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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
Most hormone-driven breast cancers are cured with surgery, radiotherapy and five to ten years of endocrine tablets. Women whose tumours are larger, higher grade or have reached the lymph nodes face a higher risk of relapse: two to three years of a CDK4/6 inhibitor added to endocrine therapy cuts recurrence, and genomic tests such as Oncotype DX and MammaPrint decide who also needs chemotherapy.
High-risk early disease is defined clinically and genomically. monarchE took node-positive tumours with four or more nodes, or one to three nodes with grade 3, a tumour of 5 cm or more or Ki-67 of 20 percent or more; NATALEE widened the net to stage II and III disease including node-negative stage IIA tumours with high-risk features. Genomic assays sort the rest: TAILORx showed that women over 50 with node-negative tumours and an Oncotype DX recurrence score of 11 to 25 gain nothing from chemotherapy (nine-year invasive disease-free survival 83.3 percent without and 84.3 percent with), RxPONDER showed the same for postmenopausal women with one to three positive nodes and a score up to 25 while premenopausal women still benefited, and MINDACT showed that clinically high-risk tumours with a low MammaPrint score reach 94.7 percent five-year distant metastasis-free survival without chemotherapy.
Endocrine therapy is the backbone. Five years of tamoxifen cuts recurrence and breast cancer death for at least fifteen years, aromatase inhibitors do slightly better in postmenopausal women, and the SOFT and TEXT trials showed that premenopausal women at higher risk do best with ovarian function suppression plus exemestane, with twelve-year disease-free survival of 80.5 percent against 75.9 percent for suppression plus tamoxifen; adding suppression to tamoxifen improved overall survival in the women who had needed chemotherapy. ATLAS and aTTom showed that ten years of tamoxifen beats five, and MA.17 that letrozole after five years of tamoxifen reduces late recurrence, so extended therapy to seven to ten years is offered in node-positive disease at the price of bone loss, joint pain and adherence that falls with every year.
| Setting | Approach | Guideline |
|---|---|---|
| Deciding on chemotherapy | Genomic assay on node-negative and one to three node-positive tumours; chemotherapy for a high recurrence score, for premenopausal women with node-positive disease and a score up to 25, and for clinically high-risk tumours without a low genomic score. | not mapped |
| Endocrine therapy | Aromatase inhibitor for postmenopausal women; tamoxifen, or ovarian function suppression with an aromatase inhibitor for premenopausal women at higher risk (SOFT and TEXT); five years, extended to seven to ten in node-positive disease. | not mapped |
| Adjuvant CDK4/6 inhibitor | Abemaciclib for two years (monarchE, node-positive high-risk disease) or ribociclib for three years (NATALEE, stage II to III) alongside the aromatase inhibitor. | not mapped |
| Germline BRCA carriers | One year of adjuvant olaparib after chemotherapy for high-risk disease (OlympiA). | not mapped |
| Local therapy | Breast-conserving surgery with hypofractionated whole-breast radiotherapy or mastectomy, sentinel node biopsy, and regional nodal irradiation when nodes are involved. | not mapped |
| Bone protection | Zoledronic acid or denosumab during aromatase inhibitor therapy in postmenopausal women reduces fractures, and bisphosphonates also reduce bone recurrence. | not mapped |