Articles Introduction Use of adjuvant endocrine treatments in premenopausal women with hormone-receptor-positive early-stage breast cancer has increased with the growing evidence of the treatments’ effectiveness, and of poorer outcomes seen in the absence of endocrine therapy. 1 Randomised clinical trials 2–4 have established that tamoxifen, oophorectomy, and goserelin are effective adjuvant treatments for premenopausal women with early-stage breast cancer. However, premenopausal women need to weigh the potential survival benefits against an array of unpleasant side-effects associated with endocrine treatment, which can include menopausal hot flashes, other vasomotor symptoms, loss of bone-mineral density, cognitive problems, vaginal dryness, changes in body image and sexual function, and altered plans for child-bearing. 5 Endocrine therapies differ in their side- effects: for example, premenopausal women given goserelin have more severe side-effects and more disruption to quality of life than do those given tamoxifen alone. 6,7 The choice between treatments is difficult because of the complex nature of probabilistic information: for an individual, the benefits and side-effects are uncertain before starting treatment, and the benefits remain uncertain. 8 Some studies 9–11 of patients’ preferences have formed the basis for bedside decision tools, visual aids, or computer programs to help patients clarify their treatment preferences, whereas other studies 12–16 have quantified the amount of benefit required by those who have had treatment for breast cancer to justify the side- effects and inconvenience of adjuvant chemotherapy. Data obtained from patients who have had treatment previously can be used to aid other patients in their choice of treatment and in the planning of clinical trials. Despite differing methods, all the studies 12–16 assessing the preferences of women with breast cancer found that most patients judged small improvements in survival sufficient to make adjuvant chemotherapy worthwhile. When the data from these studies were combined by averaging the benefits required across studies, about half the participants thought that a gain in survival of 1% and a gain in life expectancy of 6 months were sufficient to make the side-effects and inconvenience of adjuvant chemotherapy worthwhile. 8 Women who would accept smaller survival benefits to make chemotherapy worthwhile generally had dependents (not including own children), 12,16 perceived that their needs for support had been met, 12,16 had node- positive disease, 13 lived at home during chemotherapy, 16 had a friend or relative who had died from breast cancer, 16 and had not had radiotherapy. 12 Three Lancet Oncol 2005; 6: 581–88 See Reflection and Reaction page 543 Published online July 14, 2005 DOI:10.1016/S1470-2045(05) 70254-0 Prince of Wales Hospital, Randwick, Sydney, Australia (B Thewes MClinPsych, B Meiser PhD, Prof M L Friedlander FRACP), NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia (V M Duric PhD, M R Stockler FRACP); Department of Psychology, Macquarie University, Sydney, Australia (A Taylor PhD); St George Hospital, Sydney, Australia (M Links FRACP); Westmead Hospital, Sydney, Australia (N Wilcken FRACP); Royal Prince Alfred Hospital, Sydney, Australia (J Beith FRACP); Mater Misericordiae Hospital, Sydney, Australia (F Boyle FRACP); Canberra Hospital, Canberra, Australia (R Stuart-Harris FRACP); St Vincent’s Hospital, Melbourne, Australia (S A McLachlan FRACP); and Peter MacCallum Cancer Centre, Melbourne, Australia (K A Phillips FRACP) Correspondence to: Belinda Thewes, Department of Medical Oncology, Prince of Wales Hospital, Randwick, Sydney, New South Wales 2031, Australia b.thewes@unsw.edu.au http://oncology.thelancet.com Vol 6 August 2005 581 What survival benefits do premenopausal patients with early breast cancer need to make endocrine therapy worthwhile? Belinda Thewes, Bettina Meiser, Vlatka M Duric, Martin R Stockler, Alan Taylor, Robin Stuart-Harris, Matthew Links, Nicholas Wilcken, Sue Anne McLachlan, Kelly-Anne Phillips, Jane Beith, Frances Boyle, Michael L Friedlander Summary Background Adjuvant endocrine therapies such as tamoxifen, goserelin, and oophorectomy improve survival for premenopausal women diagnosed with early-stage breast cancer. However, these treatments often result in menopausal symptoms, sexual dysfunction, permanent infertility, or the need to delay pregnancy. We aimed to quantify the survival gains that premenopausal patients with early-stage breast cancer require to justify the side- effects and inconvenience of adjuvant endocrine treatments. Methods Participants consisted of 102 women who had been diagnosed with early-stage (stage I–II) breast cancer 6–60 months previously, who were aged 40 years or younger at diagnosis, and who had been treated for a minimum of 3 months with endocrine therapy (67 with tamoxifen alone, seven with goserelin alone, and 28 with tamoxifen and goserelin or oophorectomy). 76 patients also received chemotherapy, and 75 received radiotherapy. Participants attended a face-to-face patient-preference interview, in which they were presented with four hypothetical clinical scenarios that were used to quantify the gains in survival rate and life expectancy that women judged necessary to make their endocrine therapy worthwhile. They also completed a questionnaire on standard psychological measures. Findings About half of participants thought that adjuvant endocrine therapy was worthwhile for an absolute gain in survival of 2% from a baseline of either 65% or 85%, and for a gain in life expectancy of 3 months from a baseline of 5 years and of 6 months for a baseline of 15 years. Women who had had more severe endocrine side-effects required larger gains to make endocrine therapy worthwhile (univariate p=0·02, multivariate p=0·04). Interpretation Modest gains in survival are sufficient to make adjuvant endocrine treatment worthwhile for premenopausal women with early-stage breast cancer. Knowing and incorporating what women think should enhance shared decision-making.