Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Book Review
Book Reviews
Classics In Indian Medicine
Clinical Case Report
Clinical Case Reports
Clinical Research Methods
Clinico-pathological Conference
Eminent Indians in Medicine
Everyday Practice
Film Review
History of Medicine
Images In Medicine
Indian Medical Institutions
Letter from Bristol
Letter from Chennai
Letter From Ganiyari
Letter from Glasgow
Letter from London
Letter From Mumbai
Letter From Nepal
Medical Education
Medical Ethics
Medicine and Society
News From Here And There
Original Article
Original Articles
Review Article
Selected Summaries
Selected Summary
Short Report
Short Reports
Speaking for Myself
Speaking for Ourselve
Speaking for Ourselves
View/Download PDF

Translate this page into:

Selected Summaries
doi: 10.4103/0970-258X.317474
PMID: 34213458

Adding ovarian suppression to tamoxifen for pre-menopausal breast cancer

Abhenil Mittal, Ajay Gogia
 Department of Medical Oncology, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India

Corresponding Author:
Ajay Gogia
Department of Medical Oncology, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi
Published: 02-Jun-2021
How to cite this article:
Mittal A, Gogia A. Adding ovarian suppression to tamoxifen for pre-menopausal breast cancer. Natl Med J India 2020;33:289-290
Copyright: (C)2020 The National Medical Journal of India

Kim HA, Lee JW, Nam SJ, Park BW, Im SA, Lee ES, Jung YS, Yoon JH, Kang SS, Lee SJ, Park KH, Jeong J, Cho SH, Kim SY, Kim LS, Moon BI, Lee MH, Kim TH, Park C, Jung SH, Gwak G, Kim J, Kang SH, Jin YW, Kim HJ, Han SH, Han W, Hur MH, Noh WC; Korean Breast Cancer Study Group. (Korea Cancer Center Hospital, Seoul; Asan Medical Center, Seoul, Republic of Korea; Samsung Medical Center, Seoul; Yonsei University College of Medicine, Seoul; Seoul National University Hospital Seoul; National Cancer Center, Goyang; Ajou University, Suwon; Chonnam National University Hwasun Hospital, Gwangju; Cheil General Hospital and Women’s Healthcare Center, Seoul; Yeungnam University Hospital, Daegu; Korea University Anam Hospital, Seoul; Gangnam Severance Hospital, Seoul; Dong-A University Hospital, Busan; Soonchunhyang University College of Medicine, Cheonan; Hallym University Sacred Heart Hospital, Anyang; Ewha Woman’s University Mokdong Hospital, Seoul; Soonchunhyang University College of Medicine, Seoul; Inje University Busan Paik Hospital, Busan; Sungkyunkwan University School of Medicine, Seoul; Chonbuk National University Medical School, Jeonju; Inje University Sanggye Paik Hospital, Seoul; Chungnam National University Hospital, Daejeon; Keimyung University School of Medicine, Daegu; Korea Institute of Radiological and Medical Sciences, Seoul; Seoul National University, Seoul; Inha University, Incheon, Republic of Korea.) Adding ovarian suppression to tamoxifen for premenopausal breast cancer: A randomized phase III trial. J Clin Oncol 2020;38:434–43. doi: 10.1200/ JCO.19.00126. Epub 2019 Sep 16.


The ASTRAA trial by Kim et al. delves into a controversial area in breast oncology—role of ovarian function suppression (OFS) in pre-menopausal women with breast cancer. This question is more relevant in the Indian scenario where the median age of breast cancer is 47 years and a majority of women require chemotherapy as they have locally advanced disease at presentation.[1],[2] Even after the publication of the results of three large randomized trials and a meta-analysis,[3],[4],[5],[6] the value of adding OFS to standard therapy is not clear. If we look at the updated results of the SOFT and TEXT trials (reference updated analysis), the benefit of adding ovarian suppression was seen only in patients who required chemotherapy. The other group of patients who were sufficiently low risk not to warrant adjuvant chemotherapy did well irrespective of hormonal therapy regimen. Although distant recurrence-free survival and disease-free survival (DFS) were better with exemestane and OFS compared to OFS and tamoxifen, overall survival showed a reverse trend making interpretation of data difficult. Moreover, toxicity of 5 years of OFS was significant with 30% grade 3–4 toxicity in OFS arms in both SOFT and TEXT trials leading to 25%–30% early discontinuation rates.

In this context, Kim et al. tried to answer the question whether benefits of OFS are maintained when duration is reduced to 2 years. They randomized only those patients who received chemotherapy, thus addressing the limitation of SOFT trial in which benefits in overall population might have been underestimated by the good-risk subset of patients not requiring chemotherapy. They also allowed for delayed recovery of ovarian function up to 2 years allowing more patients to be randomized and mimicking the real-world scenario more closely. The trial results showed a 4% DFS benefit in favour of OFS plus tamoxifen over tamoxifen alone. The events were too few to draw any firm conclusions about overall survival.


Although these results indicate that a reduced duration of ovarian suppression may provide the same degree of benefit as extended suppression, a few issues with the trial need to be kept in mind.

First, the authors did not provide any information on the adverse events in both the groups. The major issue with extended ovarian suppression is non-compliance and toxicity, as seen in the SOFT and TEXT trials. The authors reported a 26% discontinuation rate in this trial, which is similar to the SOFT and TEXT trials when OFS was used for 5 years. This rate is higher than expected and difficult to justify in the absence of detailed safety analysis. We have already seen that longer duration of endocrine therapy results in DFS benefit in post-menopausal women.[7] Hence, more data on safety and compliance of reduced duration of OFS are needed before it can be considered standard of care.

Second, the overall DFS in this trial was significantly higher than the matched population of SOFT trial (DFS of 71% and 76% in tamoxifen and tamoxifen+OFS, respectively, in SOFT—almost 15% difference). Since all the patients received chemotherapy in this trial, they were expected to be at a high risk of recurrence and expected DFS was around 70%; this aspect deserved more clarification. A closer look at baseline characteristics suggests that almost 48% of patients had tumours <2 cm and 45% were lymph node-negative; since decision to give chemotherapy varied with institutional practice, it is possible that many low-risk patients got chemotherapy resulting in higher than expected DFS.

Third, the authors used DFS as the primary end-point and overall survival as the secondary end-point, which is acceptable. However, an equally important primary end-point in hormone-positive breast cancer is distant recurrence-free survival as most recurrences are distal (53% in SOFT trial and 70% in this trial). Although an unplanned analysis was done for this end-point and the hazard ratio was significant in favour of OFS plus tamoxifen, we believe it should have been a primary planned analysis.

In the end, we appreciate the work done by Kim et al. in this controversial area. Although this trial has some limitations, it is a step in the right direction and longer follow-up might help to clarify the benefit and duration of OFS in women with hormone-positive breast cancer.

Conflicts of interest. None declared

Sandhu DS, Sandhu S, Karwasra RK, Marwah S. Profile of breast cancer patients at a tertiary care hospital in north India. Indian J Cancer. 2010;47:16–22.
[Google Scholar]
Saxena S, Rekhi B, Bansal A, Bagga A, Chintamani, Murthy NS. Clinico-morphological patterns of breast cancer including family history in a New Delhi hospital, India—a cross-sectional study. World J Surg Oncol 2005;3:67.
[Google Scholar]
Francis PA, Regan MM, Fleming GF, Láng I, Ciruelos E, Bellet M, et al.; SOFT Investigators; International Breast Cancer Study Group. Adjuvant ovarian suppression in premenopausal breast cancer. N Engl J Med 2015;372:436–46.
[Google Scholar]
Pagani O, Regan MM, Walley BA, Fleming GF, Colleoni M, Láng I, et al.; TEXT and SOFT Investigators; International Breast Cancer Study Group. Adjuvant exemestane with ovarian suppression in premenopausal breast cancer. N Engl J Med. 2014;371:107–18.
[Google Scholar]
Francis PA, Pagani O, Fleming GF, Walley BA, Colleoni M, Láng I, et al.; SOFT and TEXT Investigators and the International Breast Cancer Study Group. Tailoring adjuvant endocrine therapy for premenopausal breast cancer. N Engl J Med 2018;379:122–37.
[Google Scholar]
Gnant M, Mlineritsch B, Stoeger H, Luschin-Ebengreuth G, Heck D, Menzel C, et al.; Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria. Adjuvant endocrine therapy plus zoledronic acid in premenopausal women with early-stage breast cancer: 62-month follow-up from the ABCSG-12 randomised trial. Lancet Oncol 2011;12:631–41.
[Google Scholar]
Davies C, Pan H, Godwin J, Gray R, Arriagada R, Raina V, et al.; Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) Collaborative Group. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. Lancet. 2013;381:805–16. Erratum in: Lancet 2013;381:804. Erratum in: Lancet 2017;389:1884.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections