Abstract
Globally, there are 500,000 annual new cases of hormone-sensitive breast cancer in premenopausal women; 400,000 of these occur in women in low and middle income countries (LMIC). With optimal adjuvant therapy, fully one third more than the half of women who might survive with primary surgery alone-more than 80%, could survive 10 years. Affordability and practicality of treatment profoundly affect global practice and these do not characterize the current standards of care – LHRH agonist plus tamoxifen or an aromatase inhibitor.
Surgical oophorectomy plus tamoxifen is a safe, efficient and affordable, patient-centered and equitable adjuvant treatment, long considered equivalent to that from LHRH agonist plus tamoxifen treatment. New data additionally suggest that women, who are in extended follicular phase of their cycles at the time of surgery, benefit much less from this treatment, and women who are in normal progesterone-confirmed follicular or luteal phases, benefit more than unselected or LHRH-treated women. New data also show that surgical oophorectomy plus tamoxifen is associated with no loss of bone mineral density at the hip, and loss for only a year in the lumbar spine.
The dominance of a business model for medicine, the narrow perspective and single metric-efficacy focus of guideline creation, and limited understanding of the practice of medicine for poor women worldwide, appear to be contributing to the social injustice of not offering women the option of surgical oophorectomy instead of LHRH treatment. 100,000 women a year could be saved. Further research investigating outcomes associated with the timing of surgical oophorectomy is strongly justified.