- Email: [email protected]
A vision to optimise the management of primary breast cancer in older women
Letter to the Editor / The Breast 19 (2010) 152–155
153
Overestimation of the effect of moving from one to two-view mammography in France Sir,
References
Seigneurin and colleagues1 showed a 37% increase in cancer detection (CD) and an even larger decrease in interval cancer (IC) between 1994–1999 and 2002–2004 in a French region (Ise`re) covered by a mammography screening program. Their interpretation, ie a nationwide shift from single to two-view mammography that occurred in-between the time periods compared, seems insufficiently supported by the data to be conclusive. Differences in screening procedures have clearly been associated with variations in IC rates.2,3 The new French screening procedures introduced in 2002 led to large, sudden changes in performance: over a 2-year period, the recall rate doubled and the CD rate rose by 20%.4 The increase in CD persisted thereafter5 and has likely induced a concomitant reduction in IC since part of the additional tumours detected under the new screening protocol would have surfaced as IC otherwise. The gradual drop in IC since 2002 (Tables 1 and 2 in Seigneurin et al.1) concords with this assumption. This study, by its design, could not isolate the residual effect of two views from other major concomitant factors. Evidence from both the French mammography screening program evaluation5 and RCT of single and double views6 reasonably suggest that the effect of the new screening protocol on CD and IC outweighs the impact of moving from one to two views. CD and IC figures for the transition period (2000–2001), when two-view mammography has progressively been performed under the old screening regimen, correspond mostly to rates in 1994–1999 and add further uncertainty to their estimation of the true improvement in sensitivity and specificity attributable to double views.
1. Seigneurin A, Exbrayat C, Labarere J, Colonna M. Comparison of interval breast cancer rates for two-versus single-view screening mammography: a population-based study. Breast 2009;18:284–8. 2. Bulliard J-L, Sasieni P, Klabunde C, De Landtsheer J-P, Yankaskas BC, Fracheboud J. Methodological issues in international comparison of interval breast cancers. Int J Cancer 2006;119:1158–63. 3. Hofvind S, Yankaskas BC, Bulliard J-L, Klabunde CN, Fracheboud J. Comparing interval breast cancer rates in Norway and North Carolina: results and challenges. J Med Screen 2009;16:131–9. 4. Seradour B, Ancelle-Park R. Breast cancer screening: are results of French and international programmes comparable? J Radiol 2006;87:1009–14. 5. Gorza M, Salines E, Bloch J. De´pistage organise´ du cancer du sein – E´valuation e´pide´miologique – Donne´es 2005. Saint-Maurice (France): Institut de veille sanitaire, 2008. p. 366. 6. Patnick J. NHS breast screening: the progression from one to two views. J Med Screen 2004;11:55–6.
Jean-Luc Bulliard* Fabio Levi Cancer Epidemiology Unit and Cancer Registries of Vaud and ˆ tel, University Institute of Social and Preventive Medicine Neucha (IUMSP), Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland * Corresponding author at: Cancer Epidemiology Unit, University Institute of Social and Preventive Medicine (IUMSP), route de la Corniche 2, Baˆtiment Biopoˆle 1, 1066 Epalinges, Lausanne, Switzerland. E-mail address: [email protected] (J.-L. Bulliard) 7 December 2009
doi:10.1016/j.breast.2009.12.009
A vision to optimise the management of primary breast cancer in older women a r t i c l e i n f o
a b s t r a c t
Article history: Received 28 September 2009 Accepted 27 January 2010
Majority of breast cancer are diagnosed at >65 years. Efforts to develop clinical service and research are spent mainly on younger patients. Little is known about the biology and long-term clinical outcome of breast cancer in the elderly. However there is data suggesting that there are differences. Knowledge related to breast cancer in the elderly is urgently needed and we need to optimise their management – not ‘over’ or ‘under’ treating them, taking into account of both physical and psychosocial dimensions. The Nottingham Breast Services established a dedicated elderly primary breast cancer service from its inception over 30 year ago, which has recently developed into a combined surgical/oncology facility. A joint effort and team approach are required in both developing clinical service and research, in order to optimise management. There is an immense need to develop a dedicated elderly breast cancer service and to support ongoing research. Ó 2010 Elsevier Ltd. All rights reserved.
Keywords Primary breast cancer Elderly Older women Clinical service Clinical trials
On 25th June 2009, headlines appeared on the press highlighting the poor care of elderly cancer patients across the UK – ‘Britain’s cancer shame as 15,000 elderly patients could be saved every year’, ‘Thousands of British elderly dying prematurely from
cancer’, ‘Up to 15,000 people aged over 75 may be dying unnecessarily from cancer each year in the UK, according to research’.. ‘According to lead researcher from the North West Cancer Intelligence Service, Dr Tony Moran, elderly cancer patients are not
154
Letter to the Editor / The Breast 19 (2010) 152–155
benefiting from improvements made to cancer care in the last 10 years. He said that if the UK was performing as well as other countries in Western Europe in the 75–84-year-old age group, and as well as the US in the 85 and over age bracket, there would be 15,000 fewer cancer deaths in the elderly each year.’ The majority of breast cancers are diagnosed at >65 years. Efforts to develop clinical service and research are however spent mainly on younger patients, from which the management of older patients is ‘copied’. They are at risk of being ‘poorly’ managed due to age and/or associated co-morbidities. Little is known about the biology and long-term clinical outcome of breast cancer in the elderly. Nonetheless there is data suggesting that there are differences. Young patients with breast cancer are associated with increased risk of local recurrence. The addition of boost radiotherapy to tumour bed after breast conserving surgery has been shown to make a significant difference in these young patients while negligible differences were seen with increasing age, as the risk of local recurrence tends to go down.1 Retrospective and prospective randomised studies show very good local control in the elderly patients with oestrogen receptor (ER) positive tumour treated by breast conservation and adjuvant tamoxifen without radiotherapy.2,3 A recent Cochrane review of seven randomised trials involving 1446 elderly women (unselected for ER status) has demonstrated no significant difference in overall survival between surgery (with or without adjuvant tamoxifen) and primary endocrine therapy using tamoxifen.4 The Oxford overview of randomised trials consistently shows diminishing benefit of adjuvant chemotherapy with increasing age.5 Knowledge related to breast cancer in older women is urgently needed. We need to optimise their management. This means not ‘over’ or ‘under’ treating them. Both physical and psychosocial dimensions must be taken into account. From the physical perspective, as described, we may be dealing with a biologically different spectrum of disease. This will require an approach different from that for their younger counterparts. In the latter, breast cancer specific survival often equates overall survival. This is unlikely to be true in the elderly population. Life expectancy has been shown to decrease with increasing number of co-morbidities. For example an 80-year old with no co-morbidity has a life expectancy of 12 years while someone at a similar age with four co-morbid diseases has two years to live on average.6 On the psychosocial front, a comprehensive geriatric assessment using established tools tailored made for breast cancer patients, impact and assessment of quality of life, and the decision making process of this group of patients are examples of issues that need to be addressed.7 The Nottingham Breast Services established a dedicated elderly primary breast cancer service from its inception over 30 year ago, and over 3000 patients diagnosed >70 years have thus far been treated. The service has recently developed into a combined surgical/oncology facility. The team comprises a breast surgeon (KLC), an oncologist (DALM) and two dedicated breast care nurses (LW and HR). A joint effort and team approach are required in both developing clinical service and research, in order to optimise management. Research is ongoing to investigate both physical and psychosocial aspects as described above, involving collaboration with experts from pathology (IOE) and nursing (DP). Research work done thus far includes (1) demonstration of a very low local recurrence (0.62% per annum) in patients treated with tamoxifen following breast conservation without radiotherapy8; (2) review of pathology based on core biopsy in around 2000 patients showing an outstandingly ER rich profile suggesting a different biology9; (3) demonstration of an equivalent breast cancer specific survival (90% in 5 years) between surgery and primary endocrine therapy in patients >80 years, and its correlation with the degree of ER
positivity10; (4) a very high efficacy of primary endocrine therapy (98% clinical benefit rate)11; and (5) dynamics influencing treatment decisions (suggesting a tendency to opt for non-operative treatment when given a free choice).12 Two national multi-centre randomised clinical trials were started not long ago: (1) ACTION – adjuvant chemotherapy versus no chemotherapy in elderly with ER negative/weakly positive breast cancer; and (2) ESTEeM – surgery with adjuvant endocrine therapy versus primary endocrine therapy in elderly with ER positive breast cancer.13 They would have been able to answer two extremely important questions to enable us to optimise the management of this group of patients, but unfortunately were closed due to poor recruitment! There appears to be a bias towards a certain therapeutic approach, which is not based on a lot of high level evidence. Because of the differences seen in effects of adjuvant treatments at different ages, differences that are independent of any other established prognostic factors, and the hitherto poor recruitment of elderly patients into trials, we suggest that when new trials are designed, consideration should always be given to abandoning age limits, and to introducing stratification by age at the time of randomization. Specific knowledge about treatment effects in elderly patients might thus be acquired. If we were to improve the long-term outcome of older women with primary breast cancer, we have to commit ourselves to optimise their management. There is an immense need to develop a dedicated elderly breast cancer service and to support ongoing research. Conflict of Interest Statement The authors declare no conflict of interest relevant to this article. References 1. Bartelink H, Horiot JC, Poortmans P, Struikmans H, Van den Bogaert W, Barillot I, et alEuropean Organization for Research and Treatment of Cancer RadiotherapyBreast Cancer Groups. Recurrence rates after treatment of breast cancer with standard radiotherapy with or without additional radiation. N Engl J Med 2001;345:1378–87. 2. Benhaim DI, Lopchinsky R, Tartter PI. Lumpectomy with tamoxifen as primary treatment for elderly women with early-stage breast cancer. Am J Surg 2000; 180:162–6. 3. Hughes KS, Schnaper LA, Berry D, Cirrincione C, McCormick B, Shank B, et alCancer and Leukemia Group BRadiation Therapy Oncology GroupEastern Cooperative Oncology Group. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 2004;351:971–7. 4. Hind D, Wyld L, Beverley CB, Reed MW. Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database Syst Rev; 2006:CD004272. 5. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005; 365:1687–717. 6. Siegelmann-Danieli N, Khandelwal V, Wood GC, Mainali R, Prichard J, Murphy TJ, et al. Breast cancer in elderly women: outcome as affected by age, tumor features, comorbidities, and treatment approach. Clin Breast Cancer 2006;7:59–66. 7. Hurria A, Lichtman SM, Gardes J, Li D, Limaye S, Patil S, et al. Identifying vulnerable older adults with cancer: integrating geriatric assessment into oncology practice. J Am Gerontol Soc 2007;55:1604–8. 8. Valassiadou K, Morgan DAL, Robertson JFR, Pinder SE, Cheung KL. Successful management of elderly breast cancer patients treated without radiotherapy. World J Surg Oncol 2007;5:62. 9. Cheung KL, Wong AWS, Parker H, Li VWY, Winterbottom L, Morgan DAL, et al. Pathological features of primary breast cancer in the elderly based on needle core biopsies – a large series from a single centre. Crit Rev Oncol Hematol 2008;67:263–7 [Epub 2008 June 3]. 10. Syed BM, Johnston SJ, Wong DWM, Morgan DAL, Ellis IO, Cheung KL. Surgery versus primary endocrine therapy for elderly women with oestrogen receptor positive early operable primary breast cancer – survival analysis and correlation with oestrogen receptor positivity. J Clin Oncol 2009;27(15S):612. ASCO annual meeting proceedings I.
Letter to the Editor / The Breast 19 (2010) 152–155 11. Al-Khyatt W, Syed BM, Morgan DAL, Cheung KL. Primary endocrine therapy for early operable primary breast cancer in elderly women – a large series from a single institution. J Clin Oncol 2009;27(15S):630. ASCO annual meeting proceedings I. 12. Tang SW, Parker H, Winterbottom L, Hassell K, Ellis IO, Morgan DAL, et al. Early primary breast cancer in the elderly – pattern of presentation and treatment. Surg Oncol 2009;Aug 11 [Epub ahead of print]. 13. Reed MW, Wyld L, Ellis P, Bliss J, Leonard RACTION and ESTEeM Trial Management Groups. Breast cancer in older women: trials and tribulations. Clin Oncol (R Coll Radiol) 2009;21:99–102.
K.L. Cheung* Division of Breast Surgery, University of Nottingham, Professorial Unit of Surgery, City Hospital Campus, Nottingham University Hospitals, Hucknall Road, Nottingham NG5 1PB, UK * Corresponding author. Tel.: þ44 (0)115 8231876; fax: þ44 (0)115 8231877. E-mail address: [email protected] (K.L. Cheung)
doi:10.1016/j.breast.2010.01.019
155
D.A.L. Morgan Department of Oncology, Nottingham University Hospitals, Nottingham, UK L. Winterbottom, H. Richardson Nottingham Breast Institute, Nottingham University Hospitals, Nottingham, UK I.O. Ellis Division of Pathology, University of Nottingham, Nottingham University Hospitals, Nottingham, UK D. Porock School of Nursing, University of Nottingham, Nottingham University Hospitals, Nottingham, UK 28 September 2009
153
Overestimation of the effect of moving from one to two-view mammography in France Sir,
References
Seigneurin and colleagues1 showed a 37% increase in cancer detection (CD) and an even larger decrease in interval cancer (IC) between 1994–1999 and 2002–2004 in a French region (Ise`re) covered by a mammography screening program. Their interpretation, ie a nationwide shift from single to two-view mammography that occurred in-between the time periods compared, seems insufficiently supported by the data to be conclusive. Differences in screening procedures have clearly been associated with variations in IC rates.2,3 The new French screening procedures introduced in 2002 led to large, sudden changes in performance: over a 2-year period, the recall rate doubled and the CD rate rose by 20%.4 The increase in CD persisted thereafter5 and has likely induced a concomitant reduction in IC since part of the additional tumours detected under the new screening protocol would have surfaced as IC otherwise. The gradual drop in IC since 2002 (Tables 1 and 2 in Seigneurin et al.1) concords with this assumption. This study, by its design, could not isolate the residual effect of two views from other major concomitant factors. Evidence from both the French mammography screening program evaluation5 and RCT of single and double views6 reasonably suggest that the effect of the new screening protocol on CD and IC outweighs the impact of moving from one to two views. CD and IC figures for the transition period (2000–2001), when two-view mammography has progressively been performed under the old screening regimen, correspond mostly to rates in 1994–1999 and add further uncertainty to their estimation of the true improvement in sensitivity and specificity attributable to double views.
1. Seigneurin A, Exbrayat C, Labarere J, Colonna M. Comparison of interval breast cancer rates for two-versus single-view screening mammography: a population-based study. Breast 2009;18:284–8. 2. Bulliard J-L, Sasieni P, Klabunde C, De Landtsheer J-P, Yankaskas BC, Fracheboud J. Methodological issues in international comparison of interval breast cancers. Int J Cancer 2006;119:1158–63. 3. Hofvind S, Yankaskas BC, Bulliard J-L, Klabunde CN, Fracheboud J. Comparing interval breast cancer rates in Norway and North Carolina: results and challenges. J Med Screen 2009;16:131–9. 4. Seradour B, Ancelle-Park R. Breast cancer screening: are results of French and international programmes comparable? J Radiol 2006;87:1009–14. 5. Gorza M, Salines E, Bloch J. De´pistage organise´ du cancer du sein – E´valuation e´pide´miologique – Donne´es 2005. Saint-Maurice (France): Institut de veille sanitaire, 2008. p. 366. 6. Patnick J. NHS breast screening: the progression from one to two views. J Med Screen 2004;11:55–6.
Jean-Luc Bulliard* Fabio Levi Cancer Epidemiology Unit and Cancer Registries of Vaud and ˆ tel, University Institute of Social and Preventive Medicine Neucha (IUMSP), Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland * Corresponding author at: Cancer Epidemiology Unit, University Institute of Social and Preventive Medicine (IUMSP), route de la Corniche 2, Baˆtiment Biopoˆle 1, 1066 Epalinges, Lausanne, Switzerland. E-mail address: [email protected] (J.-L. Bulliard) 7 December 2009
doi:10.1016/j.breast.2009.12.009
A vision to optimise the management of primary breast cancer in older women a r t i c l e i n f o
a b s t r a c t
Article history: Received 28 September 2009 Accepted 27 January 2010
Majority of breast cancer are diagnosed at >65 years. Efforts to develop clinical service and research are spent mainly on younger patients. Little is known about the biology and long-term clinical outcome of breast cancer in the elderly. However there is data suggesting that there are differences. Knowledge related to breast cancer in the elderly is urgently needed and we need to optimise their management – not ‘over’ or ‘under’ treating them, taking into account of both physical and psychosocial dimensions. The Nottingham Breast Services established a dedicated elderly primary breast cancer service from its inception over 30 year ago, which has recently developed into a combined surgical/oncology facility. A joint effort and team approach are required in both developing clinical service and research, in order to optimise management. There is an immense need to develop a dedicated elderly breast cancer service and to support ongoing research. Ó 2010 Elsevier Ltd. All rights reserved.
Keywords Primary breast cancer Elderly Older women Clinical service Clinical trials
On 25th June 2009, headlines appeared on the press highlighting the poor care of elderly cancer patients across the UK – ‘Britain’s cancer shame as 15,000 elderly patients could be saved every year’, ‘Thousands of British elderly dying prematurely from
cancer’, ‘Up to 15,000 people aged over 75 may be dying unnecessarily from cancer each year in the UK, according to research’.. ‘According to lead researcher from the North West Cancer Intelligence Service, Dr Tony Moran, elderly cancer patients are not
154
Letter to the Editor / The Breast 19 (2010) 152–155
benefiting from improvements made to cancer care in the last 10 years. He said that if the UK was performing as well as other countries in Western Europe in the 75–84-year-old age group, and as well as the US in the 85 and over age bracket, there would be 15,000 fewer cancer deaths in the elderly each year.’ The majority of breast cancers are diagnosed at >65 years. Efforts to develop clinical service and research are however spent mainly on younger patients, from which the management of older patients is ‘copied’. They are at risk of being ‘poorly’ managed due to age and/or associated co-morbidities. Little is known about the biology and long-term clinical outcome of breast cancer in the elderly. Nonetheless there is data suggesting that there are differences. Young patients with breast cancer are associated with increased risk of local recurrence. The addition of boost radiotherapy to tumour bed after breast conserving surgery has been shown to make a significant difference in these young patients while negligible differences were seen with increasing age, as the risk of local recurrence tends to go down.1 Retrospective and prospective randomised studies show very good local control in the elderly patients with oestrogen receptor (ER) positive tumour treated by breast conservation and adjuvant tamoxifen without radiotherapy.2,3 A recent Cochrane review of seven randomised trials involving 1446 elderly women (unselected for ER status) has demonstrated no significant difference in overall survival between surgery (with or without adjuvant tamoxifen) and primary endocrine therapy using tamoxifen.4 The Oxford overview of randomised trials consistently shows diminishing benefit of adjuvant chemotherapy with increasing age.5 Knowledge related to breast cancer in older women is urgently needed. We need to optimise their management. This means not ‘over’ or ‘under’ treating them. Both physical and psychosocial dimensions must be taken into account. From the physical perspective, as described, we may be dealing with a biologically different spectrum of disease. This will require an approach different from that for their younger counterparts. In the latter, breast cancer specific survival often equates overall survival. This is unlikely to be true in the elderly population. Life expectancy has been shown to decrease with increasing number of co-morbidities. For example an 80-year old with no co-morbidity has a life expectancy of 12 years while someone at a similar age with four co-morbid diseases has two years to live on average.6 On the psychosocial front, a comprehensive geriatric assessment using established tools tailored made for breast cancer patients, impact and assessment of quality of life, and the decision making process of this group of patients are examples of issues that need to be addressed.7 The Nottingham Breast Services established a dedicated elderly primary breast cancer service from its inception over 30 year ago, and over 3000 patients diagnosed >70 years have thus far been treated. The service has recently developed into a combined surgical/oncology facility. The team comprises a breast surgeon (KLC), an oncologist (DALM) and two dedicated breast care nurses (LW and HR). A joint effort and team approach are required in both developing clinical service and research, in order to optimise management. Research is ongoing to investigate both physical and psychosocial aspects as described above, involving collaboration with experts from pathology (IOE) and nursing (DP). Research work done thus far includes (1) demonstration of a very low local recurrence (0.62% per annum) in patients treated with tamoxifen following breast conservation without radiotherapy8; (2) review of pathology based on core biopsy in around 2000 patients showing an outstandingly ER rich profile suggesting a different biology9; (3) demonstration of an equivalent breast cancer specific survival (90% in 5 years) between surgery and primary endocrine therapy in patients >80 years, and its correlation with the degree of ER
positivity10; (4) a very high efficacy of primary endocrine therapy (98% clinical benefit rate)11; and (5) dynamics influencing treatment decisions (suggesting a tendency to opt for non-operative treatment when given a free choice).12 Two national multi-centre randomised clinical trials were started not long ago: (1) ACTION – adjuvant chemotherapy versus no chemotherapy in elderly with ER negative/weakly positive breast cancer; and (2) ESTEeM – surgery with adjuvant endocrine therapy versus primary endocrine therapy in elderly with ER positive breast cancer.13 They would have been able to answer two extremely important questions to enable us to optimise the management of this group of patients, but unfortunately were closed due to poor recruitment! There appears to be a bias towards a certain therapeutic approach, which is not based on a lot of high level evidence. Because of the differences seen in effects of adjuvant treatments at different ages, differences that are independent of any other established prognostic factors, and the hitherto poor recruitment of elderly patients into trials, we suggest that when new trials are designed, consideration should always be given to abandoning age limits, and to introducing stratification by age at the time of randomization. Specific knowledge about treatment effects in elderly patients might thus be acquired. If we were to improve the long-term outcome of older women with primary breast cancer, we have to commit ourselves to optimise their management. There is an immense need to develop a dedicated elderly breast cancer service and to support ongoing research. Conflict of Interest Statement The authors declare no conflict of interest relevant to this article. References 1. Bartelink H, Horiot JC, Poortmans P, Struikmans H, Van den Bogaert W, Barillot I, et alEuropean Organization for Research and Treatment of Cancer RadiotherapyBreast Cancer Groups. Recurrence rates after treatment of breast cancer with standard radiotherapy with or without additional radiation. N Engl J Med 2001;345:1378–87. 2. Benhaim DI, Lopchinsky R, Tartter PI. Lumpectomy with tamoxifen as primary treatment for elderly women with early-stage breast cancer. Am J Surg 2000; 180:162–6. 3. Hughes KS, Schnaper LA, Berry D, Cirrincione C, McCormick B, Shank B, et alCancer and Leukemia Group BRadiation Therapy Oncology GroupEastern Cooperative Oncology Group. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 2004;351:971–7. 4. Hind D, Wyld L, Beverley CB, Reed MW. Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database Syst Rev; 2006:CD004272. 5. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005; 365:1687–717. 6. Siegelmann-Danieli N, Khandelwal V, Wood GC, Mainali R, Prichard J, Murphy TJ, et al. Breast cancer in elderly women: outcome as affected by age, tumor features, comorbidities, and treatment approach. Clin Breast Cancer 2006;7:59–66. 7. Hurria A, Lichtman SM, Gardes J, Li D, Limaye S, Patil S, et al. Identifying vulnerable older adults with cancer: integrating geriatric assessment into oncology practice. J Am Gerontol Soc 2007;55:1604–8. 8. Valassiadou K, Morgan DAL, Robertson JFR, Pinder SE, Cheung KL. Successful management of elderly breast cancer patients treated without radiotherapy. World J Surg Oncol 2007;5:62. 9. Cheung KL, Wong AWS, Parker H, Li VWY, Winterbottom L, Morgan DAL, et al. Pathological features of primary breast cancer in the elderly based on needle core biopsies – a large series from a single centre. Crit Rev Oncol Hematol 2008;67:263–7 [Epub 2008 June 3]. 10. Syed BM, Johnston SJ, Wong DWM, Morgan DAL, Ellis IO, Cheung KL. Surgery versus primary endocrine therapy for elderly women with oestrogen receptor positive early operable primary breast cancer – survival analysis and correlation with oestrogen receptor positivity. J Clin Oncol 2009;27(15S):612. ASCO annual meeting proceedings I.
Letter to the Editor / The Breast 19 (2010) 152–155 11. Al-Khyatt W, Syed BM, Morgan DAL, Cheung KL. Primary endocrine therapy for early operable primary breast cancer in elderly women – a large series from a single institution. J Clin Oncol 2009;27(15S):630. ASCO annual meeting proceedings I. 12. Tang SW, Parker H, Winterbottom L, Hassell K, Ellis IO, Morgan DAL, et al. Early primary breast cancer in the elderly – pattern of presentation and treatment. Surg Oncol 2009;Aug 11 [Epub ahead of print]. 13. Reed MW, Wyld L, Ellis P, Bliss J, Leonard RACTION and ESTEeM Trial Management Groups. Breast cancer in older women: trials and tribulations. Clin Oncol (R Coll Radiol) 2009;21:99–102.
K.L. Cheung* Division of Breast Surgery, University of Nottingham, Professorial Unit of Surgery, City Hospital Campus, Nottingham University Hospitals, Hucknall Road, Nottingham NG5 1PB, UK * Corresponding author. Tel.: þ44 (0)115 8231876; fax: þ44 (0)115 8231877. E-mail address: [email protected] (K.L. Cheung)
doi:10.1016/j.breast.2010.01.019
155
D.A.L. Morgan Department of Oncology, Nottingham University Hospitals, Nottingham, UK L. Winterbottom, H. Richardson Nottingham Breast Institute, Nottingham University Hospitals, Nottingham, UK I.O. Ellis Division of Pathology, University of Nottingham, Nottingham University Hospitals, Nottingham, UK D. Porock School of Nursing, University of Nottingham, Nottingham University Hospitals, Nottingham, UK 28 September 2009