Sequential versus concurrent adjuvant chemo-endocrine therapy for HR+ early breast cancer: a systematic review and Bayesian network meta-analysis

Tianfu Li; Zhen Shan; Yawei Shi; Xiaying Kuang; Liang Yu; Shou-Ching Tang; Nan Shao; Ying Lin

doi:10.21037/tbcr-21-3

Sequential versus concurrent adjuvant chemo-endocrine therapy for HR+ early breast cancer: a systematic review and Bayesian network meta-analysis

Transl Breast Cancer Res. 2022 Jan 31:3:8. doi: 10.21037/tbcr-21-3. eCollection 2022.

Authors

Tianfu Li^#^{1

2}, Zhen Shan^#¹, Yawei Shi¹, Xiaying Kuang¹, Liang Yu¹, Shou-Ching Tang³, Nan Shao¹, Ying Lin¹

Affiliations

¹ Breast Disease Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
² Laboratory of Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
³ University of Mississippi Cancer Center and Research Institute, Jackson, MS, USA.

^# Contributed equally.

Abstract

Background: Chemo-endocrine therapy is the standard adjuvant treatment strategy for hormone receptor-positive (HR+) early breast cancer. Our research aimed to compare the efficacy of adjuvant chemo-endocrine therapies, regarding different endocrinal regimens and integration sequences (sequential or concomitant), for HR+ early breast cancer.

Methods: PubMed, Embase, the Cochrane Library and web of science were searched for articles published before October 2018 with Clinicaltrials.gov (https://clinicaltrials.gov) for registered clinical trials and ASCO, AACR, ESCO, SABCS meeting abstracts for addition. Randomized clinical trials (RCTs) comparing chemotherapy and/or endocrine therapy in the adjuvant treatment of primary breast cancer patients were included. Hazard ratios (HRs) of disease-free survival (DFS) and overall survival (OS) were extracted and analyzed in Bayesian analysis. Patients were stratified by menopause status.

Results: Thirty-three trials with 28,515 patients and 19 treatments were enrolled. Comparisons between regimens has seen better efficacy of ovarian function suppressor (OFS) + aromatase inhibitors (AI) than OFS + tamoxifen, either used concurrently [HR =0.69, 95% credible intervals (CrI): 0.47-1.02] or sequentially with chemotherapy (HR =0.72, 95% CrI: 0.49-1.06) in premenopausal patients. Adding OFS to tamoxifen was marginally better than tamoxifen used alone (DFS: HR =0.85, 95% CrI: 0.65-1.09; OS: HR =0.77, 95% CrI: 0.52-1.08). Comparisons between different sequences of chemo-endocrine therapy proved equal efficacy in premenopausal and postmenopausal patients. Recommendation was given based on ranking of treatments. Sequential and concurrent use of chemotherapy and OFS + AI ranked equally in premenopausal patients and were recommended as the best option. However, tamoxifen ranked higher when used concurrently with chemotherapy in both premenopausal and postmenopausal HR+ early breast cancer.

Conclusions: In the adjuvant chemo-endocrine therapy for premenopausal HR+ early breast cancer, concurrent and sequential adjuvant chemo-endocrine therapy was demonstrated of equal efficacy in both postmenopausal and premenopausal HR+ early breast cancer.

Trial registration: PROSPERO CRD42018104889.

Keywords: Bayesian analysis; Estrogen receptor-positive breast cancer; chemotherapy; endocrine therapy; randomized clinical trial (RCTs).