Aromatase inhibitors as neoadjuvant treatment in elderly patients with locally advanced breast cancer

Pre-operative volume reduction of locally advanced breast cancers (LABC) is an issue of great importance when approaching elderly women, who often present with extensive disease along with a burden of co-morbidity which increases the risk of complications and mortality from treatment. A comprehensive geriatric evaluation is a necessary requirement before recommending any treatment in older patients. Endocrine treatment in the neoadjuvant setting allows disease control and downstaging of tumours and is fairly well tolerated. Tamoxifen has been the mainstay of endocrine therapy for patients unable to undergo surgery, but resistance eventually develops. Aromatase inhibitors (AIs) are superior to tamoxifen in this setting, with greater downstaging of the tumour and disease control. AIs are now the treatment of choice in elderly patients with oestrogen receptor-positive breast cancer who are being considered for neoadjuvant endocrine therapy. There are some data that definitive treatment with an AI for LABC in unfit patients may guarantee long-term control of disease.