A major difference between what we studied and international guidelines is that these patients were not treated with endocrine therapy. And in almost all countries, as far as I know, patients with an ER-positive or hormone receptor-positive tumor are treated with endocrine therapy. And according to Dutch national breast cancer guidelines, endocrine therapy is not recommended for these small early-stage tumors...
A major difference between what we studied and international guidelines is that these patients were not treated with endocrine therapy. And in almost all countries, as far as I know, patients with an ER-positive or hormone receptor-positive tumor are treated with endocrine therapy. And according to Dutch national breast cancer guidelines, endocrine therapy is not recommended for these small early-stage tumors. So as far as I know, and I’m not an oncologist, but these tumors have a really low risk for distant metastasis. And we give endocrine therapy to prevent distant metastasis and improve survival and what you see from this study is that it of course it has an effect on local occurrence as well because it’s higher than expected also compared to other studies but you see that survival is not compromised up to the data we have right now so I think it’s really defensible to not treat these patients with endocrine therapy. And also there’s research from Martini et al. And they’re comparing the Europa trial radiotherapy and endocrine therapy. And then they’re looking at quality of life at the interim analysis of two years. And there you see that the patients who receive radiation therapy have a better quality of life and less decline in quality of life at the interim analysis of two years and there you see that the patients who receive radiation therapy have a better quality of life and less declining quality of life compared with patients receiving endocrine therapy. So I think we really have to consider by giving or by prescribing endocrine therapy what the benefit is for the patient, for the individual patient and also when we see a lack of survival right now. Yeah, so you really have to consider that carefully. And then regarding the radiation therapy, I think this true observed local recurrence risk without any adjuvant therapy. Yeah, it enables to find a true risk, what is not available in literature right now, what is previously not available in literature right now. So I think that’s really, that adds on to the literature that’s available. Now it is really good, like in clinical practice, you can really use the 14.8% to guide clinical decision making. And I think you can choose both with this number because it’s higher than expected. So in very vital patients, radiotherapy is very effective, especially with the development of partial breast and hypofractionated schemes or ultrahypofractionated. So that’s really different compared to a few years before, to a few years earlier. So in very vital patients, I would for sure give radiation therapy. But in very fragile patients, for example, or 85-year-old fragile patients with a lot of comorbidities and a high competing mortality risk then you can really weigh the pros and cons and maybe say okay it’s 14.8% expected local occurrence risk and we will not irradiate because of the other comorbidities.
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