Adjuvant chemotherapy and hormonotherapy versus adjuvant hormonotherapy alone for women aged 70 years and older with high-risk breast cancer based on the genomic grade index (ASTER 70s): a randomised phase 3 trial

Abstract

Background: For women aged 70 years or older with oestrogen receptor-positive HER2-negative invasive breast cancer, hormonotherapy is a standard adjuvant treatment, while the role of chemotherapy is debated. We aimed to assess the effect of adjuvant chemotherapy on overall survival in these older patients with high-risk tumours according to a prognostic genomic signature.

Methods: This phase 3, randomised, superiority study was conducted at 84 clinical sites in France and Belgium in women aged 70 years and older with oestrogen receptor-positive and HER2-negative primary breast cancer or isolated local recurrence before any systemic treatment and after complete surgery. Genomic grade index (GGI) testing was done with a reverse-transcriptase PCR assay of eight genes on paraffin-embedded tumour tissue in a central laboratory. Patients with a GGI high-risk tumour were randomly allocated (1:1) to receive either four cycles of postoperative taxane-based or anthracycline-based chemotherapy given every 3 weeks followed by hormonotherapy (chemotherapy group) or hormonotherapy alone (no chemotherapy group). Randomisation was stratified according to the G8 screening tool score for geriatric frailty, nodal status, and centre. The primary endpoint was overall survival. This study is registered with ClinicalTrials.gov (NCT01564056) and is under active follow-up.

Findings: Between April 12, 2012 and April 14, 2016, 1969 patients were screened for GGI, of whom 1089 had a GGI high-risk tumour and were randomly allocated to the chemotherapy group (n=541) or the no chemotherapy group (n=548). Median age was 75·1 years (IQR 72·5 to 78·7) and geriatric frailty (G8 score ≤14) was identified in 437 patients (40%) patients. With a median follow-up time of 7·8 years (95% CI 7·5 to 7·8), overall survival rates were 90·5% (95% CI 87·6 to 92·8) at 4 years and 72·7% (67·8 to 77·0) at 8 years in the chemotherapy group, and 89·3% (86·2 to 91·6) at 4 years and 68·3% (63·3 to 72·7) at 8 years in the no chemotherapy group (stratified log-rank p=0·2100; hazard ratio 0·83 [95% CI 0·63 to 1·11]), yielding statistically non-significant absolute differences in survival probability of 1·3 percentage points (95% CI -2·4 to 5·0) at 4 years and 4·5% (95% CI -2·1 to 11·1) at 8 years. Safety analysis favoured the no chemotherapy group: at least one grade 3 or higher adverse event occurred in 52 (9%) of 548 patients in the no chemotherapy group (including one death not related to treatment), compared with 183 (34%) of 541 patients in the chemotherapy group (including three deaths, of which one was related to treatment).

Interpretation: The addition of adjuvant chemotherapy to hormonotherapy conferred no survival benefit in women aged 70 years and above with a GGI high-risk oestrogen receptor-positive HER2-negative breast cancer, and was associated with more adverse events, providing important data on the benefit-risk balance of adding adjuvant chemotherapy to adjuvant hormonotherapy in this older age group.

Funding: Programme Hospitalier de Recherche Clinique (PHRC National Cancer 2011), Cephalon, Amgen, Ipsogen, Association d'Aide à la Recherche Cancérologique de Saint-Cloud, and Ligue Contre le Cancer.