Abstract Background: Endocrine therapy alone, with breast surgery offered only at local progression, is still sometimes considered for older women with operable early breast cancer, but the long-term risks of deferring surgery are uncertain. We evaluated long-term outcomes in the three unconfounded randomised trials that compared immediate breast surgery plus tamoxifen versus tamoxifen alone. None of these trials scheduled radiotherapy or chemotherapy. Methods: Individual patient data meta-analyses compared effects on breast cancer outcomes in 3 trials, initiated in the 1980s, among 1082 women (age ≥70, all to receive tamoxifen for at least 5 years) comparing immediate surgery versus surgery only in the event of local progression. Primary outcomes were time to locoregional failure, to distant recurrence, and to breast cancer mortality. Locoregional failure was defined as any locoregional recurrence after surgery or, if no immediate surgery, ≥25% increase in tumour diameter. Age-adjusted intent-to-treat log-rank analyses, stratified by nodal status, were used to estimate first-event-rate ratios (RRs). Results: Median age at randomisation was 76 (IQR 73-80) years, and 63% (666/1082) had clinically estimated tumour diameter >20 mm. Mean follow-up while still alive was 7.3 woman-years. Of 518 women allocated immediate surgery, 45.7% had mastectomy, 47.3% had breast-conserving surgery, and 7.0% had neither. Locoregional failure was greatly reduced by allocation to immediate surgery (RR=0.24, 95% CI 0.19-0.30, p<0.00001). This extreme RR was little affected by age, disease stage, or time period. Although the proportional reduction in the annual rate of locoregional failure was similar during years 0-1, 2-4 and 5-9, the absolute reduction in locoregional failure was mainly before year 5 (Kaplan-Meier 5-year risks 12.1% vs 45.8%). On average over the whole follow-up period the rates of distant recurrence (RR=0.72, 0.57-0.90, p=0.003), breast cancer mortality (RR=0.68, 0.54-0.86, p=0.002), and all-cause mortality (RR=0.83, 0.72-0.97, p=0.016) were also reduced, but these benefits emerged only after years 0-1. The distant recurrence rate ratio was 0.97 (0.67-1.42) during years 0-1 after randomisation, 0.73 (0.49-1.07) during years 2-4 and 0.52 (0.36-0.76) after year 5 (trend: p=0.012). Conclusion: In early breast cancer, immediate breast surgery greatly reduces locoregional progression rates during the first 5 years and approximately halves the annual rates of distant recurrence and of breast cancer death after the first 5 years, despite having had little clinically apparent effect on distant recurrence rates during the first few years. These findings could indirectly inform the planning and interpretation of trials of less extreme de-escalation of surgery or radiotherapy. Citation Format: Robert Hills, CoRosie Bradley, Jeremy Braybrooke, Lucy Davies, David Dodwell, Gurdeep Mannu, Paul McGale, Mike Clarke, Hongchao Pan, Richard Berry, Richard Peto, Carolyn Taylor, Jonas Bergh, Sandra Swain, Stewart Anderson, Allan Hackshaw, Tom Bates, Eleftherios Mamounas, Giorgio Mustacchi, John Robertson, Richard Gray. immediate breast surgery versus deferral of surgery in women aged 70+ years with operable breast cancer: patient-level meta-analysis of the three randomised trials among 1,082 women [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2024; 2024 Dec 10-13; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(12 Suppl):Abstract nr LB1-01.
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