title: Adjuvant endocrine therapy plus zoledronic acid in premenopausal women with early-stage breast cancer: 62-month follow-up from the ABCSG-12 randomised trial.
abstract: BACKGROUND
  Analysis of the Austrian Breast and Colorectal Cancer Study Group trial-12 (ABCSG-12) at 48 months' follow-up showed that addition of zoledronic acid to adjuvant endocrine therapy significantly improved disease-free survival. We have now assessed long-term clinical efficacy including disease-free survival and disease outcomes in patients receiving anastrozole or tamoxifen with or without zoledronic acid.
  
  
  METHODS
  ABSCG-12 is a randomised, controlled, open-label, two-by-two factorial, multicentre trial in 1803 premenopausal women with endocrine-receptor-positive early-stage (stage I-II) breast cancer receiving goserelin (3.6 mg every 28 days), comparing the efficacy and safety of anastrozole (1 mg per day) or tamoxifen (20 mg per day) with or without zoledronic acid (4 mg every 6 months) for 3 years. Randomisation (1:1:1:1 ratio) was computerised and based on the Pocock and Simon minimisation method to balance the four treatment arms across eight prognostic variables (age, neoadjuvant chemotherapy, pathological tumour stage; lymph-node involvement, type of surgery or locoregional therapy, complete axillary dissection, intraoperative radiation therapy, and geographical region). Treatment allocation was not masked. The primary endpoint was disease-free survival (defined as disease recurrence or death) and analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00295646; follow-up is ongoing.
  
  
  RESULTS
  At a median follow-up of 62 months (range 0-114.4 months), more than 2 years after treatment completion, 186 disease-free survival events had been reported (53 events in 450 patients on tamoxifen alone, 57 in 453 patients on anastrozole alone, 36 in 450 patients on tamoxifen plus zoledronic acid, and 40 in 450 patients on anastrozole plus zoledronic acid). Zoledronic acid reduced risk of disease-free survival events overall (HR 0.68, 95% CI 0.51-0.91; p=0.009), although the difference was not significant in the tamoxifen (HR 0.67, 95% CI 0.44-1.03; p=0.067) and anastrozole arms (HR 0.68, 95% CI 0.45-1.02; p=0.061) assessed separately. Zoledronic acid did not significantly affect risk of death (30 deaths with zoledronic acid vs 43 deaths without; HR 0.67, 95% CI 0.41-1.07; p=0.09). There was no difference in disease-free survival between patients on tamoxifen alone versus anastrozole alone (HR 1.08, 95% CI 0.81-1.44; p=0.591), but overall survival was worse with anastrozole than with tamoxifen (46 vs 27 deaths; HR 1.75, 95% CI 1.08-2.83; p=0.02). Treatments were generally well tolerated, with no reports of renal failure or osteonecrosis of the jaw. Bone pain was reported in 601 patients (33%; 349 patients on zoledronic acid vs 252 not on the drug), fatigue in 361 (20%; 192 vs 169), headache in 280 (16%; 147 vs 133), and arthralgia in 266 (15%; 145 vs 121).
  
  
  CONCLUSIONS
  Addition of zoledronic acid improved disease-free survival in the patients taking anastrozole or tamoxifen. There was no difference in disease-free survival between patients receiving anastrozole and tamoxifen overall, but those on anastrozole alone had inferior overall survival. These data show persistent benefits with zoledronic acid and support its addition to adjuvant endocrine therapy in premenopausal patients with early-stage breast cancer.
  
  
  BACKGROUND
  AstraZeneca; Novartis.
authors.affiliation: Department of Surgery, Comprehensive Cancer Centre Vienna, Medical University of Vienna, A-1090 Vienna, Austria. michael.gnant@meduniwien.ac.at
authors.forename: Michael
authors.initials: M
authors.lastname: Gnant
authors.forename: Brigitte
authors.initials: B
authors.lastname: Mlineritsch
authors.forename: Herbert
authors.initials: H
authors.lastname: Stoeger
authors.forename: Gero
authors.initials: G
authors.lastname: Luschin-Ebengreuth
authors.forename: Dietmar
authors.initials: D
authors.lastname: Heck
authors.forename: Christian
authors.initials: C
authors.lastname: Menzel
authors.forename: Raimund
authors.initials: R
authors.lastname: Jakesz
authors.forename: Michael
authors.initials: M
authors.lastname: Seifert
authors.forename: Michael
authors.initials: M
authors.lastname: Hubalek
authors.forename: Gunda
authors.initials: G
authors.lastname: Pristauz
authors.forename: Thomas
authors.initials: T
authors.lastname: Bauernhofer
authors.forename: Holger
authors.initials: H
authors.lastname: Eidtmann
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Eiermann
authors.forename: Guenther
authors.initials: G
authors.lastname: Steger
authors.forename: Werner
authors.initials: W
authors.lastname: Kwasny
authors.forename: Peter
authors.initials: P
authors.lastname: Dubsky
authors.forename: Gerhard
authors.initials: G
authors.lastname: Hochreiner
authors.forename: Ernst-Pius
authors.initials: EP
authors.lastname: Forsthuber
authors.forename: Christian
authors.initials: C
authors.lastname: Fesl
authors.forename: Richard
authors.initials: R
authors.lastname: Greil
mesh_terms: D000328:Adult; D000077384:Anastrozole; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D018931:Antineoplastic Agents, Hormonal / Q000627:therapeutic use; D050071:Bone Density Conservation Agents / Q000627:therapeutic use; D001943:Breast Neoplasms / Q000188:drug therapy*; D017024:Chemotherapy, Adjuvant; D004164:Diphosphonates / Q000627:therapeutic use*; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007093:Imidazoles / Q000627:therapeutic use*; D008875:Middle Aged; D009367:Neoplasm Staging; D009570:Nitriles / Q000627:therapeutic use; D017697:Premenopause; D013629:Tamoxifen / Q000627:therapeutic use; D016896:Treatment Outcome; D014230:Triazoles / Q000627:therapeutic use; D000077211:Zoledronic Acid
chemical_list: D000970:Antineoplastic Agents; D018931:Antineoplastic Agents, Hormonal; D050071:Bone Density Conservation Agents; D004164:Diphosphonates; D007093:Imidazoles; D009570:Nitriles; D014230:Triazoles; D013629:Tamoxifen; D000077384:Anastrozole; D000077211:Zoledronic Acid