Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial

Christina Davies*, Hongchao Pan, Jon Godwin, Richard Gray, Rodrigo Arriagada, Vinod Raina, Mirta Abraham, Victor Hugo Medeiros Alencar, Atef Badran, Xavier Bonfill, Joan Bradbury, Michael Clarke, Rory Collins, Susan R. Davis, Antonella Delmestri, John F. Forbes, Peiman Haddad, Ming Feng Hou, Moshe Inbar, Hussein KhaledJoanna Kielanowska, Wing Hong Kwan, Beela S. Mathew, Indraneel Mittra, Bettina Müller, Antonio Nicolucci, Octavio Peralta, Fany Pernas, Lubos Petruzelka, Tadeusz Pienkowski, Ramachandran Radhika, Balakrishnan Rajan, Maryna T. Rubach, Sera Tort, Gerard Urrútia, Miriam Valentini, Yaochen Wang, Richard Peto

*Corresponding author for this work

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1065 Citations (Scopus)

Abstract

Background For women with oestrogen receptor (ER)-positive early breast cancer, treatment with tamoxifen for 5 years substantially reduces the breast cancer mortality rate throughout the first 15 years after diagnosis. We aimed to assess the further effects of continuing tamoxifen to 10 years instead of stopping at 5 years. Methods In the worldwide Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) trial, 12 894 women with early breast cancer who had completed 5 years of treatment with tamoxifen were randomly allocated to continue tamoxifen to 10 years or stop at 5 years (open control). Allocation (1:1) was by central computer, using minimisation. After entry (between 1996 and 2005), yearly follow-up forms recorded any recurrence, second cancer, hospital admission, or death. We report effects on breast cancer outcomes among the 6846 women with ER-positive disease, and side-effects among all women (with positive, negative, or unknown ER status). Long-term follow-up still continues. This study is registered, number ISRCTN19652633. Findings Among women with ER-positive disease, allocation to continue tamoxifen reduced the risk of breast cancer recurrence (617 recurrences in 3428 women allocated to continue vs 711 in 3418 controls, p=0•002), reduced breast cancer mortality (331 deaths vs 397 deaths, p=0•01), and reduced overall mortality (639 deaths vs 722 deaths, p=0•01). The reductions in adverse breast cancer outcomes appeared to be less extreme before than after year 10 (recurrence rate ratio [RR] 0•90 [95% CI 0•79-1•02] during years 5-9 and 0•75 [0•62-0•90] in later years; breast cancer mortality RR 0•97 [0•79-1•18] during years 5-9 and 0•71 [0•58-0•88] in later years). The cumulative risk of recurrence during years 5-14 was 21•4% for women allocated to continue versus 25•1% for controls; breast cancer mortality during years 5-14 was 12•2% for women allocated to continue versus 15•0% for controls (absolute mortality reduction 2•8%). Treatment allocation seemed to have no effect on breast cancer outcome among 1248 women with ER-negative disease, and an intermediate effect among 4800 women with unknown ER status. Among all 12 894 women, mortality without recurrence from causes other than breast cancer was little affected (691 deaths without recurrence in 6454 women allocated to continue versus 679 deaths in 6440 controls; RR 0•99 [0•89-1•10]; p=0•84). For the incidence (hospitalisation or death) rates of specific diseases, RRs were as follows: pulmonary embolus 1•87 (95% CI 1•13-3•07, p=0•01 [including 0•2% mortality in both treatment groups]), stroke 1•06 (0•83-1•36), ischaemic heart disease 0•76 (0•60-0•95, p=0•02), and endometrial cancer 1•74 (1•30-2•34, p=0•0002). The cumulative risk of endometrial cancer during years 5-14 was 3•1% (mortality 0•4%) for women allocated to continue versus 1•6% (mortality 0•2%) for controls (absolute mortality increase 0•2%). Interpretation For women with ER-positive disease, continuing tamoxifen to 10 years rather than stopping at 5 years produces a further reduction in recurrence and mortality, particularly after year 10. These results, taken together with results from previous trials of 5 years of tamoxifen treatment versus none, suggest that 10 years of tamoxifen treatment can approximately halve breast cancer mortality during the second decade after diagnosis. Funding Cancer Research UK, UK Medical Research Council, AstraZeneca UK, US Army, EU-Biomed.

Original languageEnglish
Pages (from-to)805-816
Number of pages12
JournalThe Lancet
Volume381
Issue number9869
DOIs
Publication statusPublished - 01 Jan 2013

ASJC Scopus subject areas

  • Medicine(all)

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    Davies, C., Pan, H., Godwin, J., Gray, R., Arriagada, R., Raina, V., Abraham, M., Medeiros Alencar, V. H., Badran, A., Bonfill, X., Bradbury, J., Clarke, M., Collins, R., Davis, S. R., Delmestri, A., Forbes, J. F., Haddad, P., Hou, M. F., Inbar, M., ... Peto, R. (2013). Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. The Lancet, 381(9869), 805-816. https://doi.org/10.1016/S0140-6736(12)61963-1