ADJUVANT CHEMOTHERAPY FOR EARLY BREAST CANCER
The seminal studies that demonstrated that long-term chemotherapy could have an important survival advantage emerged from the National Surgical Adjuvant Breast and Bowel Project, led by Professor Bernard Fisher, and the historic trial of cyclophosphamide, methotrexate and fluorouracil led by Dr Gianni Bonadonna in Milan. It was probably this second trial more than any other that established the role of adjuvant chemotherapy in the management of early breast cancer. Many subsequent trials have attempted to fine-tune or better select the optimum duration and combination of cytotoxic drugs.

—Michael Baum, ChM, FRCS; Joan Houghton BSc
Br Med J 1999;319:568-571. Full-Text

ADJUVANT TAXANES
It is necessary to wait for future results of ongoing trials before pronouncing judgment on the value of taxanes in the adjuvant setting. It is also necessary to better define the population most likely to benefit from therapies of longer duration, intensification and multiple regimens. It no longer is reasonable to judge all breast cancer patients as having equal probability of benefit from a given therapy.

That was a paradigm that worked well when adjuvant chemotherapy for breast cancer was in its infancy and little was known about the molecular heterogeneity of breast cancer. It is now of critical importance to design trials with the aid of molecular tumor profiles with potential predictive value to prospectively identify the subgroup most likely to benefit from the addition to therapy of taxanes and other new drugs.

—Martine J Piccart, MD, PhD et al.
NIH Consensus Conference 2000. Abstract

ADJUVANT THERAPY FOR LOW-RISK PATIENTS
Sometimes we neglect using some fairly well-established, reproducible prognostic factors. The SEER data and the American College of Surgeons’ National Cancer Database cannot reliably identify a subset of node-negative patients with tumors under a centimeter with a long-term survival of less than 90 percent.
There are also very good data showing that patients with histologic grade one tumors that are 1.1 to 2 centimeters have a survival that’s greater than 90 percent.

Patients with grade one tumors are overwhelmingly ER-positive, so endocrine therapy is certainly a reasonable choice there. But the added absolute benefit of chemotherapy in this subset is extremely small, and sometimes that is not conveyed to women in a way that they can understand. Another group is the special histologic subtypes, most notably tubular carcinoma but also mucinous carcinoma.

Even a two to three centimeter tubular cancer has an outstanding prognosis, and again, these are receptor-positive. So, if physicians look at old consensus guidelines and just go in lock-step with the greater-than-1-centimeter number, they might potentially overtreat some patients by using chemotherapy.

—Monica Morrow, MD