To the Editor: In their article, de Boer et al. (Aug. 13 issue)1 suggest that adjuvant systemic therapy may improve disease-free survival in breast cancer. However, the apparent treatment effect may also be due to imbalances in prognostic and predictive factors (such as hormone-receptor status) that drive clinical decision making. The failure to distinguish between systemic chemotherapy and hormonal therapy and the use of composite outcomes that are mostly unrelated to nodal involvement further cloud the primary questions. Adjunctive hormonal therapy is currently recommended in most patients with hormone-receptor–positive tumors that are larger than 1 cm in diameter on the . . .
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