Editor's Note: With the global aging population, treatment strategies for breast cancer patients over 70 years old have garnered increasing attention. At the 2024 SABCS conference, a patient-level meta-analysis conducted by the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) addressed the impact of immediate versus delayed surgery on outcomes in operable breast cancer patients aged 70+ (Abstract No.: LB1-01). The study highlighted that, for operable breast cancer patients over 70 who did not receive radiotherapy, immediate surgery significantly reduced local recurrence rates and positively influenced long-term survival. This research not only provides robust evidence for treatment decision-making in elderly breast cancer patients but also prompts a reevaluation of therapeutic strategies for this population. Oncology Frontier invited Dr. Baoliang Guo from The Second Affiliated Hospital of Harbin Medical University to provide insightful commentary on this study.01
Oncology Frontier: Could you briefly summarize the key findings of the study “LB1-01: Immediate breast surgery versus deferral of surgery in women aged 70+ years with operable breast cancer: patient-level meta-analysis of the three randomized trials among 1,082 women”?
Dr. Baoliang Guo: This meta-analysis by the EBCTCG explored the effects of immediate versus delayed surgery on local recurrence, distant metastasis, and survival in operable breast cancer patients aged 70 and above. The study pooled data from three randomized clinical trials, including 1,082 patients who received at least five years of tamoxifen (TAM) treatment without radiotherapy, with a median follow-up of five years. The primary endpoints were local recurrence, distant recurrence, and mortality, with stratification based on axillary lymph node status.
The results demonstrated that among 655 patients with negative axillary lymph nodes, those treated with tamoxifen alone had a five-year local recurrence rate of 45.4%, compared to 14.4% in those who received tamoxifen combined with surgery, yielding an absolute five-year benefit of 31%. For the 262 patients with positive axillary lymph nodes, the five-year local recurrence rates were 48.1% for tamoxifen alone and 6.8% for tamoxifen with surgery, with an absolute benefit of 41.3%.
Moreover, multivariate analysis revealed that immediate surgery significantly reduced the local recurrence rate, lowering it by three-quarters regardless of tumor characteristics, with statistically significant differences. Long-term follow-up also showed that patients in the immediate surgery group had lower rates of distant recurrence and breast cancer mortality.
The study concluded that, in the absence of radiotherapy, immediate surgery significantly reduces local recurrence rates in the first five years and halves distant recurrence and breast cancer mortality rates beyond five years. Although the clinical impact on distant recurrence within the initial years appeared limited, these findings offer valuable insights for designing trials aimed at reducing or de-escalating surgery and radiotherapy.
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Oncology Frontier: The meta-analysis showed that immediate surgery significantly reduces local recurrence rates and positively impacts long-term survival in early breast cancer patients aged 70 and above. How do you interpret the clinical significance of these findings, particularly for elderly breast cancer patients over 70 years old?
Dr. Baoliang Guo: This study provides valuable clinical guidance. Among the defined population—patients aged 70 and above with hormone receptor-positive breast cancer not receiving radiotherapy—immediate surgery significantly improves the five-year local recurrence rate, regardless of axillary lymph node involvement. Long-term follow-up also revealed improvements in distant recurrence and survival rates. Therefore, immediate surgery holds clinical importance in eligible patients and could address the current underutilization of surgery in elderly breast cancer patients.
For patients over 70, if they can tolerate surgery following comprehensive evaluation, immediate surgery should be actively recommended, coupled with tailored endocrine therapy postoperatively. From a surgical perspective, in cases of low-burden, hormone receptor-positive early-stage breast cancer in elderly patients, axillary lymph node management can also reference related guideline recommendations.
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Oncology Frontier: Based on the results of this study, should operable breast cancer patients aged 70 and above undergo immediate surgery or consider delayed surgery? What other factors should be considered in treatment planning?
Dr. Baoliang Guo: According to the findings of this meta-analysis, immediate surgery should be prioritized for eligible patients, followed by appropriate endocrine therapy. However, treatment decisions should not be rigid but rather made based on a comprehensive evaluation. Key factors to consider include the patient’s vital organ function, physical condition, risk of complications from anesthesia and surgery, the molecular and biological characteristics of the tumor, sensitivity and tolerance to endocrine therapy, and the patient’s adherence to treatment. Additionally, the impact of comorbidities on survival in elderly breast cancer patients must be assessed. If a shorter life expectancy is anticipated and the short-term benefits of treatment are minimal, the risks and benefits should be carefully weighed before making clinical decisions.
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Oncology Frontier: What limitations do you see in this meta-analysis? What further research is needed in this field to improve treatment strategies?
Dr. Baoliang Guo: Firstly, as a meta-analysis pooling data from three randomized trials, patient selection bias may exist. Secondly, the survival benefits of local treatment comparisons require long-term follow-up to detect, while confounding factors such as deaths from other causes in elderly patients might impact the final analysis. Moreover, the drug used in this study (tamoxifen) is no longer the first-line endocrine therapy, and the study did not include patients receiving radiotherapy (the NSABP B-06 trial demonstrated that whole-breast adjuvant radiotherapy reduces cumulative recurrence and improves survival). These factors might influence the prognosis evaluation.
Currently, only partial data from the study have been published, and the full text is yet to be released. Detailed analyses of patient characteristics, median age, surgical approaches, and axillary lymph node status are still needed. Furthermore, the subsequent treatment adjustments following disease progression on tamoxifen or post-surgery management strategies significantly impact prognosis, but the study has not provided detailed data on these aspects.
Looking ahead, more prospective randomized controlled trials (RCTs) are necessary to validate these findings. However, conducting studies in elderly patients poses considerable challenges. Therefore, prioritizing real-world studies may be more practical, offering greater therapeutic support for elderly breast cancer patients.
Dr. Baoliang Guo
- Director, Department of Breast Surgery II, Second Affiliated Hospital of Harbin Medical University
- Chief Physician, Professor, Doctoral Supervisor
- Member, Breast Cancer Expert Committee, Chinese Society of Clinical Oncology (CSCO)
- Member, Breast Cancer Professional Committee, China Anti-Cancer Association
- Standing Member, Breast Disease Professional Committee, Chinese Medical Education Association
- Member, Breast Disease Training Expert Committee, Chinese Medical Doctor Association
- Member, MDT Professional Committee, Chinese Medical Doctor Association Surgery Branch
- Chairperson, Youth Committee, Breast Disease Branch, Heilongjiang Medical Association
