What are the recommended management strategies for early-stage breast cancer in postmenopausal women?

Management of early-stage breast cancer in postmenopausal women primarily involves surgery followed by adjuvant systemic therapies tailored to tumour biology and risk factors. Surgery typically includes breast-conserving surgery or mastectomy depending on tumour size and patient preference, followed by radiotherapy if breast-conserving surgery is performed NICE NG101.

For hormone receptor-positive, HER2-negative early breast cancer, adjuvant endocrine therapy is strongly recommended. Aromatase inhibitors (either non-steroidal or steroidal) are the preferred first-line endocrine treatment for postmenopausal women, including those with no prior endocrine therapy or those previously treated with tamoxifen NICE NG101. This approach is supported by evidence showing improved disease-free survival and overall survival with aromatase inhibitors compared to tamoxifen alone Lumachi et al. 2016.

In cases of high-risk, node-positive hormone receptor-positive breast cancer, the addition of abemaciclib to endocrine therapy is recommended to reduce recurrence risk NICE NG101.

Neoadjuvant endocrine therapy may be considered for postmenopausal women with ER-positive invasive breast cancer to reduce tumour size when chemotherapy is not clearly indicated NICE NG101.

Adjuvant chemotherapy is considered based on tumour characteristics and risk assessment, with neoadjuvant chemotherapy an option in selected cases of ER-positive disease NICE NG101. For patients with germline BRCA1/2 mutations and high-risk HER2-negative early breast cancer treated with chemotherapy, olaparib is recommended as adjuvant therapy NICE NG101.

Bone health management is critical during aromatase inhibitor therapy due to increased risk of bone loss; adjuvant bisphosphonates are recommended to reduce bone loss and may also reduce breast cancer recurrence in postmenopausal women Brufsky 2007Mathew & Brufsky 2014.

Overall, the integrated management strategy for early-stage breast cancer in postmenopausal women involves surgery, radiotherapy as indicated, adjuvant endocrine therapy with aromatase inhibitors, consideration of targeted agents like abemaciclib in high-risk cases, chemotherapy based on risk stratification, and bone health optimization with bisphosphonates NICE NG101 Lumachi et al. 2016Brufsky 2007Mathew & Brufsky 2014.