Adjuvant Chemotherapy for ER+ Breast Cancer: A Sea Change is Underway

Adjuvant breast cancer treatments—chemotherapy, human epidermal growth factor receptor 2 (HER2)–targeted therapies, and endocrine therapy—prevent recurrence and extend survival. Unfortunately, because risk assessment is imprecise and treatments are not uniformly effective, many women are treated to benefit a small number. If these therapies were entirely harmless, we would have few qualms about overtreatment. Chemotherapy has the most onerous short-term side effects and is the treatment that patients most wish to avoid. Moreover, long-term toxicities include secondary leukemia, heart failure, neuropathy, premature menopause, and infertility. Some women who receive adjuvant chemotherapy do not return to work or face difficulty in role functioning (1,2). The recognition that benefits are limited and that toxicity can be formidable has led to gradual adjustments in most oncologists' approach. There has also been a steady improvement in prognosis over the past decades, partially attributed to better outcomes associated with screen-detected cancers (3,4).

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