Systematic review
Tamoxifen with radiotherapy compared with Tamoxifen alone in elderly women with early-stage breast cancer treated with breast conserving surgery: A systematic review and meta-analysis

https://doi.org/10.1016/j.radonc.2017.02.019Get rights and content

Abstract

Background

Our aim was to assess the effect of adjuvant radiotherapy on recurrence and survival for elderly women (≥70) with early-stage hormone receptor-positive breast cancer treated with breast conserving surgery (BCS) and Tamoxifen.

Materials and methods

MEDLINE, EMBASE, and Evidence-Based Medicine Reviews were systematically searched through August 12, 2016 for randomized controlled trials (RCTs) comparing radiotherapy to no radiotherapy and presenting outcomes for women ≥70 years. Two investigators screened citations, abstracted results, and appraised studies using Cochrane Risk of Bias tool. Pooled risk ratios (RR) for breast, axillary, and distant recurrence, and overall survival were determined using weights from fixed-effects models.

Results

Four RCTs with low risk of bias were identified (2387 elderly women). Tamoxifen plus radiotherapy reduced breast recurrence compared to Tamoxifen alone from 60 to 10 (95% CI 6–20) per 1000 patients at 5 years (RR 0.18, 95% CI 0.10–0.34; 4 trials, 2387 patients). This effect was maintained at 10 years (RR 0.27, 95% CI 0.13–0.54; 2 trials, 891 patients). Radiotherapy minimally reduced axillary recurrence from 12 to 3 (95% CI 1–10) per 1000 at 5 years (RR 0.28, 95% CI 0.10–0.81; 3 trials, 2287 patients). Radiotherapy did not affect distant recurrence (RR 1.49, 95% CI 0.87–2.54; 3 trials, 2287 patients) or overall survival (RR 0.98, 95% CI 0.79–1.22; 3 trials, 2287 patients).

Conclusion

For elderly women (≥70), radiotherapy reduces the risk of breast and axillary recurrence, but does not impact distant recurrence or overall survival in early-stage breast cancer treated with BCS and Tamoxifen. The value of this risk reduction must be weighed by women and their physicians when considering the omission of adjuvant radiotherapy.

Section snippets

Methods

We registered our protocol with the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42015024598) [23]. We reported this systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) standards [24].

Systematic search

Fig. 1 illustrates citation selection. Our initial search strategy yielded 7231 citations after removal of duplicates. Three citations were added after citation tracking. After level 1 screening of titles and abstracts, 7206 citations were excluded. After level 2 screening of the remaining 28 full-text articles, 22 were excluded. Five were excluded as multiple reports of the same trial, 3 did not have available full texts, 1 did not use adjuvant endocrine therapy, 6 were not RCTs, 1 did not

Discussion

We identified four RCTs of low overall risk of bias comparing adjuvant Tamoxifen plus radiotherapy to adjuvant Tamoxifen alone reporting outcomes specific for elderly women with early-stage breast cancer treated with breast conserving surgery. There is strong evidence that the addition of radiotherapy reduces the risk of breast and axillary recurrence. However, the absolute risk reduction with the addition of radiotherapy in this population is low. Radiotherapy reduces the risk of breast

Conclusion

Our meta-analysis provides the most robust estimate of effect for adjuvant radiotherapy, or its omission, in elderly women with early-stage breast cancer treated with BCS and adjuvant endocrine therapy. These findings provide precise estimates that can be included in guideline recommendations, can be used by patients and their physicians in shared decision-making, and provide data for the development of a decision aid to assist elderly women in making this choice. Indeed, the addition of

Funding source

Andrea C. Tricco is funded by a Tier 2 Canada Research Chair in Knowledge Synthesis.

Disclaimers

There are no conflicts of interest to disclose.

Acknowledgements

Christine Neilson, information specialist.

Bridget Morant, information specialist.

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