Optimizing Premenopausal Hormone Receptor-Positive Human Epidermal Growth Factor Receptor 2-Negative Early Breast Cancer Management in India: Insights From Expert Consensus

Abstract

This research aims to optimize adjuvant ovarian function suppression (OFS) for premenopausal Indian women with hormone receptor-positive (HR+) /human epidermal growth factor receptor 2-negative (HER2-) early breast cancer (eBC). To address specific challenges identified in clinical practice, a comprehensive questionnaire consisting of 21 statements was developed. These statements were reviewed and validated by a scientific committee, ensuring their accuracy and relevance to the study's objectives. A panel of 46 Indian experts and one global expert in the field of eBC were asked to rate their level of agreement/disagreement with each statement. Consensus was defined as achieving ≥80% agreement among participants. Following two rounds of the modified Delphi technique, a consensus was achieved on 19 out of 21 statements addressing critical aspects of premenopausal HR+ HER2- eBC management. The expert panel strongly recommended comprehensive risk stratification for premenopausal patients with HR+ HER2- eBC, highlighting age ≤40 as a high-risk factor and advising composite assessments for patients ≥40 years. For high-risk patients, OFS coupled with an aromatase inhibitor emerged as the recommended therapeutic strategy. The panel recommended a potential duration of up to five years for OFS, provided tolerability is maintained. For patients under 40, simultaneous OFS and chemotherapy is advised when needed. For those over 40, sequential initiation is acceptable. Triptorelin is preferred among luteinizing hormone-releasing hormone analogs, though all options have similar efficacies. The outcomes of this consensus offer valuable clinical guidance, enabling individualized and evidence-based approaches for OFS in Indian patients with HR+ HER2- eBC.

Keywords: chemotherapy; ovarian function suppression; premenopausal women; risk stratification; triptorelin.

Figure 1. Steps in the development of the consensus statements

Source: This is an original image created by the author Ashok K. Vaid

Figure 2. Consensus-based algorithm for the role of OFS in the treatment of HR+/HER2- eBC in premenopausal women.

^§Offered to patients with node-negative HR+ EBC ^#In patients with a higher stage tumor or extensive lymph node involvement (greater than or equal to four nodes) ^†May be discontinued at two years based on treatment tolerability ^{^}Based on clinical practice in selected cases by extrapolating the results of AIs in postmenopausal women ^*Case-to-case basis with close monitoring of ovarian function for patient feasibility ^‡Chemotherapy administered concomitantly with OFS+AI is preferred in younger women, whereas sequential initiation is preferred in older women AI: aromatase inhibitor; eBC: early-stage breast cancer; ER: estrogen receptor; HER2-: human epidermal growth factor receptor 2; HR: hormone receptor; LV/PI: lymphovascular and perineural invasion; OFS: ovarian function suppression; PgR: progesterone receptor Source: [13,34,39,48-53]