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

Dr Christina Davies MBChB a

, Hongchao Pan PhD a, Jon Godwin DPhil b, Prof Richard Gray MSc a, Prof Rodrigo Arriagada MD c, Prof Vinod Raina MD d, Mirta Abraham MD e, Victor Hugo Medeiros Alencar MD f, Atef Badran PhD g, Xavier Bonfill MD h, Joan Bradbury i, Prof Michael Clarke DPhil j, Prof Rory Collins FMedSci a, Prof Susan R Davis MBBS i, Antonella Delmestri PhD a, Prof John F Forbes MD k, Prof Peiman Haddad MD l, Prof Ming-Feng Hou MD m, Prof Moshe Inbar MD n, Prof Hussein Khaled MD g, Joanna Kielanowska MD o, Wing-Hong Kwan MD p, Beela S Mathew MD q, Bettina Müller MD r, Antonio Nicolucci MD s, Octavio Peralta MD r, Fany Pernas t, Prof Lubos Petruzelka MD u, Prof Tadeusz Pienkowski MD v, Balakrishnan Rajan MD w, Maryna T Rubach MD o, Sera Tort MD h, Gerard Urrútia MD h, Miriam Valentini MD s, Yaochen Wang MD a, Prof Richard Peto FRS a, for the Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) Collaborative Group†

Summary

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.