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Electronic Letters to:

special article:
A. Goldhirsch, J. N. Ingle, R. D. Gelber, A. S. Coates, B. Thürlimann, H.-J. Senn, and Panel members
Thresholds for therapies: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2009
Ann Oncol 2009; 0: mdp322v1-322 [Abstract] [Full text] [PDF]
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[Read eLetter] Endocrine Therapy in Early Breast Cancer and Tamoxifen Resistence
Salvatore Polizzi   (7 September 2009)

Endocrine Therapy in Early Breast Cancer and Tamoxifen Resistence 7 September 2009
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Salvatore Polizzi,
Coordinator Screening Programme
San Remigio Hospital - Department of Oncological Prevention - ASLTO5 NHS Unit Carignano (TO) - IT

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Re: Endocrine Therapy in Early Breast Cancer and Tamoxifen Resistence

Recently there has been an important debate on the subject of “over- diagnosis”, better described as over-treatment(1), especially in screening detected lesions (2). Yet it has been shown that survival increases with early detection and good local surgery and therapy even if without chemotherapy (3).

The recent Sankt Gallen Guidelines 2009(4) are welcome and are of special assistance in a screening context where detection tends to be early. The guidelines suggest, appropriately, that endocrine treatment is sufficient without chemotherapy especially in higher ER+ and PgR+ staining, as pointed out in Table 2 and 3 of the guidelines .

On this important subject, it is well known that over expression of growth factor receptors in breast cancer, especially those of the EGFR/HER2 family, is associated with resistance to endocrine therapy in particular to tamoxifen (5, 6). The mechanism of tamoxifen resistance in this subgroup of patients, has been proposed by Arpino et al. (7).

I suggest it would be useful to clarify that these subgroups of patients (ER+, PgR- and HER2+), could be resistant to tamoxifen. This applies in particular to post menopausal women who are more likely to be in a screening population.

The recommendations in these guidelines will have a welcome effect in reduction of over treatment that is the current bane of screening.

References

1. Jorgensen J and Goetsche PC. Overdiagnosis in publicly organised mammography screening programmes. Systemic review of incidence trends. BMJ 2009; 339: b2587.

2. Welch HJ, Woloshin S, Schwartz LM. The sea of uncertainty surrounding Ductal Carcinoma in Situ - The price of screening mammography. J Natl Cancer Inst 2008; 100 (4): 228 – 229

3. Punglia RS, Morrow M, Winer E et al. Local Therapy and Survival in Breast Cancer. New Engl J Med 2007; 356:2399-2405

4. Goldhirsch. A, Ingle. J.N. Gelber et al. Thresholds for Therapy. Highlights of the San Gallen International Experts Consenuss on Primary Therapy of Early Breast Cancer 2009. Ann of Oncol 2009; 20: 1319-1329

5. De Laurentis M, Arpino G, Massarelli E et al. A meta-analysis of the interaction between HER2 expression and response to endocrine treatment in advanced breast cancer. Clin Cancer Res 2005; 11: 4741-4748

6. Leitzel K. Teramoto Y, Conrad K et al. Elevated Serum C-ERB - 2 antigen levels and decreased response to hormone therapy of breast cancer. J Clin Oncol 1995; 13: 1129-35

7. Arpino G, Weiss G, Lee A, et al. Estrogen receptor positive, progesterone receptor negative breast cancer : Association with growth factor receptor expression and tamoxifen resistance. J Natl Cancer Inst 2005; 97: 1254-1261

Conflict of Interest:

None declared