Patterns of Care in Patterns of Care in Medical OncologyMedical Oncology

Adjuvant Endocrine Therapy

What endocrine therapy, if any, wouldWhat endocrine therapy, if any, wouldyou recommend for a you recommend for a 55-year-old 55-year-old

postmenopausalpostmenopausal woman with a 1.2-cm, woman with a 1.2-cm, Grade II, ER-positive, PR-positive, HER2-Grade II, ER-positive, PR-positive, HER2-

negative tumor with negative tumor with 3 positive nodes3 positive nodes??

2005 2006 2007

Clinical investigators (CI)

Al alone 82% 89% 84%

Tamoxifen for 5 years, then switch to an AI

2% 0% 2%

Tamoxifen for 2-3 years, then switch to an AI

16% 9% 14%

Other 0% 2% 0%

What endocrine therapy, if any, wouldWhat endocrine therapy, if any, wouldyou recommend for a you recommend for a 55-year-old 55-year-old

postmenopausalpostmenopausal woman with a 1.2-cm, woman with a 1.2-cm, Grade II, ER-positive, PR-positive, HER2-Grade II, ER-positive, PR-positive, HER2-

negative tumor with negative tumor with 3 positive nodes3 positive nodes??

2005 2006 2007

Practicing oncologists (PO)

Al alone 80% 80% 84%

Tamoxifen for 5 years, then switch to an AI

8% 4% 6%

Tamoxifen for 2-3 years, then switch to an AI

8% 9% 5%

Other 4% 7% 5%

What endocrine therapy, if any, wouldWhat endocrine therapy, if any, wouldyou recommend for a you recommend for a 35-year-old 35-year-old woman with awoman with a

1.2-cm, Grade II, ER-positive, PR-positive,1.2-cm, Grade II, ER-positive, PR-positive,HER2-negative tumor with HER2-negative tumor with 3 positive nodes3 positive nodes??

2005 2006 2007

Clinical investigators (CI)

Tamoxifen + LHRH agonist or ovarian ablation

20% 16% 38%

Tamoxifen for 5 years, then switch to an AI*

9% 11% 24%

Tamoxifen for 5 years, then no further treatment

47% 42% 12%

AI + LHRH agonist or ovarian ablation

22% 18% 12%

Tamoxifen for 2-3 years, then switch to an AI*

0% 0% 12%

Other 2% 13% 2%

* If patient becomes postmenopausal

2005 2006 2007

Practicing oncologists (PO)

Tamoxifen + LHRH agonist or ovarian ablation

20% 21% 19%

Tamoxifen for 5 years, then switch to an AI*

10% 13% 24%

Tamoxifen for 5 years, then no further treatment

52% 37% 18%

AI + LHRH agonist or ovarian ablation

6% 11% 17%

Tamoxifen for 2-3 years, then switch to an AI*

4% 6% 15%

Other 8% 12% 7%

* If patient becomes postmenopausal

What endocrine therapy, if any, wouldWhat endocrine therapy, if any, wouldyou recommend for a you recommend for a 35-year-old 35-year-old woman with awoman with a

1.2-cm, Grade II, ER-positive, PR-positive,1.2-cm, Grade II, ER-positive, PR-positive,HER2-negative tumor with HER2-negative tumor with 3 positive nodes3 positive nodes??

* If patient becomes postmenopausal

What endocrine therapy, if any, would you What endocrine therapy, if any, would you recommend for a woman with a 1.2-cm, recommend for a woman with a 1.2-cm,

Grade II, ER-positive, PR-positive, HER2-Grade II, ER-positive, PR-positive, HER2-negative, negative, node-negativenode-negative tumor? tumor?

Age 35, premenopausal

Tamoxifen for 5 years, then no further treatment

52% 36%

Tamoxifen for 5 years, then switch to an AI*

24% 29%

Tamoxifen for 2-3 years, then switch to an AI*

12% 13%

Tamoxifen + LHRH agonist or ovarian ablation

12% 15%

Other/no endocrine therapy 0% 7%

Clinical investigators Practicing oncologists

What endocrine therapy, if any, would you What endocrine therapy, if any, would you recommend for a woman with a 1.2-cm, recommend for a woman with a 1.2-cm,

Grade II, ER-positive, PR-positive, HER2-Grade II, ER-positive, PR-positive, HER2-negative, negative, node-negativenode-negative tumor? tumor?

Age 55, postmenopausal

Anastrozole alone 51% 69%

Letrozole alone 20% 14%

Tamoxifen for 2-3 years, then switch to an AI

25% 7%

Tamoxifen for 5 years, then switch to an AI

0% 5%

Other 4% 5%

Clinical investigators Practicing oncologists

2002 2005 2007

Practicing oncologists (PO)

Anastrozole 39% 72% 69%

Letrozole 3% 0% 14%

Exemestane 0% 2% 3%

Tamoxifen 58% 26% 14%

What endocrine therapy do you generally What endocrine therapy do you generally recommend for postmenopausal women recommend for postmenopausal women

with ER-positive, HER2-negative,with ER-positive, HER2-negative,node-negative tumors?node-negative tumors?

When you use an aromatase inhibitor (AI)When you use an aromatase inhibitor (AI)as initial adjuvant therapy, whatas initial adjuvant therapy, what

percent is with each AI? percent is with each AI?

2005 2006 2007

Clinical investigators (CI)

Anastrozole 86% 75% 61%

Letrozole 11% 22% 35%

Exemestane 3% 3% 4%

When you use an aromatase inhibitor (AI)When you use an aromatase inhibitor (AI)as initial adjuvant therapy, whatas initial adjuvant therapy, what

percent is with each AI? percent is with each AI?

2005 2006 2007

Practicing oncologists (PO)

Anastrozole 86% 71% 67%

Letrozole 11% 23% 27%

Exemestane 3% 6% 6%

What percent of your patients onWhat percent of your patients onadjuvant AIs have significant adjuvant AIs have significant arthralgiasarthralgias to tothe point that you the point that you consider discontinuing orconsider discontinuing or

switching agentsswitching agents??

2005 2006 2007

Clinical investigators (CI)

Mean 10% 11% 12%

Practicing oncologists (PO)

Mean 5% 8% 9%

What action would you take initiallyWhat action would you take initiallywhen you consider discontinuing orwhen you consider discontinuing or

switching agents with patients who haveswitching agents with patients who havesignificant arthralgias?significant arthralgias?

Switch to another AI 82% 76%

Switch to tamoxifen 8% 20%

Discontinue hormonal therapy 0% 0%

Other 10% 4%

Clinical investigators Practicing oncologists

What percent of your patients on adjuvant What percent of your patients on adjuvant AIs have significant AIs have significant vasomotor symptomsvasomotor symptomsto the point that you to the point that you consider interventions consider interventions

such as SSRI antidepressantssuch as SSRI antidepressants??

2005 2006 2007

Clinical investigators (CI)

Mean 25% 23% 16%

Practicing oncologists (PO)

Mean 18% 19% 15%

What action would you take initially when What action would you take initially when you consider interventions with the patients you consider interventions with the patients who have significant vasomotor symptoms?who have significant vasomotor symptoms?

Continue therapy and add an SSRI 85% 79%

Switch to another AI 4% 15%

Switch to tamoxifen 0% 4%

Discontinue hormonal therapy 0% 1%

Other 11% 1%

Clinical investigators Practicing oncologists

What endocrine therapy, if any, would youWhat endocrine therapy, if any, would yourecommend for a 65-year-old woman with a 1.2-cm, recommend for a 65-year-old woman with a 1.2-cm, Grade II, ER-positive, PR-positive, HER2-negative Grade II, ER-positive, PR-positive, HER2-negative

tumor with 3 positive nodes who tumor with 3 positive nodes who completed 5 yearscompleted 5 yearsof tamoxifenof tamoxifen 1 year ago1 year ago??

2005 2006 2007

Clinical investigators (CI)

Start letrozole 88% 93% 96%

Start anastrozole 2% 2% 2%

Use no further hormonal therapy 10% 5% 2%

What endocrine therapy, if any, would youWhat endocrine therapy, if any, would yourecommend for a 65-year-old woman with a 1.2-cm, recommend for a 65-year-old woman with a 1.2-cm, Grade II, ER-positive, PR-positive, HER2-negative Grade II, ER-positive, PR-positive, HER2-negative

tumor with 3 positive nodes who tumor with 3 positive nodes who completed 5 yearscompleted 5 yearsof tamoxifen of tamoxifen 1 year ago1 year ago??

2005 2006 2007

Practicing oncologists (PO)

Start letrozole 64% 63% 62%

Start anastrozole 12% 24% 20%

Use no further hormonal therapy 24% 13% 18%

What endocrine therapy, if any, would youWhat endocrine therapy, if any, would yourecommend for a 65-year-old woman with a 1.2-cm, recommend for a 65-year-old woman with a 1.2-cm, Grade II, ER-positive, PR-positive, HER2-negative Grade II, ER-positive, PR-positive, HER2-negative

tumor with 3 positive nodes who tumor with 3 positive nodes who completed 5 yearscompleted 5 yearsof tamoxifen of tamoxifen 3 years ago3 years ago??

2005 2006 2007

Clinical investigators (CI)

Start letrozole 20% 64% 71%

Start anastrozole 0% 0% 0%

Use no further hormonal therapy 80% 36% 29%

What endocrine therapy, if any, would youWhat endocrine therapy, if any, would yourecommend for a 65-year-old woman with a 1.2-cm, recommend for a 65-year-old woman with a 1.2-cm, Grade II, ER-positive, PR-positive, HER2-negative Grade II, ER-positive, PR-positive, HER2-negative

tumor with 3 positive nodes who tumor with 3 positive nodes who completed 5 yearscompleted 5 yearsof tamoxifen of tamoxifen 3 years ago3 years ago??

2005 2006 2007

Practicing oncologists (PO)

Start letrozole 18% 28% 30%

Start anastrozole 6% 6% 12%

Use no further hormonal therapy 76% 66% 58%

Which of the following best describes the action Which of the following best describes the action you would take in the following scenarios?you would take in the following scenarios?

A A 60-year-old woman60-year-old woman was treated 8 years ago at was treated 8 years ago atage 52 (postmenopausal) for an ER-positive, PR-positive, age 52 (postmenopausal) for an ER-positive, PR-positive,

HER2-negative, HER2-negative, node-negativenode-negative tumor. She received tumor. She received tamoxifentamoxifen for 5 years and now presents for routine follow-up, doing well for 5 years and now presents for routine follow-up, doing well

after being off tamoxifen for 3 years.after being off tamoxifen for 3 years.

Discuss the option of an aromatase inhibitor but state that this would not be your recommendation

53% 29%

Recommend an aromatase inhibitor 10% 11%

Not recommend any endocrine therapy and continue with follow-up

29% 59%

Other 8% 1%

Clinical investigators Practicing oncologists

Which of the following best describes the action Which of the following best describes the action you would take in the following scenarios?you would take in the following scenarios?

A A 60-year-old woman60-year-old woman was treated 8 years ago at was treated 8 years ago atage 52 (postmenopausal) for an ER-positive, PR-positive, age 52 (postmenopausal) for an ER-positive, PR-positive,

HER2-negative tumor HER2-negative tumor with 4 positive nodeswith 4 positive nodes. She. Shereceived received chemotherapy/tamoxifenchemotherapy/tamoxifen for 5 years and now for 5 years and now presents for routine follow-up, doing well after beingpresents for routine follow-up, doing well after being

off tamoxifen for 3 years.off tamoxifen for 3 years.

Discuss the option of an aromatase inhibitor but state that this would not be your recommendation

20% 17%

Recommend an aromatase inhibitor 70% 35%

Not recommend any endocrine therapy and continue with follow-up

6% 47%

Other 4% 1%

Clinical investigators Practicing oncologists

Clinical investigators Practicing oncologists

Which of the following would you Which of the following would you recommend in the following scenarios?recommend in the following scenarios?

A A 61-year-old 61-year-old woman was treated 5 years ago at agewoman was treated 5 years ago at age56 (postmenopausal) for an ER-positive, PR-positive,56 (postmenopausal) for an ER-positive, PR-positive,

HER2-negative tumor with HER2-negative tumor with 4 positive nodes4 positive nodes. She received . She received chemotherapy/anastrozole for 5 years and has chemotherapy/anastrozole for 5 years and has

tolerated therapy without major difficulties.tolerated therapy without major difficulties.

Stop anastrozole and give no further endocrine treatment

36% 44%

Continue anastrozole 25% 22%

Switch to another AI 0% 5%

Explain that few data exist to support either continuing or discontinuing endocrine therapy and ask which option the patient would prefer

25% 25%

Other 14% 4%

Clinical investigators Practicing oncologists

Which of the following would you Which of the following would you recommend in the following scenarios?recommend in the following scenarios?An An 81-year-old 81-year-old woman was treated 5 years ago at agewoman was treated 5 years ago at age76 (postmenopausal) for an ER-positive, PR-positive,76 (postmenopausal) for an ER-positive, PR-positive,

HER2-negative tumor with HER2-negative tumor with 4 positive nodes4 positive nodes. She received . She received chemotherapy/anastrozole for 5 years and haschemotherapy/anastrozole for 5 years and has

tolerated therapy without major difficulties.tolerated therapy without major difficulties.

Stop anastrozole and give no further endocrine treatment

58% 57%

Continue anastrozole 16% 15%

Switch to another AI 0% 3%

Explain that few data exist to support either continuing or discontinuing endocrine therapy and ask which option the patient would prefer

22% 23%

Other 4% 2%