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Vol.:(0123456789)Ann Surg Oncol (2025) 32:8169–8179 https://doi.org/10.1245/s10434-025-17861-1ORIGINAL ARTICLE – BREAST ONCOLOGYNinety Days of Preoperative Endocrine Therapy Informs Patient and Physician Preference for Radiation Therapy: Primary Results from the Preoperative Window of Endocrine Therapy to Inform Radiation Therapy Decisions (POWER) TrialTrish Millard, MD 1 , Lena M. Turkheimer, MD, MPH 2 , Gina Petroni, PhD 3 , David Brighton, MS 3 , Max O. Meneveau, MD, MS 2 , Prisca Obidike, MD 2 , Kandace McGuire, MD 4 , and Shayna L. Showalter, MD, FACS 21 Present Address: Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA; 2 Present Address: Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA; 3 Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA; 4 Department of Surgery, Virginia Commonwealth University Health, Richmond, VA ABSTRACT Background. Clinical trial data support the omission of radiation therapy (RT) in older women with early-stage breast cancer. The majority of older women still receive RT largely due to a lack of insight regarding endocrine therapy (ET) tolerance. The POWER trial is a phase II trial designed to determine whether 90 days of preoperative ET (pre-ET) changes patient or surgeon preferences for RT.Methods. Between 2020 and 2024, two centers enrolled women aged 65 years or older with invasive carcinoma measuring ≤2 cm, N0, and ER+/PR±/HER2−. All partici-pants were recommended for 90 days of pre-ET. Patient and surgeon preferences for RT were evaluated before and after pre-ET. A change in preference was tested from an assumed low change rate of 5% to a rate of ≥15%, with a one-sided 5% level binomial test.Results. Seventy-five women enrolled. Adverse events attributed to pre-ET occurred in 35 participants (47%). After pre-ET, 21 (28.0%) patients changed RT preference and sur-geons changed RT recommendation for 18 (24.0%) patients (p < 0.001 and p = 0.015, respectively). General agreement between patient and surgeon preferences before pre-ET was 53% (Kappa = −0.04) and increased to 81% (Kappa = 0.59) after pre-ET.Conclusion. Pre-ET signif i cantly changed patient and sur-geon preferences for RT and increased patient and surgeon agreement. The intentional resequencing of treatments enables patients to assess tolerance to ET before decid-ing whether to omit RT. This study validates pre-ET as an innovative method to inform adjuvant therapy decisions and recommendations.There are over 125,000 new breast cancer diagnoses among women in the United States each year, and more than 45% of these patients are aged 65 years and older. 1 For more than 2 decades, breast-conserving surgery (BCS) followed by adjuvant endocrine therapy (AET) has been a widely recommended and commonly utilized treatment approach for many patients with early-stage, estrogen recep-tor-positive (ER+) breast cancer. Adjuvant radiation therapy (RT) reduces ipsilateral breast tumor recurrences if admin-istered within 8 weeks of BCS. 2–4 AET is routinely initiated after RT to reduce local recurrence, distant recurrence, and mortality. 5As breast cancer treatment has become more personal-ized, clinical trials have sought to de-escalate treatment for Trish Millard and Lena M. Turkheimer contributed equally to this study and subsequent manuscript and should be considered as co-f i rst authors.© The Author(s) 2025First Received: 29 April 2025 Accepted: 11 June 2025 Published online: 2 August 2025S. L. Showalter, MD, FACS e-mail: SNL2T@uvahealth.org