breast cancer remains the leading cause of cancer related morbidity and mortality in women , worldwide . every tenth new cancer diagnosed is that of breast , and nearly a quarter of cancers in the women are breast cancer . about 1.4 million new breast cancer cases are diagnosed every year , and the burden is going to rise tremendously . the incidence of breast cancer rises with increasing age , about 80% of breast cancer occur in women above 50 years of age and nearly half in the age group range of 50 to 69 . the majority of this postmenopausal women with early breast cancer are hormone , that is , estrogen ( er ) and progesterone ( pr ) receptor positive hormone therapy , which essentially deprives the tumor cells of hormone , relies on the fact that the tumor cells from the breast retain the property of thriving in the presence of female sex hormones , and dispossession of which results in inhibition of cancer cell regrowth . hormonal therapy is confirmed to render at least a benefit of 47% risk reduction for recurrence and that of 26% for mortality . this benefit alone surpasses the combined gain obtained by all other interventions in the adjuvant setting . most noticeably , the hormonal therapy intervention benefits all the patients who are hormone positive , regardless of their tumor size and nodal status . tamoxifen has traditionally been considered the gold standard for adjuvant hormonal therapy in hormone receptor positive breast cancer . the newer third generation aromatase inhibitors have challenged this unparalleled status of tamoxifen in postmenopausal women , in whom cessation of ovarian function leaves only peripheral conversion of steroids as the source of production of estrogen and therefore making it an attractive target to block . data from randomized phase iii trials has now shown for most available ais to have better toxicity profile and at least equal , if not superior , efficacy than the traditionally used tamoxifen . the physicians who still prefer to use tamoxifen quote unique mechanism of action with possible intrinsic benefits and low cost as the reason behind the choice . while the advocates of the newer third generations ai cite greater safety and improved pfs including a possible overall survival benefit as strong reasons for shifting the gear in favor of ais as initial therapy . there is now in addition a data to support the switch strategy , in which one agent is alternated with the other , to have actually more beneficial effects than traditionally used continuous single agent for five years . this mix of emerging and existing data has understandably expanded the options for physician prescription ; besides , the many unanswered or half answered questions regarding whether to use ais , which ai , longer use and switching between ais and tamoxifen , has left the treating physician to use the best personal judgment in making a choice before solid clinical data are available . with this background we conducted a survey to on practicing oncology physicians worldwide as to see the trends of prescriptions of hormonal treatment for postmenopausal women in early adjuvant setting . with the propose of identifying what questions still need to be answered unequivocally from clinical trials that would set the standards from which this , the majority , of breast cancer patients would benefit the most . a web page was developed , which asked physicians five main questions , after collecting data on their profile and country of practice . the questions asked about the choice of physicians hormonal agent in early adjuvant setting for the postmenopausal women without having a significant co - morbid , such as a history of osteoporosis , stroke , ischemic heart disease , and hyperlipidemia . the questionnaire also asked duration of use of hormonal therapy ,  switching therapy ,  laboratory investigations done on followup , and the frequency of follow up . the webpage address was sent to contactable physicians whose emails were available in the oncology conference database . the survey was sent out to 522 physicians , a total of 182 physicians responded to the questionnaire , and the response percentage is 34.8% . most of participants that are 142 ( 78.0% ) were medical oncologists , 24 ( 13.2% ) clinical oncologists , while 14 ( 7.8% ) were radiation oncologists by profession . approximately one - third ( 38.5% ) of them were above 45 years of age while remaining participants were younger than 45 ; likewise one - third ( 33% ) of them were in clinical practice for less than 5 years while remaining two - thirds have clinical experience of more than 5 years . most of the responding physicians were working either as private physicians or in teaching hospitals ( 40.7% each ) . participants were from most parts of the world , including pakistan , india , saudi arabia , middle east , uk , europe , and usa . a detailed list of the participants is given in table 1 . in response to question what is your first choice of hormonal agent in early adjuvant setting for receptor positive postmenopausal breast cancer patients , without significant comorbid like osteoporosis , dvt , heart disease ? 36.3% chose anastrozole as their choice of therapy , 35.2% favored tamoxifen , and 22% preferred letrozole as their first choice . more than two - thirds ( 67% ) of the participants gave the reason of having a robust clinical data behind their choice of therapy , while one - third stated concerns regarding safety as their primary motivation behind the choice of the agent of their preference . 31% physicians stated they consider cost , and 34% consider ease of availability as an additional factor in making a choice for the hormonal agents . about 8% stated that a trustworthy pharmaceutical company was the major factor behind the decision regarding the drug of their choice . figure 2 summarizes the reason considered for prescription by different physicians . in answer to the question do you switch your patient from one agent to other during treatment , in a patient who does not have any progression of disease ? 63.7% responding physicians said yes while 33% replied in negative . amongst the physicians who switched to another agent 67.2% based their decisions on presence of data , and 24% had to switch the therapy due to problems encountered during the patient management . of 33% of physicians who do not switch their patients from one agent to other 80% of them based their decisions on lack of data favoring the benefit of switching the therapy according to them . medical oncologists switched therapy more often than a clinical or radiation oncologists ( 0.002 ) . when the participants were asked about the number of investigation do they undertake before starting the treatment of the patients in early adjuvant breast cancer treatment for postmenopausal women , without a major known comorbidity , 73.6% replied that they do some investigations . table 2 summarizes the laboratory and radiological investigations frequently requested by the physicians on followup . nearly two - thirds of physicians ( 61.5% ) followed their patients 36 monthly during the 1st year of followup while 21% follow them every other month , 10% every month , and 2% follow their patients every 6 monthly . most of physicians ( 73.6% ) keep their patients for 5 years on chosen hormonal therapy ; 8.8% want their patients to take hormonal therapy for 2 years , 6.6% for 7 years , and 4.4% for 10 years . insignificant differences were also noticed based on designation , type , country , age , and years of practice . the concept of breast cancer 's hormone sensitivity is more than a century old , when oophorectomies were shown to result in regression of advanced breast cancers . deriving benefits from the same concept , subsequent pharmacologic developments , and refining breast cancer subtypes , today hormonal therapies are the mainstay of hormone receptor positive breast cancers , which make up about 75% to 80% of the breast cancer population . the data looking at effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival by evaluation of all randomized trials from early breast cancer trialists group ( ebctg ) suggest a 40% reduction in the risk of recurrence and 30% reduction in the risk of death with intervention from hormonal therapy , in women with hormone positive breast cancer , making hormone therapy , the single most powerful intervention , in terms of patient benefit . tamoxifen an oral nonsteroidal , antiestrogenic compound with an intrinsic proestrogenic activity was first discovered in 1966 and first approved for clinical use in 1977 for metastatic breast cancer . tamoxifen was found , through series of studies , to render sufficient therapeutic benefits without significant toxicity to justify the title of being gold standard for antiestrogen treatment in breast cancer . the status of tamoxifen as a gold standard has been significantly challenged by the newer generation of aromatize inhibitors which in themselves are a robust group of antiestrogenic therapy . the mechanism of action of ais relies on the fact that most estrogen in the postmenopausal women comes from conversion of steroid hormones to estrogen . the conversion takes place primarily in the adrenals and at multiple other sites and is mediated by the aromatase enzyme . the third - generation aromatase inhibitors first made their impact when they were compared to megestrol acetate in metastatic breast cancer ( mbc ) setting and showed superior time to progression ( ttp ) . to date in at least five randomized phase iii studies done subsequently ais demonstrated mostly superior response rate and time to progression compared to tamoxifen , when used in metastatic breast cancer [ 14 , 15 ] . ais have been clinically tested in adjuvant setting where they have unequivocally proved , in at least four phase iii trials ; that early adjuvant therapy with third - generation aromatase inhibitor in postmenopausal women with hormone positive breast cancer provides better disease - free survival ( dfs ) compared to the traditionally used tamoxifen . all three available ais anastrozole , letrozole , and exemestane have been separately compared with tamoxifen . the intergroup exemestane study studied switching to exemestane after initial 2 - 3 years of tamoxifen therapy in more than 4500 patients and showed improved disease free and a modest improvement in overall survival in er positive women . the followup study results of long - term use letrozole versus placebo after 5 years of tamoxifen in the ncic ctg ma.17 trial analysis were recently published and suggest that extended adjuvant letrozole was superior to placebo in dfs and os . there are , however , serious considerations associated with the use of ais in the form of increased expense and adverse impact on quality of life with increased bone loss and joint pains . there have , thus , been calls for careful interpretation of complex scientific data available and to identify important subsets of population who are to actually derive the greatest benefit from the use of ais [ 19 , 20 ] . the existing and evolving knowledge and research on refinement in hormonal therapy for postmenopausal women generally is favoring the use of ais , a longer duration of therapy and possibly for using the agents alternatively . however , the existing data appears not to have reached a threshold of generating distinct guidelines in favor of their use in this particular patient population , except for suggestions for the same , neither has been the duration of therapy , and the  switch strategy  reached a point where recommendation can be made unequivocally . controversies in setting up the end points , complexity of the data and crossover of the patients from one arm to the other are some of the factors responsible for the ambiguity . our survey clearly demonstrates the discord that is seen in general amongst the treating physicians . although our survey has limitations in the form of number of participants and geographical variance to claim global representation ; we , nevertheless , find that tamoxifen is still prescribed as frequently in postmenopausal women with early stage breast cancer in adjuvant setting as are ais . switch therapy has been found to be sufficiently practiced amongst our survey population where close to 64% physicians actually do mention to switch the patients to exemestane based on the data . there were individual differences in the frequency of followups and laboratory or radiological investigations requested by physicians . it seems that in general there is a lack of clear guidelines available to physicians on how to follow the patients after they are over with the active adjuvant treatments that involve chemotherapy and radiation therapy . physicians vary over choices on the preferred agents of hormonal therapy in postmenopausal women in whom there are no significant comorbid . they also differ quite significantly among the duration , switching the therapy , frequency of followup , and necessary laboratory and radiological investigations in such setting . in order to benefit the patients the most from what is believed to be corner stone of the therapy , further optimization of hormonal therapy with answers from clinical trials designed to identify the subgroups , benefitting the most from a specific hormonal therapy , shall perhaps set the standards .