ideasIdea
Hormone tablets instead of surgery for small breast cancers in the frail over-80s
Frail women over 80 with small hormone-sensitive breast cancers may do as well with a daily tablet as with surgery. A trial would define who can safely avoid the operation.
Older trials of primary endocrine therapy showed equal survival but more local progression; modern imaging and aromatase inhibitors change the calculus. Propose an RCT in women aged 80 and over with ER-positive tumours under 2 cm and frailty, comparing primary endocrine therapy with surgery, with quality of life and overall survival endpoints.
Hypothesis
Primary endocrine therapy is non-inferior for overall survival at five years and superior for quality of life and independence.
Rationale
Competing mortality dominates; post-surgical functional decline is common in the frail.
What would test it
800-patient pragmatic RCT.
Maturity
early clinical
Who has to act
clinic
Cost to try
Medium ($1M to $50M)
Years to first evidence
6
Bottlenecks it attacks
- Overdiagnosis and false alarms · Finding more cancer is not the same as saving lives. Screening also finds cancers that would never have hurt anyone, and treats them.
- Older and multimorbid patients are excluded and undertreated · Most people with cancer are over 65 but most trial patients are younger and fitter. We guess how to treat the majority.