Danee, I responded in your previous thread:

Topic: MO said hormone therapy reduces recurrence risk by 20%?? https://community.breastcancer.org/forum/78/topics...

.

Here is some additional information:

The 50% rate you mention is either for total recurrences or just local recurrences - not distant recurrences, which is the risk that is measured by Oncotype test. When you look only at distant recurrences or mortality (as an outcome of a distant recurrence) the benefit from Tamoxifen is in the range of 30% to 1/3rd. The benefit from the AIs is a few percentage points higher - about 35% (to 40%, max).

Following is the definitive article about Tamoxifen benefit based on 5 years of Tamox. It is a meta-analysis of 20 trials representing data from over 21,000 patients:

"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)."

There was a later study that looked at 10 years of Tamoxifen usage. This study only compared 5 years of Tamox to 10 years of Tamox; there was no study arm that didn't take Tamoxifen at all. That said, by assessing previous studies and doing some calculations, they did determine that 10 years of Tamoxifen might reduce mortality rates in the years beyond 10 years (after diagnosis, assuming taking Tamoxifen the whole time) by as much as 48%. However the confidence interval on this result is not high, and the conclusion is that the benefit might be only 1/3. And in any case, even if the 48% reduction is true, when you average out the entire period of time, the risk reduction benefit is lower, because the rates over the earlier years are in the 30% t0 33% range.

"By combining results from the previous trials1 with the new results from ATLAS, we can estimate what would be seen in trials of 10 years of adjuvant tamoxifen compared with no treatment. Table 3 provides, by time since diagnosis, the recurrence RRs from the trials of 5 years of tamoxifen versus no tamoxifen and from the ATLAS trial of continuing tamoxifen to 10 years versus stopping at 5 years, and multiplies these RRs together to estimate what would be seen in trials of 10 years of tamoxifen versus no tamoxifen. Table 3 also provides similar estimates for breast cancer mortality. The recurrence and, particularly, the mortality findings are remarkable, and suggest that in trials of 10 years of tamoxifen versus no tamoxifen, breast cancer mortality rates during the second decade after diagnosis would be almost halved, although the real finding is not the point estimate but the CI (which shows that the reduction could be as little as a third rather than a half)."

Looking at AIs, you can assume results that are slightly more favorable. But still, the overall metastatic risk reduction for the AIs will fall in the range of 35%-40%, not 50%. And definitely not a 20 absolute percentage point reduction.

Therefore if your risk (based on your Oncotype score, I assume) is 3%, your risk if you don't take endocrine therapy will be about 5%.

Your MO is flat out lying to you (because surely he understands the real numbers and can do the math).

Ugh that makes me so angry Danee78. It's infuriating, patronizing, and just bad medicine, to lie to patients.

If you have a way to see a new doctor, that would be great. If you do, it would be worthwhile to give feedback to this doctor's practice/center (assuming he isn't a solo practitioner) about what he said to you.

Beesie said “Your MO is flat out lying to you (because surely he understands the real numbers and can do the math).“

Sadly, it is also possible he does not understand and can’t do the math. I went to a first MO visit with a relative, and it was appalling. I caught several factual errors, errors in standard of care, etc. and got the impression that this person was actually quite uneducated and/or unintelligent. Question: What do they call the person who graduated at the bottom of their medical school class? Answer: “Doctor”

My relative and I typed up a letter and filed an official complaint, and commenced a battle with insurance to get her into a different oncology practice. Ultimately we were successful.

Shetland and Beesy, for some reason Danee deleted her original post which takes the context away from all the responses.

I can't believe that any MO with even the slightest bit understanding of Tamoxifen - even one who finished last in his class and doesn't stay up-to-date on the research - would insist that not taking endocrine therapy would turn a 97% distant recurrence free survival rate (or a 3% metastatic recurrence risk) into a 77% distance recurrence free survival rate (or 23% metastatic recurrence risk). That represents more than a 600% risk reduction benefit from anti-hormone therapy. Even if the guy can't do the math, he would have to know this is wrong. Assuming he treats other BC patients, he would have seen Oncotype reports for those with higher scores and for whom chemo would be recommended, and he would know that the order of magnitude difference (3% to 23%) is way out of line.

True that some MOs can't do math and don't understand relative vs. absolute risk but from my reading of posts on this site, I think it's more common that MOs tweek the numbers to try to coerce patients into taking a treatment they recommend. I just don't know if I've seen a situation where it is this extreme and obvious.

hello all I was on tamoxifen for 5yrs after cancer treatment was complete and I am this yr a 26yr breast cancer Survivor Praise God. Age 42 at diagnosis while making wedding plans for our 2nd marriages .msphil idc stage2 0/3 nodes 3mo chemo before and after Lmast with reconstruction after 1 filling the expander hardened and temp 102 was removed. Then got married then 7wks rads and 5yrs on Tamoxifen.

dbrooks, because Tamoxifen was already an approved and proven therapy when the AIs were being tested, to my knowledge all the trials of the AIs were done against a control group who took Tamoxifen, and none had an control group with the patients not taking any therapy. Because Tamox. was on the market and proven effective, a 'no therapy' arm would have been irresponsible. So there is no clinical trial data available comparing usage of AIs to not taking endocrine therapy at all, although the following meta-analysis does speculate on this. But there are numerous studies comparing AIs to Tamoxifen.

You need to dig into the details of any of these studies to separate out total recurrences (which would include local, in the breast area recurrences) from metastatic recurrences. Overall, both AIs and Tamoxifen reduce the risk of local recurrences by more than they reduce the risk of distant recurrences (45%-50 or higher vs. 30%-40% at most) so a 'total recurrences' figure will be a bit inflated if you are specifically looking for the benefit related to metastatic recurrence (which is what is relevant when considering the Oncotype risk). Not all the studies break this out.

The following 2015 report is a meta-analysis, so it incorporates all of the earlier studies:

Aromatase inhibitors versus tamoxifen in early breast cancer: patient-level meta-analysis of the randomised trials

"The reduction in breast cancer mortality with aromatase inhibitor compared with tamoxifen is only slight, as expected in an already relatively good-prognosis population, but persists during years 0–4 and 5–9, significantly reducing 10-year breast cancer mortality. Overall 10-year mortality was also significantly reduced, even though about half the deaths were not due to breast cancer. Non-breast cancer death rates were similar with aromatase inhibitor and tamoxifen except that, after 2–3 years of tamoxifen, there appeared to be fewer such deaths with an aromatase inhibitor than with continuing tamoxifen. This finding was unexpected, not explained by any one cause, and not replicated in the other comparisons. Though likely to be a chance finding, it is reassuring for the safety of aromatase inhibitors."

"We can infer from the present results the proportional reductions that would be achieved with 5 years of aromatase inhibitor compared with no adjuvant endocrine therapy. Treatment with tamoxifen for 5 years reduces recurrence by about half during years 0–4 and one-third during years 5–9, and reduces the breast cancer mortality rate by about 30% throughout the first decade and beyond.¹ Therefore, 5 years of an aromatase inhibitor compared with no endocrine therapy would reduce breast cancer recurrence by about two-thirds during treatment and by about one-third during years 5–9, and would reduce the breast cancer mortality rate by around 40% throughout the first decade, and perhaps beyond. Though these proportional reductions in risk are approximately independent of nodal status, tumour grade, diameter, PR, and HER2 status, these prognostic factors substantially affect the absolute risk with no endocrine treatment, and hence substantially affect the absolute reduction in that risk produced by aromatase inhibitors."

Beesie, not Bessie. Check out her avatar