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Recommendations for use of Endocrine therapy

Statements of evidence

STATEMENTS LEVEL OF EVIDENCE20 REFERENCE
In women with hormone receptor-positive advanced breast cancer:
Endocrine therapy is preferred for women with hormone receptor-positive advanced breast cancer in preference to chemotherapy except in the presence of rapidly progressive visceral disease I Cochrane 20034
Endocrine therapy shows no significant difference in overall survival compared with chemotherapy I Cochrane 20034
Incidence of adverse events including nausea, vomiting and alopecia is less frequent with endocrine therapy compared with chemotherapy I Cochrane 20034
In pre-menopausal women with hormone receptor-positive advanced breast cancer:
Combination of luteinising hormone-releasing hormone (LH-RH) agonist and tamoxifen shows significant benefit in overall survival, progression-free survival and overall response rate compared with LH-RH agonist alone I Klijn 20012
Combination of LH-RH agonist and tamoxifen shows significant benefit in overall survival, progression-free survival and overall response rate compared with tamoxifen alone III Klijn 20005
Incidence of hot flushes is significantly higher in women treated with combined tamoxifen and LH-RH agonist compared with tamoxifen alone III Klijn 20005
There are insufficient data to guide the use of third generation aromatase inhibitors in combination with functional ovarian ablation/suppression or fulvestrant in pre-menopausal women
In post-menopausal women with hormone receptor-postive advanced breast cancer:
Combination of aromatase inhibitors and trastuzumab in women with HER2-positive hormone dependent advanced breast cancer leads to improved progression-free survival compared with aromatase inhibitors alone II NBCC21 *
First-line therapy
Third generation aromatase inhibitorsa show no significant difference in overall survival compared with tamoxifen I NBOCC3 *
Third generation aromatase inhibitorsb show significant benefit in progression-free survival compared with tamoxifen I NBOCC3 *
Third generation aromatase inhibitorsc show significant benefit in overall response rate compared with tamoxifen I NBOCC3 *
Adverse events
Overall incidence of adverse events is not significantly different between third generation aromatase inhibitors and tamoxifen I NBOCC3 *
Incidence of thromboembolic events and vaginal bleeding is significantly lower with third generation aromatase inhibitors compared with tamoxifen I NBOCC3 *
Incidence of arthralgia, diarrhoea, dyspnoea, hot flushes, and nausea is not significantly different with third generation aromatase inhibitors compared with tamoxifen I NBOCC3 *
Quality of life
There are insufficient data to indicate any differences in quality of life between third generation aromatase inhibitors and tamoxifen    

a Trials relate to anastrozole
b Trials relate to anastrozole, letrozole
c Trials relate to anastrozole, exemestane, letrozole

STATEMENTS LEVEL OF EVIDENCE20 REFERENCE
Second-line therapy
(following progression on tamoxifen)
Third generation aromatase inhibitorsc show significant benefit in overall survival and progression-free survival compared with progestinsd I NBOCC3 *
Third generation aromatase inhibitorsc show no significant difference in overall response rate compared with progestins I NBOCC3 *
Third generation aromatase inhibitors show no significant difference in overall survival compared with fulvestranta II NBOCC3 *
Third generation aromatase inhibitors show no significant difference in progression-free survival and overall response rate compared with fulvestrante I NBOCC3 *
Adverse events
Overall incidence of adverse events is not significantly different with third generation aromatase inhibitors compared with progestins I NBOCC3 *
Incidence of dyspnoea is significantly lower with third generation aromatase inhibitors compared with progestins I NBOCC3 *
Incidence of nausea, hot flushes and diarrhoea is significantly higher with third generation aromatase inhibitors compared with progestins I NBOCC3 *
There are no significant differences in the incidence of thromboembolic events, vaginal bleeding and arthralgia between third generation aromatase inhibitors and progestins I NBOCC3 *
Quality of life
Where reported there is conflicting evidence about quality of life and no firm conclusions can be drawn II NBOCC3 *
Aromatase inhibitor vs aromatase inhibitor
There are insufficient data to indicate a significant difference in overall survival, progression free survival or overall response rate for one aromatase inhibitor over another aromatase inhibitor

a Trials relate to anastrozole
c Trials relate to anastrozole, exemestane, letrozoled
d Trials relate to megastrol acetate
e Trials relate to anastrozole and exemestane
f For trial details please see table 1

* In February 2008, National Breast Cancer Centre (NBCC), incorporating the Ovarian Cancer Program, changed its name to National Breast and Ovarian Cancer Centre (NBOCC). In July 2011, NBOCC amalgamated with Cancer Australia to form a single national agency, Cancer Australia, to provide leadership in cancer control and improve outcomes for Australians affected by cancer.

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