De-escalation of Endocrine Therapy in Early Hormone Receptor-positive Breast Cancer: When Is Local Treatment Enough?

Roi Weiser, Efstathia Polychronopoulou, Yong Fang Kuo, Waqar Haque, Sandra S. Hatch, Douglas S. Tyler, William J. Gradishar, V. Suzanne Klimberg

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


OBJECTIVE: To identify subgroups of hormone receptor-positive (HR+) breast cancer patients that might not benefit from adding endocrine therapy (ET) to their local treatment.

BACKGROUND: De-escalation in breast cancer treatment has included surgery, radiation, and chemotherapy and has often focused on older patient populations. Systemic ET has yet to be de-escalated, though it carries serious side-effects, decreasing quality of life over 5 to 10 years. We hypothesize the 21-gene recurrence score (RS) could identify subgroups of younger patients whose long-term survival is unaffected by adjuvant ET.

METHODS: The National Cancer Database was used to identify women aged ≥50, with HR+, HER2-negative tumors, ≤3 cm in size, N0 status, and a RS≤25, who underwent breast-conserving surgery in 2010 to 2016. Kaplan-Meier and Cox proportional hazards models were used to identify association between treatment and overall survival (OS).

RESULTS: Of the 45,217 patients identified, 80.6% were 50 to 69 years old. 42,632 (94.3%) patients received ET and 2585 (5.7%) did not. The 5-year OS was 96.4% for patients receiving ET and 93.1% for those who did not (P < 0.001). After adjusting for all covariates, patients aged 50 to 69 with RS < 11 showed no statistically significant improvement in OS when adding ET to surgery, with or without radiation (P = 0.40). With RS 11 to 25, there was a significant improvement of OS with ET plus radiation (P < 0.001).

CONCLUSIONS: Local treatment only, with de-escalation of long-term ET, for patients aged 50 to 69 with RS < 11, seems not to impact OS and should have an anticipated quality of life improvement. Prospective studies investigating this approach are warranted.

Original languageEnglish (US)
Pages (from-to)654-663
Number of pages10
JournalAnnals of surgery
Issue number4
StatePublished - Oct 1 2021


  • 21-gene recurrence score
  • Oncotype
  • breast cancer
  • de-escalation
  • endocrine therapy
  • estrogen receptor
  • hormone sensitive
  • omission
  • Antineoplastic Agents, Hormonal/administration & dosage
  • Drug Administration Schedule
  • Humans
  • Middle Aged
  • Survival Rate
  • Treatment Outcome
  • Socioeconomic Factors
  • Female
  • Aged
  • Retrospective Studies
  • Chemotherapy, Adjuvant
  • Breast Neoplasms/drug therapy

ASJC Scopus subject areas

  • Surgery


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