Seems like a very vaild concern, HereToHelpMyMom. I don't have the answers, but hopefully others more familiar with Osteo and AIs will be on to share their experiences. I think from my reading in prep for my own DEXA scan and transition to AIs, that I recall tamoxifen being associated with less fracture risk than AIs. However, I think I also recall that there are other treatments that can coincide/support treatment with AIs to manage the Osteoporosis. Again, sorry I'm not much help, but wishing you both the best in her journey and decision making....at least I can bump your thread and hope others with more info will be by soon. Hang in there.

The question isn't an AI vs. Tamoxifen. The question is whether any endocrine therapy is beneficial. An Oncotype of 9 equates to no more than a 3% risk of mets, assuming endocrine therapy. This means that without endocrine therapy, the risk is 4%. The risk of serious side effects from endocrine therapy for someone age 80 is higher than the 1% metastatic breast cancer risk reduction that endocrine therapy would provide.

I'm pretty certain that my MO, who specializes in the side effects of cancer treatments, would refuse to prescribe either an AI or Tamoxifen to an 80 year old patient with an Oncotype score of 9.

edj3, what I am saying is:

"Why subject an elderly patient to all the risks of endocrine therapy (whether Tamoxifen or AI) when their risk of metastatic breast cancer is already so low based on having such a low Oncotype score, and would only be reduced by 1% by taking the endocrine therapy".

For someone of this age who has such a low riskof mets based on the Oncotype score, who could suffer greatly and seriously from the side effects, the risks from the treatment are greater than the risks from the disease.

Edited (italicized words added) to provide clarity that I am not suggesting that endocrine therapy is inappropriate for all elderly patients but am questioning the rationale for endocrine therapy in situations such as this one where the risk of mets is so low that the risk reduction benefit from the meds will possibly be lower than the serious health risks the patient is exposed to from the meds.

No, the Oncotype test does not indicate the level of risk reduction with endocrine therapy. But many studies have been done over the past 2 decades on the efficacy of endocrine therapy. Endocrine therapy on average reduces the risk of a metastatic recurrence by 30% - 35%.

I was in my 50s taking anastrozole and exemestane and I suffered bone loss but nothing earth shattering. My bone density scan is acceptable for someone my age. If I were 80 years old and already had significant degradation, I would ask why AI drug over tamoxifen. Tamoxifen has some risk factors as well but I would make sure they explain why one drug was better than the other.

If your Mom was er+ pr- I might understand, but she is er+ pr+.

Bessie, my MO does not prescribe endocrine therapy for those with early stage disease, over 80 years of sge

Beesie, do you know of anywhere you can find your risk without treatment just surgery for hormone positive cancers?

I was under the impression overall risk is about 30% for doing surgery alone but that is combined for all early stage breast cancers.

Just curious if you have run accross something I haven't seen.

I should have mentioned my reduction to 10% on oncodx score was assuming chemo such as CMF and taking tamoxifen. The oncodx scoring and risks are taking into consideration you will take tamoxifen. I have been assuming my risk of recurrence doing nothing but surgery was about 30% but could it have been higher?

Yes, it is correct that the Oncotype report only states the risk of mets with Endocrine therapy alone, or with Endocrine therapy and chemo.

But it's not difficult to estimate, with a fair degree of certainty, the risk without endocrine therapy. Endocrine therapy on average reduces the risk of a metastatic recurrence by 30% - 35%. This has been verified in many studies over the past 2 decades. This means that if the risk level with Endocrine therapy is 3%, it is impossible for the risk with no treatment to be 20%, 30% or 40%. To get a risk of 20% down to 3% would mean that endocrine therapy would be reducing the risk by 85%. To get a risk of 40% down to 3% would mean that endocrine therapy would be reducing the risk by 92.5%. While there might be some fluctuation in the 30% - 35% risk reduction figure, there isn't going to be that much fluctuation. Considering a reasonable range of fluctuation, a 3% risk of mets with endocrine therapy will translate to around a 3.7% - 5% risk without.

To put it another way, the way the Oncotype score works is that it assumes the standard benefit for endocrine therapy. Someone who has a 40% risk without endocrine therapy is going to be getting a very high Oncotype score, and a recommendation for chemo in addition to endocrine therapy.

Meow, I think the information you are looking for will be too variable depending on the size and pathology of the tumor, as well as the age of the patient. Surgery alone will result in a low risk for one patient but a high risk for another. Averages will be misleading.

Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials

- A summary of 20 trials done on Tamoxifen.

- "In oestrogen receptor (ER)-positive disease (n=10,645), allocation to about 5 years of tamoxifen substantially reduced recurrence rates throughout the first 10 years (RR 0·53)" In other words, a 47% reduction in recurrence over 10 years, based on taking 5 years of Tamoxifen. Note however that this includes all recurrences, both local and distant.

- "Breast cancer mortality was reduced by about a third throughout the first 15 years (RR 0·71 [0·05] during years 0-4, 0·66 [0·05] during years 5-9, and 0·68 [0·08] during years 10-14; p<0·0001 for extra mortality reduction during each separate time period)." This finding better reflects the results relative to distant recurrence, with breast cancer mortality reduced by approx. 1/3 over 15 years, for those who took Tamoxifen for 5 years.

Thanks for the explanation Beesie, as always very informative.

FYI, I did edit my post to make sure it's clear that BarredOwl's post was in response to another member, not specifically to me.

FWIW, back in Feb, I did ask my own MO about my MERs/Rrisk if I'm not able to tolerate any kind of endocrine therapy, she told me it would be 28-35%. My Oncotype gave me a score of 17. Which seems to fall in line with the 1/3 you were outlining Beesie. For me, I have confidence in her and her statement, given my young age, health history, and my own tumor specifics.

I am confused. Have they recently changed the Oncotype recurrence ranges? I ask because 2 years ago my score was 3 and my chance of recurrence was 4% at 10 years. Now it seems those with a score of 9 have a 3% chance of recurrence. Having trouble understanding the change.

Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials

This is the full report of the study I quoted earlier. Lots of information about the recurrence risk reduction benefit and mortality reduction benefit (i.e. risk of mets) of Tamoxifen.

With regard to side effects, in the conclusion, it says:

"Although age is not a strong independent correlate of distant recurrence or of tamoxifen efficacy, being young is a major determinant of the gain in life expectancy from avoidance of distant recurrence. Worldwide, half of all patients with breast cancer are younger than 55 years when diagnosed. For premenopausal or perimenopausal women with ER-positive breast cancer, tamoxifen is a major hormonal treatment option (because ovarian function cannot be controlled by aromatase inhibitors), and there is little uterine cancer risk or excess risk of fatal pulmonary embolus from administration of tamoxifen before age 45 years or at ages 45–54 years. By contrast, for older women with an intact uterus the excess risk of death from endometrial cancer or pulmonary embolus could well be about 1%."

Unfortunately, my SIL was one of those rare cases she died August 2017. She developed endocrine cancer and her doctor was not paying attention she could actually feel her tumors, it was too late. She was 56 years old. Be careful if detected early enough it could mean the difference between life and death.

Salamandra, it appears that although the TAILORx study had been released, it was not yet incorporated into your results. Note that your prognosis chart indicates "from NSABP-14", which was the original study used to determine the Oncotype scores.

The report today would indicate that the results are from TAILORx and NSABP-20 (for chemo benefit).