Response to Hormonal Therapy Before Surgery Different in Black and White Women
Early-stage, hormone receptor-positive breast cancer was more likely to shrink after hormonal therapy before surgery in Black women than in white women. But Black women had worse outcomes than white women if the breast cancer was a higher stage, according to a City of Hope study.
The research, “Differential response to neoadjuvant endocrine therapy for Black and White women in NCDB,” was presented on Sept. 17, 2022, at the 15th American Association for Cancer Research Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved.
Doctors call treatments given before surgery neoadjuvant treatments. So doctors call hormonal therapy given before surgery neoadjuvant hormonal therapy.
What is hormonal therapy?
Also called anti-estrogen therapy or endocrine therapy, hormonal therapy is used to treat all stages of hormone receptor-positive breast cancer. More than 70% of all breast cancers are hormone receptor-positive.
There are three main types of hormonal therapy medicines used to treat breast cancer:
aromatase inhibitors: Arimidex (chemical name: anastrozole), Aromasin (chemical name: exemestane), and Femara (chemical name: letrozole)
selective estrogen receptor modulators (SERMs): tamoxifen, Evista (chemical name: raloxifene), and Fareston (chemical name: toremifene)
estrogen receptor downregulators (ERDs): Faslodex (chemical name: fulvestrant)
Doctors may recommend neoadjuvant hormonal therapy to shrink larger breast cancers before surgery. It's important to know that Evista, Fareston, and Faslodex are not approved by the U.S. Food and Drug Administration (FDA) to treat early-stage breast cancer.
About the study
Nearly all people diagnosed with hormone receptor-positive breast cancer receive a hormonal therapy medicine. But Black women are four times more likely to die from hormone receptor-positive breast cancer than white women.
In this study, the researchers wanted to look at the differences in outcomes between Black women and white women diagnosed with breast cancer who received hormonal therapy before surgery.
Using information from the National Cancer Database, the researchers identified 3,521 white women and 365 Black women diagnosed with stage I to stage III hormone receptor-positive breast cancer. All the women received hormonal therapy before surgery between 2004 and 2017.
The researchers excluded women who also received chemotherapy before surgery from the study.
The National Cancer Database is a national registry that includes data from more than 1,500 medical institutions in the United States.
When diagnosed, Black women were:
1.6 times more likely than white women to have cancer in their lymph nodes
1.5 times more likely than white women to have stage III breast cancer
Black women also received neoadjuvant hormonal therapy for longer than white women:
Black women received neoadjuvant hormonal therapy for about 128 days.
White women received neoadjuvant hormonal therapy for about 114 days.
After neoadjuvant hormonal therapy, 0.8% of the cancers were either:
down-staged to DCIS, which is stage 0 cancer
eliminated, meaning no cancer was found during surgery
All the cancers that were down-staged or eliminated were either stage I or stage II cancers.
Black women were 2.9 times more likely than white women to have the cancer down-staged or eliminated after neoadjuvant hormonal therapy.
On the other hand, after neoadjuvant hormonal therapy, 0.9% of the cancers — all but two of which were stage II or stage III — up-staged to stage IV cancer. Stage IV breast cancer is cancer that has spread to parts of the body away from the breast, such as the bones or liver.
Black women were 2.6 times more likely than white women to have the cancer up-staged after neoadjuvant hormonal therapy.
“While lower-stage cancers in Black women responded better to endocrine therapy compared to white women, higher-stage cancers in Black women did more poorly in response to endocrine therapy,” presenter Veronica Jones, MD, assistant professor of breast surgery at City of Hope, said in a statement. “This suggests a different tumor biology that may impact the treatment we give.”
What this means for you
The results of this study are troubling. But it is important to know that the researchers had no information on how well the women stuck to their hormonal therapy treatment plans.
The aromatase inhibitors are known to cause bone and joint pain. Studies suggest that up to half the women prescribed an aromatase inhibitor stop taking the medicine early, in many cases because of bone and joint pain.
Tamoxifen can cause hot flashes and other menopausal symptoms. Like the aromatase inhibitors, studies suggest that about half the women prescribed tamoxifen stop taking the medicine early.
If women stopped taking hormonal therapy early, it would affect the outcomes of this study.
The researchers plan to look at which genes are active in breast cancers from Black women and white women. They can use this information to understand how the biology of breast cancer is different between Black women and white women. The new information also may lead to new treatments that target specific genes and other proteins that control how cancer cells behave.
“This project is a critical step in unpacking the heterogeneity of hormone receptor tumor biology,” Dr. Jones said. “It brings into question how we can more effectively manage this disease to mitigate breast cancer racial disparities.”
Learn more about tumor heterogeneity.
— Last updated on November 16, 2022 at 7:23 PM