risk breast cancer and advances in radiotherapy delivery that have reduced treatment burden, many older women might consider radiotherapy alone without endocrine therapy if offered. This article reviews the relevant literature and proposes a trial to inform the de-escalation of adjuvant therapy in older patients with estrogen receptor-positive, human epidermal growth factor receptor type 2-negative breast cancer.