• Overall survival at 5 years [ Designated as safety issue: No ]
• Systemic disease-free survival at 5 years [ Designated as safety issue: No ]
• Quality of life as measured by presence of menopausal symptoms (e.g., hot flushes) and/or loss of sexual interest at 0, 6, 12,18, 24, 36, 48, 60, and 72 months from randomization [ Designated as safety issue: No ]

• Overall survival at 5 years
• Systemic disease-free survival at 5 years
• Quality of life as measured by presence of menopausal symptoms (e.g., hot flushes) and/or loss of sexual interest at 0, 6, 12,18, 24, 36, 48, 60, and 72 months from randomization

RATIONALE: Estrogen can stimulate the growth of breast tumor cells. Ovarian function suppression combined with hormone therapy using tamoxifen or exemestane may fight breast cancer by reducing the production of estrogen. It is not yet known whether suppression of ovarian function plus either tamoxifen or exemestane is more effective than tamoxifen alone in preventing the recurrence of hormone-responsive breast cancer.

PURPOSE: This randomized phase III trial is studying ovarian suppression with either tamoxifen or exemestane to see how well they work compared to tamoxifen alone in treating premenopausal women who have undergone surgery for hormone-responsive breast cancer.

OBJECTIVES:

• Compare ovarian function suppression (by triptorelin, oophorectomy, or ovarian irradiation) in combination with tamoxifen vs tamoxifen alone; exemestane vs tamoxifen alone; and exemestane vs ovarian function suppression in patients with endocrine-responsive breast cancer.
• Compare the disease-free and overall survival of patients treated with these regimens.
• Compare the quality of life, including late side effects of early menopause, of patients treated with these regimens.
• Compare the incidence of second (nonbreast) malignancies in patients treated with these regimens.
• Compare the sites of first treatment failure in patients treated with these regimens.

OUTLINE: This is a randomized, multicenter study. Patients are stratified according to participating center, prior adjuvant/neoadjuvant chemotherapy (yes vs no), and number of positive axillary and/or internal mammary lymph nodes (0 vs 1 or more) and intented initial method of ovarian function suppression (triptorelin vs oophorectomy vs ovarian irradiation) . Patients are randomized to 1 of 3 treatment arms.

• Arm I: Patients receive oral tamoxifen daily.

• Arm II: Patients receive tamoxifen as in arm I and ovarian function suppression by 1 of the following treatments:

  • Triptorelin intramuscularly once every 28 days
  • Surgical oophorectomy
  • Ovarian irradiation once daily for 4 or 5 days
• Arm III: Patients receive oral exemestane daily and ovarian function suppression as in arm II.

Treatment continues for 5 years in the absence of disease progression or unacceptable toxicity.

Quality of life is assessed at baseline, every 6 months for 2 years, and then annually for 4 years.

After completion of study therapy, patients are followed periodically.

PROJECTED ACCRUAL: A total of 3,000 patients (1,000 per treatment arm) will be accrued for this study within 5 years.

• Drug: exemestane
• Drug: tamoxifen citrate
• Drug: triptorelin
• Procedure: oophorectomy
• Radiation: radiation therapy

• Active Comparator: Patients receive oral tamoxifen daily.
• Experimental: Patients receive tamoxifen as in arm I and ovarian function suppression by 1 of the following treatments: 1)triptorelin intramuscularly once every 28 days, 2) surgical oophorectomy, or 3) ovarian irradiation once daily for 4 or 5 days.
• Experimental: Patients receive oral exemestane daily and ovarian function suppression as in arm II.

DISEASE CHARACTERISTICS:

• Histologically confirmed breast cancer

• Completely resected disease

  • No clinically detectable residual loco-regional axillary disease

  • Prior surgery for primary breast cancer of 1 of the following types:

    • Total mastectomy with or without adjuvant radiotherapy

      • Ductal carcinoma in situ at a margin is permitted if a complete mastectomy has been performed
    • Breast-conserving procedure (e.g., lumpectomy, quadrantectomy, or partial mastectomy with margins clear* of invasive disease and ductal carcinoma in situ) with radiotherapy
  • No more than 12 weeks since prior surgery if no adjuvant chemotherapy
  • No more than 8 months since prior adjuvant chemotherapy NOTE: *If all other margins are clear a positive posterior (deep) margin is permitted, provided the excision was performed down to the pectoral fascia and all tumor has been removed OR a positive anterior (superficial; abutting skin) margin is allowed provided all tumor was removed

• Tumor confined to the breast and axillary nodes

  • Tumor detected in internal mammary chain nodes that are not enlarged is allowed
• Prior neoadjuvant therapy allowed provided disease was operable prior to neoadjuvant therapy

• Axillary lymph node dissection or a negative axillary sentinel node biopsy required

  • Patients with microscopically positive axillary sentinel nodes or negative sentinal nodes do not require further axillary therapy
  • Patients with positive sentinel nodes must have axillary dissection or radiation of axillary nodes
• No distant metastases

• No locally advanced inoperable breast cancer, including any of the following:

  • Inflammatory breast cancer
  • Supraclavicular node involvement
  • Enlarged internal mammary nodes (unless pathologically negative)

• No prior ipsilateral or contralateral invasive breast cancer

  • Histologically diagnosed synchronous bilateral invasive breast cancer within the past 2 months allowed if the bilateral disease meets all other eligibility criteria

• Hormone receptor status:

  • Estrogen and/or progesterone receptor positive

    • Each tumor must be hormone receptor positive

PATIENT CHARACTERISTICS:

Age

• Premenopausal

Sex

• Female

Menopausal status

• Premenopausal

  • Estradiol in the premenopausal range, unless the patient meets the following criteria within the past 6 months:

    • No chemotherapy
    • Menstruating regularly
    • No use of hormonal contraception
    • No other use of hormonal treatments
  • Temporary chemotherapy-induced amenorrhea allowed provided premenopausal status is confirmed by estradiol level within 8 months of the final dose of chemotherapy

Performance status

• Not specified

Life expectancy

• Not specified

Hematopoietic

• Not specified

Hepatic

• No systemic hepatic disease that would preclude prolonged follow-up

Renal

• No systemic renal disease that would preclude prolonged follow-up

Cardiovascular

• No systemic cardiovascular disease that would preclude prolonged follow-up
• No prior thrombosis (e.g., deep vein thrombosis) and/or embolism unless patient is medically suitable

Pulmonary

• No systemic pulmonary disease that would preclude prolonged follow-up

Other

• Not pregnant or nursing
• Fertile patients must use effective nonhormonal contraception
• No history of noncompliance to medical regimens
• No other nonmalignant systemic disease that would preclude prolonged follow-up

• No prior or concurrent invasive malignancy except adequately treated basal cell or squamous cell skin cancer, carcinoma in situ of the cervix or bladder, contralateral or ipsilateral carcinoma in situ of the breast, or nonbreast invasive malignancy diagnosed at least 5 years ago without recurrence, including only the following:

  • Stage I papillary thyroid cancer
  • Stage IA carcinoma of the cervix
  • Stage IA or B endometrioid endometrial cancer
  • Borderline or stage I ovarian cancer
• No psychiatric, addictive, or other disorder that would preclude study compliance

PRIOR CONCURRENT THERAPY:

Biologic therapy

• Prior and/or concurrent adjuvant, trastuzumab (herceptin) allowed

Chemotherapy

• See Disease Characteristics

Endocrine therapy

• More than 1 year since prior selective estrogen-receptor modulators (SERMs) before the breast cancer diagnosis
• No hormone replacement therapy during the year before the breast cancer diagnosis
• No prior endocrine therapy, including adjuvant or neoadjuvant therapy, for more than 8 months after breast cancer diagnosis
• No prior gonadotropin-releasing hormone analogues for breast cancer
• No concurrent oral or transdermal hormonal therapy
• No other concurrent estrogen, progesterone, or androgens
• No other concurrent aromatase inhibitors
• No concurrent hormone replacement therapy
• No concurrent oral or other hormonal contraceptives (i.e., implants or depot injections)
• No other concurrent SERMs (e.g., raloxifene)

Radiotherapy

• See Disease Characteristics
• No prior ovarian radiotherapy

Surgery

• See Disease Characteristics
• No prior bilateral oophorectomy

• No concurrent oophorectomy unless performed as part of this study

  • No patients who have been recommended to undergo oophorectomy within the next 5 years (e.g., BRCA1/2 gene carrier)

Other

• No concurrent bisphosphonates, except in the following cases:

  • Bone density is at least 1.5 standard deviations below the young adult normal mean
  • Participation in a randomized clinical study testing bisphosphonates in the adjuvant breast cancer setting
• No other concurrent investigational agent

• National Cancer Institute (NCI)
• Breast International Group
• Cancer and Leukemia Group B
• NCIC Clinical Trials Group
• North Central Cancer Treatment Group
• National Surgical Adjuvant Breast and Bowel Project (NSABP)
• Southwest Oncology Group