Hard pill to swallow.

Most people would say that it is reasonable to omit adjuvant radiation in older women with early stage, hormone receptor positive breast cancer based on some pretty solid data. The one caveat is that your actual (off-study) patient has to actually take endocrine therapy every day for at least five years for this data to apply. This week’s study in Cancer reports that among 800 Medicare beneficiaries with breast cancer meeting the above criteria, one-third opted to omit radiation. Great. But, wait, how many of these women ended up taking their recommended endocrine therapy? Two out of five. This means over half of women who omitted radiation (per guidelines) have a higher than signed-up for risk of recurrence. The real-world question then becomes which adjuvant therapy is more likely to be implemented as studied: A treatment with a few side effects that is delivered daily over no more than 4 weeks or a treatment with a few side effects that is delivered daily over at least 5 years? You probably never read the Hughes study in this light, which is why we’re glad this pragmatic pub reminded us in a real way of the difference between efficacy and effectiveness.