Professional Documents
Culture Documents
BREAST CANCER
-Dr.A.Joseph Stalin Mch Postgraduate
PROF.DR.R.RAJARAMANS UNIT
CENTRE FOR ONCOLOGY
GOVT. ROYAPETTAH HOSPITAL
The farther backward you can look, the
farther forward you are likely to see.
Winston Churchill
SURGICAL ASPECTS
CHEMOTHERAPHY
HORMONE THERAPHY
RADIOTHERAPHY
SURGICAL ASPECTS
* RADICAL MASTECTOMY VS
MODIFIED RADICAL MASTECTOMY
* MODIFIED RADICAL MASTECTOMY VS
BREAST CONSRVATION SURGERY
* AXILLARY DISSECTION VS
SENTINEL NODE BIOPSY
PRE INDUSTRIAL ERA
HIPPOCRATES- 2400 years back described
many forms of cancer and coined the term
CANCER.
1600 BC, the Edwin Smith Papyrus describes 8
cases of tumors or ulcers of the breast that
were treated by cauterization.
GALEN-200 AD classified tumours and
considered cancer as a systemic disease
related to excess of black bile.
PRE INDUSTRIAL ERA
CONSIDERED AS
INCURABLE TILL 17TH
CENTURY
THEORY OF
HUMORALISM,
DIVINE CURSE
PREVAILED
HALSTEDIAN ERA
VALSALVA(1704) ,LEDRAN(1757)&
MORGAGNI(1769) Local lesion capable of
cure by operation ,spreads through lymphatics
to regional nodes,tends to recur.
WILLIAM HALSTED(1894) popularised radical
mastectomy as the treatment of choice for
breast cancer ,considered breast cancer
strictly as a locoregional disease.
HALSTEDIAN PRINCIPLE
Tumor spreads in an orderdly pattern
Lymphnodes acts as barrier to spread, blood
stream is of little significance
More radical the surgery , more the chance of
cure
Recurrance & death are due to inadequacy of
surgery
FISHER CONCEPT
During the second half of 19th century
alternate hypothesis (Fisher Concept)emerged
which stressed breast cancer as a systemic
disease.
Operable breast cancer is a systemic disease
Blood stream is of considerable importance
for tumour dissemination
No orderly spread
Regional lymph nodes are of biological
importance
The Contribution of Recent NSABP Clinical Trials of Primary
Breast Cancer Therapy to an Understanding of Tumor
Biology -An Overview of Findings
BERNARD FISHER, MD, CAROL REDMOND, SCD, EDWIN R. FISHER, MD
AND PARTICIPATING NSABP INVESTIGATORS*
Figure Legend:
ALND indicates axillary lymph node dissection; SLND, sentinel lymph node dissection.
CMF REGIMEN
N Engl J Med. 1976 Feb 19;294(8):405-10.
Combination chemotherapy as an adjuvant treatment in operable breast cancer.
Bonadonna G, Brusamolino E, Valagussa P, Rossi A, Brugnatelli L, Brambilla C, De
Lena M, Tancini G, Bajetta E, Musumeci R,Veronesi U.
Abstract
Prolonged cyclic combination chemotherapy with cyclophosphamide,
methotrexate and fluorouracil was evaluated as adjuvant treatment to radical
mastectomy in primary breast cancer with positive axillary lymph nodes. After 27
months of study, treatment occurred in 24 per cent of 179 control patients and in
5.3 per cent of 207 women given combination chemotherapy (P less than 10(-6)),
the advantage appearing statistically significant in all subgroups of patients.
Patients with four or more positive axillary nodes had a higher per cent of relapses
than those with fewer nodes. The initial new clinical manifestations occurred in
distant sites in 81.5 per cent of relapsed patients. Long-term chemotherapy
produced an acceptable toxicity, thus allowing the administration of a high
percentage of drug dosage. These results should be considered with caution, since,
at present, the effect of this therapy on survival and possible long-term side effects
remain unknown.
MILAN TRIAL
PROTOCOL B-13
A Protocol To Assess Sequential Methotrexate Fluorouracil In
Patients With Primary Breast Cancer And Negative Axillary Nodes
Whose Tumors Are Negative For Estrogen Receptors
Specific Aims
The primary objective of this study is to determine whether the
sequential combination MF is more effective than no treatment
with respect to disease-free survival and survival in patients whose
tumors are estrogen-receptor-negative.
In addition, this study, in conjunction with Protocol B-14, will permit
evaluation of treatment failure and survival in untreated patients
relative to their ER level.
NSABP 13
NSABP 19
PROTOCOL B-19
A Clinical Trial to Compare Sequential Methotrexate, 5-
Fluorouracil (MF) with Conventional CMF in Primary
Breast Cancer Patients with Negative Nodes and Estrogen-
Receptor-Negative Tumors
Specific Aims
The objective of this study is to determine whether six
cycles of conventional cyclophosphamide, methotrexate
and 5-fluorouracil (CMF) are as effective with respect to
disease-free survival and survival as six cycles of sequential
methotrexate and 5-fluorouracil (MF) followed by
leucovorin for negative-node patients whose tumors are
estrogen-receptor-negative.
Sequential Methotrexate 5-Fluorouracil (MF) for the Treatment of Node-Negative Breast Cancer Patients
with Estrogen-Receptor-Negative Tumors: Eight-Year Results from NSABP B-13 and First Report of Findings
from NSABP B-19 Comparing MF with Conventional CMF
Fisher B, Dignam J, Mamounas EP, Costantino J, Wickerham DL, Redmond C, Wolmark N, Dimitrov N, Bowman
D, Glass A, Atkins J, Abramson N, Sutherland C, Aron B, Margolese R, and other contributing NSABP
investigators
Journal of Clinical Oncology 14:7:1982-1992, 1996
Methods: A total of 760 patients were randomized to B-13; 1,095 patients with the same eligibility
requirements were randomized to B-19. Disease-free survival (DFS), distant disease-free survival
(DDFS), and survival were determined using life-table estimates.
Results: A significant benefit in overall DFS (74% v 59%; P < .001) was demonstrated at 8 years in all
B-13 patients who received MF (69% v 56% [P = .006] in those 50 years). A survival advantage
was evident in older patients (89% v 80%; P = .03). In B-19, through 5 years, an overall DFS
advantage (82% v 73%; P < .001) and a borderline survival advantage (88% v 85%; P = .06) were
evident with CMF. The DFS (84% v 72%; P < .001) and survival (89% v 84%; P = .04) benefits from
CMF were greater in women aged F or CMF after lumpectomy and breast irradiation resulted in a
low probability of ipsilateral breast tumor recurrence (IBTR). In B-13, the frequency of IBTR was
2.6% following MF versus 13.4% in women treated by lumpectomy; it was 0.6% following CMF in
B-19. Toxicity > or = grade 3 was more frequent among CMF patients in B-19. The age-related
difference in CMF benefit was not related to amount of drug received.
Conclusion: MF and CMF are effective for node-negative patients with ER-negative tumors. The
incidence of local-regional or distant metastases and IBTR decreased after either therapy. The
benefit from either therapy was evident in all patients, but the CMF advantage was greater in those
F may be used in patients with medical problems that would preclude CMF administration.
30 years' follow up of randomised studies of adjuvant CMF in
operable breast cancer: cohort study
BMJ 2005; 330 (Published 27 Jan 2005)
Results After a median follow up of 28.5 years for the initial study,
adjuvant CMF was found to reduce the relative risk of relapse
significantly (hazard ratio 0.71, 95% confidence interval 0.56 to
0.91, P = 0.005) and death (0.79, 0.63 to 0.98, P = 0.04).
Administration of CMF for 12 cycles does not seem superior to a
shorter administration of six cycles. In the node negative and
oestrogen receptor negative trial, intravenous CMF significantly
reduced the relative risk of relapse of disease (0.65, 0.47 to 0.90, P
= 0.009) and death (0.65, 0.47 to 0.92, P = 0.01) at a median follow
up of 20 years.
Conclusions When delivered optimally, CMF benefits patients at
risk of relapse of distant disease without evidence of detrimental
effects in any of the examined subgroups.
ANTHRACYCLINES
Br Med J. 1969 Aug 30;3(5669):503-6.
Clinical evaluation of adriamycin, a new antitumour
antibiotic.
Bonadonna G, Monfardini S, De Lena M, Fossati-Bellani F.
Abstract
Adriamycin, a new antitumour antibiotic of the
anthracycline group with a structural formula very similar
to daunorubicin, has proved to have potent tumour-
growth-inhibiting properties, and to be particularly
effective in childhood malignancies. Though adriamycin
produces a higher percentage of side-effects than
daunorubicin-namely, stomatitis and alopecia-a lower
dosage may be used for therapy.
NSABP B 15
To determine, in patients with histologically positive axillary nodes
who are not classified as tamoxifen-responsive, whether short,
intensive adjuvant chemotherapy (AC, with or without interval
reinduction with CMF) is as effective as or more effective than
"conventional" CMF with respect to disease-free survival and survival.
NSABP 15
J Clin Oncol. 1990 Sep;8(9):1483-96.
Two months of doxorubicin-cyclophosphamide with and without interval reinduction therapy compared with 6
months of cyclophosphamide, methotrexate, and fluorouracil in positive-node breast cancer patients with
tamoxifen-nonresponsive tumors: results from the National Surgical Adjuvant Breast and Bowel Project B-15.
Fisher B, Brown AM, Dimitrov NV, Poisson R, Redmond C, Margolese RG, Bowman D, Wolmark N, Wickerham
DL, Kardinal CG, et al.
Author information
Abstract
The National Surgical Adjuvant Breast and Bowel Project (NSABP) implemented protocol B-15 to compare 2
months of Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH) and cyclophosphamide (AC) with 6 months
of conventional cyclophosphamide, methotrexate, and fluorouracil (CMF) in patients with breast cancer
nonresponsive to tamoxifen (TAM, T). A second aim was to determine whether AC followed in 6 months by
intravenous (IV) CMF was more effective than AC without reinduction therapy. Through 3 years of follow-up,
findings from 2,194 patients indicate no significant difference in disease-free survival (DFS, P = .5), distant disease-
free survival (DDFS, P = .5) or survival (S, P = .8) among the three groups. Since the outcome from AC and CMF was
almost identical, the issue arises concerning which regimen is more appropriate for the treatment of breast cancer
patients. AC seems preferable since, following total mastectomy, AC was completed on day 63 versus day 154 for
conventional CMF; patients visited health professionals three times as often for conventional CMF as for AC;
women on AC received therapy on each of 4 days versus on each of 84 days for conventional CMF; and nausea-
control medication was given for about 84 days to conventional CMF patients versus for about 12 days to patients
on AC. The difference in the amount of alopecia between the two treatment groups was less than anticipated.
While alopecia was almost universally observed following AC therapy, 71% of the CMF patients also had hair loss
and, in 41%, the loss was greater than 50%. This study and NSABP B-16, which evaluates the worth of AC therapy
in TAM-responsive patients, indicate the merit of 2 months of AC therapy for all positive-node breast cancer
patients.
J Natl Cancer Inst. 2000 Dec 20;92(24):1991-8.
HER2 and choice of adjuvant chemotherapy for invasive breast cancer: National Surgical Adjuvant Breast and
Bowel Project Protocol B-15.
Paik S, Bryant J, Tan-Chiu E, Yothers G, Park C, Wickerham DL, Wolmark N.
Author information
Abstract
BACKGROUND:
Recent retrospective analyses have suggested that breast cancer patients whose tumors overexpress HER2 derive
preferential benefit from treatment with anthracyclines such as doxorubicin. This has led some clinicians to
propose that HER2 should be used as a predictive marker in choosing between anthracycline-based regimens and
combination chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil (CMF). We evaluated this
recommendation in a retrospective study of National Surgical Adjuvant Breast and Bowel Project Protocol B-15, in
which patients received a combination of doxorubicin and cyclophosphamide (AC), CMF, or AC followed by CMF.
We hypothesized that AC would be superior to CMF only in the HER2-positive patients.
METHODS:
Immunohistochemical detection of HER2 was performed on tumor sections from 2034 of 2295 eligible patients.
We used statistical analysis to evaluate the interaction between the efficacy of the assigned treatments and HER2
overexpression. All statistical tests were two-sided.
RESULTS:
Tumor sections from 599 patients (29%) stained positive for HER2. AC was superior to CMF in HER2-positive
patients only, although differences in outcomes did not reach statistical significance. In the HER2-positive cohort,
relative risks of failure (i.e., after AC treatment as compared with CMF treatment) were 0.84 for disease-free
survival (DFS) (95% confidence interval [CI] = 0.65--1.07; P =.15), 0.82 for survival (95% CI = 0.63--1.06; P =.14), and
0.80 for recurrence-free survival (RFS) (95% CI = 0.62--1.04; P =.10). Tests for interaction between treatment and
HER2 status were suggestive but not statistically significant (P =.19 for DFS, P =.11 for survival, and P =.08 for RFS).
CONCLUSIONS:
These results, together with overview results indicating minor overall superiority for anthracycline-based regimens
relative to CMF, indicate a preference for the AC regimen in patients with HER2-positive tumors. Both AC and CMF
regimens may be considered for patients with HER2-negative tumors.
CMF VS CAF REGIMEN
2005 by American Society of Clinical Oncology
Randomized, Controlled Trial of Cyclophosphamide, Methotrexate,
and Fluorouracil Versus Cyclophosphamide, Doxorubicin, and
Fluorouracil With and Without Tamoxifen for High-Risk, Node-
Negative Breast Cancer: Treatment Results of Intergroup Protocol
INT-0102
SWOG INT0102
Abstract
Purpose We evaluated the efficacy of cyclophosphamide, methotrexate, and fluorouracil (CMF)
versus cyclophosphamide, doxorubicin, and fluorouracil (CAF) in node-negative breast cancer
patients with and without tamoxifen (TAM), overall and by hormone receptor (HR) status.
Patients and Methods Node-negative patients identified by tumor size (> 2 cm), negative HR, or
high S-phase fraction (n = 2,690) were randomly assigned to CMF, CAF, CMF + TAM (CMFT), or CAF +
TAM (CAFT). Cox regression evaluated overall survival (OS) and disease-free survival (DFS) for CAF
versus CMF and TAM versus no TAM separately. Two-sided CIs and one-sided P values for planned
comparisons were calculated.
Results Ten-year estimates indicated that CAF was not significantly better than CMF (P = .13) for the
primary outcome of DFS (77% v 75%; HR = 1.09; 95% CI, 0.94 to 1.27). CAF had slightly better OS
than CMF (85% v 82%, HR = 1.19 for CMF v CAF; 95% CI, 0.99 to 1.43); values were statistically
significant in the planned one-sided test (P = .03). Toxicity was greater with CAF and did not
increase with TAM. Overall, TAM had no benefit (DFS, P = .16; OS, P = .37), but the TAM effect
differed by HR groups. For HR-positive patients, TAM was beneficial (DFS, HR = 1.32 for no
TAM v TAM; 95% CI, 1.09 to 1.61; P = .003; OS, HR = 1.26; 95% CI, 0.99 to 1.61; P = .03), but not for
HR-negative patients (DFS, HR = 0.81 for no TAMv TAM; 95% CI, 0.64 to 1.03; OS, HR = 0.79; 95% CI,
0.60 to 1.05).
Conclusion CAF did not improve DFS compared with CMF; there was a slight effect on OS. Given
greater toxicity, we cannot conclude CAF to be superior to CMF. TAM is effective in HR-positive
disease, but not in HR-negative disease.
EBCTCG 2010 OVERVIEW
POLYCHEMOTHERAPHY VS NONE
10 YR RESULTS IN
23500 PATIENTS
CMF VS NO ADJUVANT
ANTHRACYCLINES VS NO ADJUVANT
ANTHRACYCLINES(AC) VS CMF
ADJUVANT CHEMOTHERAPHY HAS
DEFNITIVE BENEFIT IN ALL
SUBGROUPS
Overall, we can conclude that CMF adjuvant chemotherapy is better than no treatment for early-
stage breast cancer. For low-risk patients, the above studies conclude that six cycles of oral CMF or
four cycles of AC every 3 weeks are equivalent in efficacy. Clinical trials that have incorporated
doxorubicin and epirubicin into polychemotherapy regimens (CAF and CEF for six cycles) show a
modest but clear benefit for anthracycline-based therapy compared to six cycles of CMF in adjuvant
breast cancer. Based on these results, anthracycline therapy with six cycles of CAF or CEF is
recommended for higher-risk patients (ie, node-positive patients), and may be used as a
benchmark for newer regimens incorporating taxanes and other novel agents. It is important to
note that six cycles of CAF/CEF chemotherapy regimens have not been directly compared to four or
six cycles of AC in the adjuvant setting. Also, there is no current evidence of excessive cardiac
toxicity in women with normal heart function who receive anthracyclines at the cumulative doses
utilized in standard adjuvant programs. The trade-off for a small survival benefit with anthracyclines
is a different treatment-related toxicity profile including higher incidences of alopecia, vomiting,
and cytopenias compared to CMF. With the availability of effective antiemetics (5-HT3 receptor
antagonists and NK1 inhibitors) and the use of growth factor support, most of these acute toxicities
can be fairly manageable. Data regarding the long-term toxicities of anthracyclines demonstrate a
low risk of cardiomyopathy and treatmentrelated leukemia. Overall, we seldom recommend CMF as
adjuvant therapy in our practice, and most often recommend anthracycline-based therapy,
although we remain very interested in the development of nonanthracycline combinations other
than CMF. - See more at: http://www.cancernetwork.com/review-article/anthracycline-vs-
nonanthracycline-adjuvant-therapy-breast-cancer#sthash.J7msq62m.dpuf
TAXANES
CALGB 9344
3128 patients with positive LNs were randomized
to 3 groups
A(60mg/m2)C x 4 course +/- Taxol (175mg/m2) x 4 courses
A(75mg/m2)C x 4 course +/- Taxol (175mg/m2) x 4 courses
A(90mg/m2)C x 4 course +/- Taxol (175mg/m2) x 4 courses
At 5 years, disease free survival was 69%, 66%
and 67 % for patients with different adrimycin
dosage
The hazard reduction from adding paclitaxel to AC
were 17% for recurrence (p=0.0011) and 18% for
death (p=0.0098)
JCO 2003;21:976-983
CALGB 9344 Adjuvant Study
R
N=3,170
A A60 C 4 P4
Node+ N
D
O A75 C 4
Statification:
Premenopausal & M
Postmenopausal I A90 C 4 No P
Z
E
Lancet Oncol. 2013 Jan;14(1):72-80. doi: 10.1016/S1470-2045(12)70525-9. Epub 2012 Dec 12.
Adjuvant docetaxel, doxorubicin, and cyclophosphamide in node-positive breast cancer: 10-year follow-up of the phase 3 randomised BCIRG 001
trial.
Mackey JR, Martin M, Pienkowski T, Rolski J, Guastalla JP, Sami A, Glaspy J, Juhos E, Wardley A, Fornander T, Hainsworth J, Coleman R, Modiano
MR,Vinholes J, Pinter T, Rodrguez-Lescure A, Colwell B, Whitlock P, Provencher L, Laing K, Walde D, Price C, Hugh JC, Childs BH, Bassi K, Lindsay
MA, Wilson V,Rupin M, Hou V, Vogel C; TRIO/BCIRG 001 investigators.
Collaborators (72)
Author information
Abstract
BACKGROUND:
We compared standard adjuvant anthracycline chemotherapy with anthracycline-taxane combination chemotherapy in women with operable node-
positive breast cancer. Here we report the final, 10-year follow-up analysis of disease-free survival, overall survival, and long-term safety.
METHODS:
BCIRG 001 was an open label, phase 3, multicentre trial in which 1491 patients aged 18-70 years with node-positive, early breast cancer and a
Karnofsky score of 80% or more were randomly assigned to adjuvant treatment with docetaxel, doxorubicin, and cyclophosphamide (TAC) or
fluorouracil, doxorubicin, and cyclophosphamide (FAC) every 3 weeks for six cycles. Randomisation was stratified according to institution and number
of involved axillary lymph nodes per patient (one to three vs four or more). Disease-free survival was the primary endpoint and was defined as the
interval between randomisation and breast cancer relapse, second primary cancer, or death, whichever occurred first. Efficacy analyses were based
on the intention-to-treat principle. BCIRG 001 is registered with ClinicalTrials.gov, number NCT00688740.
FINDINGS:
Enrolement took place between June 11, 1997 and June 3, 1999; 745 patients were assigned to receive TAC and 746 patients were assigned to
receive FAC. After a median follow-up of 124 months (IQR 90-126), disease-free survival was 62% (95% CI 58-65) for patients in the TAC group and
55% (51-59) for patients in the FAC group (hazard ratio [HR] 080, 95% CI 068-093; log-rank p=00043). 10-year overall survival was 76% (95% CI 72-
79) for patients in the TAC group and 69% (65-72) for patients in the FAC group (HR 074, 061-090; log-rank p=00020). TAC improved disease-free
survival relative to FAC irrespective of nodal, hormone receptor, and HER2 status, although not all differences were significant in these subgroup
analyses. Grade 3-4 heart failure occurred in 26 (3%) patients in the TAC group and 17 (2%) patients in the FAC group, and caused death in two
patients in the TAC group and four patients in the FAC group. A substantial decrease in left ventricular ejection fraction (defined as a relative
decrease from baseline of 20% or more) was seen in 58 (17%) patients who received TAC and 41 (15%) patients who received FAC. Six patients who
received TAC developed leukaemia or myelodysplasia, as did three patients who received FAC.
INTERPRETATION:
Our results provide evidence that the initial therapeutic outcomes seen at the 5-year follow-up with a docetaxel-containing adjuvant regimen are
maintained at 10 years. However, a substantial percentage of patients had a decrease in left ventricular ejection fraction, probably caused by
anthracycline therapy, which warrants further investigation.
2006 by American Society of Clinical Oncology
Sequential Adjuvant Epirubicin-Based and Docetaxel Chemotherapy
for Node-Positive Breast Cancer Patients: The FNCLCC PACS 01 Trial
Abstract
Purpose The PACS 01 trial compared six cycles of fluorouracil, epirubicin, and cyclophosphamide
(FEC) with a sequential regimen of three cycles of FEC followed by three cycles of docetaxel (FEC-D)
as adjuvant treatment for women with node-positive early breast cancer.
Patients and Methods Between June 1997 and March 2000, 1,999 patients with operable node-
positive breast cancer were randomly assigned to either FEC every 21 days for six cycles, or three
cycles of FEC followed by three cycles of docetaxel, both given every 21 days. Hormone-receptor
positive patients received tamoxifen for 5 years after chemotherapy. The primary end point was 5-
year disease-free survival (DFS).
Results Median follow-up was 60 months. Five-year DFS rates were 73.2% with FEC and 78.4% with
FEC-D (unadjusted P = .011; adjusted P = .012). Multivariate analysis adjusted for prognostic factors
showed an 18% reduction in the relative risk of relapse with FEC-D. Five-year overall survival rates
were 86.7% with FEC and 90.7% with FEC-D, demonstrating a 27% reduction in the relative risk of
death (unadjusted P = .014; adjusted P = .017). The incidence of grade 3 to 4 neutropenia, the need
for hematopoietic growth factor, and incidence of nausea/vomiting were higher with FEC.
Docetaxel was associated with more febrile neutropenia in the fourth cycle, stomatitis, edema, and
nail disorders. Though rare overall, there were fewer cardiac events after FEC-D (P = .03),
attributable mainly to the lower anthracycline cumulative dose.
Conclusion Sequential adjuvant chemotherapy with FEC followed by docetaxel significantly
improves disease-free and overall survival in node-positive breast cancer patients and has a
favorable safety profile.
J Clin Oncol. 2003 Apr 15;21(8):1431-9. Epub 2003 Feb 13.
Randomized trial of dose-dense versus conventionally scheduled and
sequential versus concurrent combination chemotherapy as
postoperative adjuvant treatment of node-positive primary breast
cancer: first report of Intergroup Trial C9741/Cancer and Leukemia
Abstract Group B Trial 9741.
PURPOSE:
Using a 2 x 2 factorial design, we studied the adjuvant chemotherapy of women with axillary node-positive breast
cancer to compare sequential doxorubicin (A), paclitaxel (T), and cyclophosphamide (C) with concurrent
doxorubicin and cyclophosphamide (AC) followed by paclitaxel (T) for disease-free (DFS) and overall survival (OS);
to determine whether the dose density of the agents improves DFS and OS; and to compare toxicities.
PATIENTS AND METHODS:
A total of 2,005 female patients were randomly assigned to receive one of the following regimens: (I) sequential A
x 4 (doses) --> T x 4 --> C x 4 with doses every 3 weeks, (II) sequential A x 4 --> T x 4 --> C x 4 every 2 weeks with
filgrastim, (III) concurrent AC x 4 --> T x 4 every 3 weeks, or (IV) concurrent AC x 4 --> T x 4 every 2 weeks with
filgrastim.
RESULTS:
A protocol-specified analysis was performed at a median follow-up of 36 months: 315 patients had experienced
relapse or died, compared with 515 expected treatment failures. Dose-dense treatment improved the primary end
point, DFS (risk ratio [RR] = 0.74; P =.010), and OS (RR = 0.69; P =.013). Four-year DFS was 82% for the dose-dense
regimens and 75% for the others. There was no difference in either DFS or OS between the concurrent and
sequential schedules. There was no interaction between density and sequence. Severe neutropenia was less
frequent in patients who received the dose-dense regimens.
CONCLUSION:
Dose density improves clinical outcomes significantly, despite the lower than expected number of events at this
time. Sequential chemotherapy is as effective as concurrent chemotherapy.
Fluorouracil, Epirubicin, and Cyclophosphamide With Either
Docetaxel or Vinorelbine, With or Without Trastuzumab, As Adjuvant
Treatments of Breast Cancer: Final Results of the FinHer Trial 2009 by
American Society of Clinical Oncology
Abstract
Purpose Docetaxel has not been compared with vinorelbine as adjuvant treatment of early breast
cancer. Efficacy and long-term safety of a short course of adjuvant trastuzumab administered
concomitantly with chemotherapy for human epidermal growth factor receptor 2 (HER2) positive
cancer are unknown.
Patients and Methods One thousand ten women with axillary nodepositive or high-risk node-
negative breast cancer were randomly assigned to receive three cycles of docetaxel or vinorelbine,
followed in both groups by three cycles of fluorouracil, epirubicin, and cyclophosphamide (FEC).
Women with HER2-positive cancer (n = 232) were further assigned to either receive or not receive
trastuzumab for 9 weeks with docetaxel or vinorelbine. The median follow-up time was 62 months
after random assignment.
Results Women assigned to docetaxel had better distant diseasefree survival (DDFS) than those
assigned to vinorelbine (hazard ratio [HR] = 0.66; 95% CI, 0.49 to 0.91; P = .010). In the subgroup
of HER2-positive disease, patients treated with trastuzumab tended to have better DDFS than those
treated with chemotherapy only (HR = 0.65; 95% CI, 0.38 to 1.12; P = .12; with adjustment for
presence of axillary nodal metastases, HR = 0.57; P = .047). In exploratory analyses, docetaxel,
trastuzumab, and FEC improved DDFS compared with docetaxel plus FEC (HR = 0.32; P = .029) and
vinorelbine, trastuzumab, and FEC (HR = 0.31; P = .020). The median left ventricular ejection
fraction of trastuzumab-treated patients remained unaltered during the 5-year follow-up; only one
woman treated with trastuzumab was diagnosed with a heart failure.
Conclusion Adjuvant treatment with docetaxel improves DDFS compared with vinorelbine. A brief
course of trastuzumab administered concomitantly with docetaxel is safe and effective and
warrants further evaluation.
2 years versus 1 year of adjuvant trastuzumab for HER2-positive
breast cancer (HERA): an open-label, randomised controlled trial.
Lancet. 2013 Sep 21;382(9897):1021-8. doi: 10.1016/S0140-6736(13)61094-6. Epub
2013 Jul 18.
Abstract
BACKGROUND:
Trastuzumab has established efficacy against breast cancer with overexpression or amplification of the HER2 oncogene. The
standard of care is 1 year of adjuvant trastuzumab, but the optimum duration of treatment is unknown. We compared 2
years of treatment with trastuzumab with 1 year of treatment, and updated the comparison of 1 year of trastuzumab versus
observation at a median follow-up of 8 years, for patients enrolled in the HERceptin Adjuvant (HERA) trial.
METHODS:
The HERA trial is an international, multicentre, randomised, open-label, phase 3 trial comparing treatment with trastuzumab
for 1 and 2 years with observation after standard neoadjuvant chemotherapy, adjuvant chemotherapy, or both in 5102
patients with HER2-positive early breast cancer. The primary endpoint was disease-free survival. The comparison of 2 years
versus 1 year of trastuzumab treatment involved a landmark analysis of 3105 patients who were disease-free 12 months
after randomisation to one of the trastuzumab groups, and was planned after observing at least 725 disease-free survival
events. The updated intention-to-treat comparison of 1 year trastuzumab treatment versus observation alone in 3399
patients at a median follow-up of 8 years (range 0-10) is also reported. This study is registered with ClinicalTrials.gov, number
NCT00045032.
FINDINGS:
We recorded 367 events of disease-free survival in 1552 patients in the 1 year group and 367 events in 1553 patients in the
2 year group (hazard ratio [HR] 099, 95% CI 085-114, p=086). Grade 3-4 adverse events and decreases in left ventricular
ejection fraction during treatment were reported more frequently in the 2 year treatment group than in the 1 year group
(342 [204%] vs 275 [163%] grade 3-4 adverse events, and 120 [72%] vs 69 [41%] decreases in left ventricular ejection
fraction, respectively). HRs for a comparison of 1 year of trastuzumab treatment versus observation were 076 (95% CI 067-
086, p<00001) for disease-free survival and 076 (065-088, p=00005) for overall survival, despite crossover of 884 (52%)
patients from the observation group to trastuzumab therapy.
INTERPRETATION:
2 years of adjuvant trastuzumab is not more effective than is 1 year of treatment for patients with HER2-positive early breast
cancer. 1 year of treatment provides a significant disease-free and overall survival benefit compared with observation and
remains the standard of care.
NEOADJUVANT
CHEMOTHERAPHY
J Clin Oncol. 1997 Jul;15(7):2483-93.
Effect of preoperative chemotherapy on local-regional disease
in women with operable breast cancer: findings from National
Surgical Adjuvant Breast and Bowel Project B-18.
NSABP 18
Abstract
PURPOSE:
To determine whether preoperative doxorubicin and cyclophosphamide (AC) permits more lumpectomies to be
performed and decreases the incidence of positive nodes in women with primary breast cancer.
PATIENTS AND METHODS:
Women (n = 1,523) were randomized to National Surgical Adjuvant Breast and Bowel Project (NSABP) B-18; 759
eligible patients received postoperative AC and 747, preoperative AC. The clinical size of breast and axillary tumors
was determined before each of four cycles of AC and before surgery. Tumor response to preoperative therapy was
clinically complete (cCR), partial (cPR), stable (cSD), or progressive disease (cPD). Tissue from patients with a cCR
was evaluated for a pathologic complete response (pCR).
RESULTS:
Breast tumor size was reduced in 80% of patients after preoperative therapy; 36% had a cCR. Tumor size and
clinical nodal status were independent predictors of cCR. Twenty-six percent of women with a cCR had a pCR.
Clinical nodal response occurred in 89% of node-positive patients: 73% had a cCR and 44% of those had a pCR.
There was a 37% increase in the incidence of pathologically negative nodes. Before randomization, lumpectomy
was proposed for 86% of women with tumors < or = 2 cm, 70% with tumors 2.1 to 5.0 cm, and 3% with tumors >
or = 5.1 cm. Clinical tumor size and nodal status influenced the physician's decision. Overall, 12% more
lumpectomies were performed in the preoperative group; in women with tumors > or = 5.1 cm, there was a 175%
increase.
CONCLUSION:
Preoperative therapy reduced the size of most breast tumors and decreased the incidence of positive nodes. The
greatest increase in lumpectomy after preoperative therapy occurred in women with tumors > or = 5 cm, since
women with tumors less than 5 cm were already lumpectomy candidates. Preoperative therapy should be
considered for the initial management of breast tumors judged too large for lumpectomy.
NSABP Protocol B-27. Preoperative doxorubicin plus
cyclophosphamide followed by preoperative or postoperative
docetaxel.
Preoperative Chemotherapy: Updates of National Surgical
Adjuvant Breast and Bowel Project Protocols B-18 and B-27.
Abstract
Purpose: National Surgical Adjuvant Breast and Bowel Project (NSABP) Protocol B-18 was designed to determine
whether four cycles of doxorubicin and cyclophosphamide (AC) administered preoperatively improved breast
cancer disease-free survival (DFS) and overall survival (OS) compared with AC administered postoperatively.
Protocol B-27 was designed to determine the effect of adding docetaxel (T) to preoperative AC on tumor response
rates, DFS, and OS.
Patients and Methods: Analyses were limited to eligible patients. In B-18, 751 patients were assigned to receive
preoperative AC, and 742 patients were assigned to receive postoperative AC. In B-27, 784 patients were assigned
to receive preoperative AC followed by surgery, 783 patients were assigned to AC followed by T and surgery, and
777 patients were assigned to AC followed by surgery and then T.
Results: Results from B-18 show no statistically significant differences in DFS and OS between the two groups.
However, there were trends in favor of preoperative chemotherapy for DFS and OS in women less than 50 years
old (hazard ratio [HR] = 0.85, P = .09 for DFS; HR = 0.81, P = .06 for OS). DFS conditional on being event free for 5
years also demonstrated a strong trend in favor of the preoperative group (HR = 0.81, P = .053). Protocol B-27
results demonstrated that the addition of T to AC did not significantly impact DFS or OS. Preoperative T added to
AC significantly increased the proportion of patients having pathologic complete responses (pCRs) compared with
preoperative AC alone (26% v 13%, respectively; P < .0001). In both studies, patients who achieved a pCR continue
to have significantly superior DFS and OS outcomes compared with patients who did not.
Conclusion: B-18 and B-27 demonstrate that preoperative therapy is equivalent to adjuvant therapy. B-27 also
showed that the addition of preoperative taxanes to AC improves response.
J Clin Oncol. 2008 Feb 10;26(5):778-85.
Clin Breast Cancer. 2002 Oct;3 Suppl 2:S69-74.
Neoadjuvant docetaxel in breast cancer: 3-year survival results from
the Aberdeen trial.
Abstract
Over the past 30 years there has been an increased use of neoadjuvant (or
primary) chemotherapy for treating patients with breast cancer. However, while it
is clear that chemotherapy given in the adjuvant setting after surgery does prolong
patients' overall and disease-free survival, the evidence that chemotherapy in the
neoadjuvant setting also increases survival remains unproven. In the Aberdeen
study, 162 patients with large and locally advanced breast cancer underwent 4
cycles of CVAP (cyclophosphamide/vincristine/doxorubicin/prednisone) primary
chemotherapy. Patients with a complete or partial response were then
randomized to either 4 further cycles of CVAP or 4 cycles of docetaxel (100
mg/m2). It was shown that the addition of sequential docetaxel (100 mg/m2) to
CVAP neoadjuvant chemotherapy resulted in a significantly enhanced clinical
response rate (94% vs. 64%) and a substantially increased complete
histopathological response rate (34% vs. 16%) when compared to patients
receiving CVAP alone. Furthermore, patients receiving docetaxel had an increased
breast conservation rate (67% vs. 48%) and an increased survival at a median
follow-up of 3 years. It is important to note that this was a small study, and the
survival results should be interpreted with caution. The results are encouraging,
however, and further studies are urgently required.
GEPAR duo TRIAL
Neoadjuvant docetaxel followed by adjuvant doxorubicin and
cyclophosphamide in patients with stage III breast cancer
Neoadjuvant chemotherapy produces substantial increases in clinical response rates and rates of breast
conserving therapy. Pathologic response rate, though generally low, is an important outcome as it is presumably
associated with eradication of micrometastatic disease and may likely result in improved outcomes. Anthracyclines
have long been considered the most efficacious chemotherapy agents for neoadjuvant therapy of early breast
cancer. Unfortunately, not all patients respond to neoadjuvant anthracycline-based chemotherapy. In an effort to
improve primary tumor response, docetaxel, an active agent in breast cancer, has been evaluated in the
neoadjuvant setting. Several randomized trials, including the NSABP B-27, GEPAR-duo, and the Aberdeen trial,
evaluating docetaxel in sequence with a doxorubicin-based neoadjuvant regimen have been reported, with
encouraging findings. We designed the Aberdeen trial with two primary aims: (1) to evaluate primary docetaxel in
patients that initially fail a neoadjuvant anthracycline-based polychemotherapy regimen, and (2) to compare a
docetaxel-based neoadjuvant regimen with a standard anthracycline-based regimen in patients who do respond to
the first four cycles of the anthracycline-based regimen. Eligible patients (n = 162) had previously untreated large
(> or = 3 cm) or locally advanced (T3, T4, T x N2) breast cancer. All received four cycles of CVAP, after which clinical
response was assessed. Responding patients were then randomized to four additional cycles of CVAP or to
docetaxel 100 mg/m2 every 3 weeks for four cycles. Patients failing to respond to CVAP received the docetaxel
regimen. After the first four cycles of CVAP, the overall response rate (ORR) was 67%. Ultimately, responses were
higher in the group randomized to docetaxel compared with those continuing CVAP (cCR: 94% vs. 66%; p = 0.001;
pCR 34% vs. 16%; p = 0.04). The addition of docetaxel improved overall survival and disease-free survival for
patients responding to four cycles of CVAP as compared with those receiving eight cycles of CVAP. Relative dose
intensity was higher and the incidence of severe leukopenia was lower in the group randomized to docetaxel.
These data and data from the NSABP B-27 and GEPAR-duo trials strongly support a combined
anthracycline/docetaxel regimen in the neoadjuvant setting.
PMID: 12868802 [PubMed - indexed for MEDLINE]
HORMONE THERAPHY
Tamoxifen for Prevention of Breast Cancer: Report of the National
Surgical Adjuvant Breast and Bowel Project P-1 Study
Abstract
Background: The finding of a decrease in contralateral breast cancer incidence following tamoxifen administration for
adjuvant therapy led to the concept that the drug might play a role in breast cancer prevention. To test this hypothesis,
the National Surgical Adjuvant Breast and Bowel Project initiated the Breast Cancer Prevention Trial (P-1) in 1992.
Methods: Women (N = 13 388) at increased risk for breast cancer because they 1) were 60 years of age or older, 2) were
3559 years of age with a 5-year predicted risk for breast cancer of at least 1.66%, or 3) had a history of lobular carcinoma
in situ were randomly assigned to receive placebo (n = 6707) or 20 mg/day tamoxifen (n = 6681) for 5 years. Gail's
algorithm, based on a multivariate logistic regression model using combinations of risk factors, was used to estimate the
probability (risk) of occurrence of breast cancer over time. Results: Tamoxifen reduced the risk of invasive breast cancer
by 49% (two-sided P<.00001), with cumulative incidence through 69 months of follow-up of 43.4 versus 22.0 per 1000
women in the placebo and tamoxifen groups, respectively. The decreased risk occurred in women aged 49 years or
younger (44%), 5059 years (51%), and 60 years or older (55%); risk was also reduced in women with a history of lobular
carcinoma in situ (56%) or atypical hyperplasia (86%) and in those with any category of predicted 5-year risk. Tamoxifen
reduced the risk of noninvasive breast cancer by 50% (two-sided P<.002). Tamoxifen reduced the occurrence of estrogen
receptor-positive tumors by 69%, but no difference in the occurrence of estrogen receptor-negative tumors was seen.
Tamoxifen administration did not alter the average annual rate of ischemic heart disease; however, a reduction in hip,
radius (Colles'), and spine fractures was observed. The rate of endometrial cancer was increased in the tamoxifen group
(risk ratio = 2.53; 95% confidence interval = 1.354.97); this increased risk occurred predominantly in women aged 50
years or older. All endometrial cancers in the tamoxifen group were stage I (localized disease); no endometrial cancer
deaths have occurred in this group. No liver cancers or increase in colon, rectal, ovarian, or other tumors was observed in
the tamoxifen group. The rates of stroke, pulmonary embolism, and deep-vein thrombosis were elevated in the
tamoxifen group; these events occurred more frequently in women aged 50 years or older.
Conclusions: Tamoxifen decreases the incidence of invasive and noninvasive breast cancer. Despite side effects resulting
from administration of tamoxifen, its use as a breast cancer preventive agent is appropriate in many women at increased
risk for the disease. [J Natl Cancer Inst 1998;90:137188]
1998 Oxford University Press
PROTOCOL B-14
A Clinical Trial to Assess Tamoxifen in Patients With Primary Breast
Cancer and Negative Axillary Nodes Whose Tumors are Positive for
Estrogen Receptors
NSABP 14
Five versus more than five years of tamoxifen for lymph node-negative breast cancer: updated findings from the National
Surgical Adjuvant Breast and Bowel Project B-14 randomized trial.
Fisher B, Dignam J, Bryant J, Wolmark N.
Author information
Abstract
BACKGROUND:
Previously reported information from B-14, a National Surgical Adjuvant Breast and Bowel Project (NSABP) randomized,
placebo-controlled clinical trial, demonstrated that patients with estrogen receptor (ER)-positive breast cancer and negative
axillary lymph nodes experienced a prolonged benefit from 5 years of tamoxifen therapy. When these women were
rerandomized to receive either placebo or more prolonged tamoxifen therapy, they obtained no additional advantage from
tamoxifen through 4 years of follow-up. Because the optimal duration of tamoxifen administration continues to be
controversial and because there have been 3 more years of follow-up and a substantial increase in the number of events
since our last report, an update of the B-14 study is appropriate.
METHODS:
Patients (n = 1172) who had completed 5 years of tamoxifen therapy and who were disease free were rerandomized to
receive placebo (n = 579) or tamoxifen (n = 593). Survival, disease-free survival (DFS), and relapse-free survival (RFS) were
estimated by the Kaplan-Meier method; the differences between the treatment groups were assessed by the log-rank test.
Relative risks of failure (with 95% confidence intervals) were determined by the Cox proportional hazards model. P values
were two-sided.
RESULTS:
Through 7 years after reassignment of tamoxifen-treated patients to either placebo or continued tamoxifen therapy, a slight
advantage was observed in patients who discontinued tamoxifen relative to those who continued to receive it: DFS = 82%
versus 78% (P =.03), RFS = 94% versus 92% (P =.13), and survival = 94% versus 91% (P =.07), respectively. The lack of benefit
from additional tamoxifen therapy was independent of age or other characteristics.
CONCLUSION:
Through 7 years of follow-up after rerandomization, there continues to be no additional benefit from tamoxifen
administered beyond 5 years in women with ER-positive breast cancer and negative axillary lymph nodes.
Lancet Oncol. 2010 Dec;11(12):1135-41. doi: 10.1016/S1470-
2045(10)70257-6. Epub 2010 Nov 17.
Effect of anastrozole and tamoxifen as adjuvant treatment for early-
stage breast cancer: 10-year analysis of the ATAC trial.
ATAC
Results of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial after completion of 5
years' adjuvant treatment for breast cancer.
Howell A, Cuzick J, Baum M, Buzdar A, Dowsett M, Forbes JF, Hoctin-Boes G, Houghton J, Locker
GY, Tobias JS; ATAC Trialists' Group.
Author information
Abstract
The standard adjuvant endocrine treatment for postmenopausal women with hormone-receptor-
positive localised breast cancer is 5 years of tamoxifen, but recurrences and side-effects restrict its
usefulness. The aromatase inhibitor anastrozole was compared with tamoxifen for 5 years in 9366
postmenopausal women with localised breast cancer. After a median follow-up of 68 months,
anastrozole significantly prolonged disease-free survival (575 events with anastrozole vs 651 with
tamoxifen, hazard ratio 0.87, 95% CI 0.78-0.97, p=0.01) and time-to-recurrence (402 vs 498, 0.79,
0.70-0.90, p=0.0005), and significantly reduced distant metastases (324 vs 375, 0.86, 0.74-0.99,
p=0.04) and contralateral breast cancers (35 vs 59, 42% reduction, 12-62, p=0.01). Almost all
patients have completed their scheduled treatment, and fewer withdrawals occurred with
anastrozole than with tamoxifen. Anastrozole was also associated with fewer side-effects than
tamoxifen, especially gynaecological problems and vascular events, but arthralgia and fractures
were increased. Anastrozole should be the preferred initial treatment for postmenopausal women
with localised hormone-receptor-positive breast cancer.
ATAC
Abstract
BACKGROUND:
The Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial was designed to compare the efficacy and safety of
anastrozole (1 mg) with tamoxifen (20 mg), both given orally every day for 5 years, as adjuvant treatment for
postmenopausal women with early-stage breast cancer. In this analysis, we assess the long-term outcomes after a median
follow-up of 120 months.
METHODS:
We used a proportional hazards model to assess the primary endpoint of disease-free survival, and the secondary endpoints
of time to recurrence, time to distant recurrence, incidence of new contralateral breast cancer, overall survival, and death
with or without recurrence in all randomised patients (anastrozole n=3125, tamoxifen n=3116) and hormone-receptor-
positive patients (anastrozole n=2618, tamoxifen n=2598). After treatment completion, we continued to collect data on
fractures and serious adverse events in a masked fashion (safety population: anastrozole n=3092, tamoxifen n=3094). This
study is registered as an International Standard Randomised Controlled Trial, number ISRCTN18233230.
FINDINGS:
Patients were followed up for a median of 120 months (range 0-145); there were 24,522 woman-years of follow-up in the
anastrozole group and 23,950 woman-years in the tamoxifen group. In the full study population, there were significant
improvements in the anastrozole group compared with the tamoxifen group for disease-free survival (hazard ratio [HR] 091,
95% CI 083-099; p=004), time to recurrence (084, 075-093; p=0001), and time to distant recurrence (087, 077-099;
p=003). For hormone-receptor-positive patients, the results were also significantly in favour of the anastrozole group for
disease-free survival (HR 086, 95% CI 078-095; p=0003), time to recurrence (079, 070-089; p=00002), and time to
distant recurrence (085, 073-098; p=002). In hormone-receptor-positive patients, absolute differences in time to
recurrence between anastrozole and tamoxifen increased over time (27% at 5 years and 43% at 10 years) and recurrence
rates remained significantly lower on anastrozole than tamoxifen after treatment completion (HR 081, 95% CI 067-098;
p=003), although the carryover benefit was smaller after 8 years. There was weak evidence of fewer deaths after recurrence
with anastrozole compared with tamoxifen treatment in the hormone-receptor-positive subgroup (HR 087, 95% CI 074-
102; p=009), but there was little difference in overall mortality (095, 95% CI 084-106; p=04). Fractures were more
frequent during active treatment in patients receiving anastrozole than those receiving tamoxifen (451 vs 351; OR 133, 95%
CI 115-155; p<00001), but were similar in the post-treatment follow-up period (110 vs 112; OR 098, 95% CI 074-130;
p=09). Treatment-related serious adverse events were less common in the anastrozole group than the tamoxifen group (223
anastrozole vs 369 tamoxifen; OR 057, 95% CI 048-069; p<00001), but were similar after treatment completion (66 vs 78;
OR 084, 95% CI 060-119; p=03). No differences in non-breast cancer causes of death were apparent and the incidence of
other cancers was similar between groups (425 vs 431) and continue to be higher with anastrozole for colorectal (66 vs 44)
and lung cancer (51 vs 34), and lower for endometrial cancer (six vs 24), melanoma (eight vs 19), and ovarian cancer (17 vs
28). No new safety concerns were reported.
Neoadjuvant chemotherapy with trastuzumab followed by
Neo adjuvant trastuzumab versus neoadjuvant chemotherapy alone, in
patients with HER2-positive locally
Neoadjuvant chemotherapy with advanced breast cancer (the NOAH trial): a
randomised controlled superiority trial with a parallel HER2-negative cohort
Background
The monoclonal antibody trastuzumab has survival benefit when given with chemotherapy to patients
with early, operable, and metastatic breast cancer that has HER2 (also known as ERBB2) overexpression or
amplification. We aimed to assess event-free survival in patients with HER2-positive locally advanced or
inflammatory breast cancer receiving neoadjuvant chemotherapy with or without 1 year of trastuzumab.
Methods
We compared 1 year of treatment with trastuzumab (given as neoadjuvant and adjuvant treatment;
n=117) with no trastuzumab (118), in women with HER2-positive locally advanced or inflammatory breast
cancer treated with a neoadjuvant chemotherapy regimen consisting of doxorubicin, paclitaxel,
cyclophosphamide, methotrexate, and fluorouracil. Randomisation was done with a computer program
and minimisation technique, taking account of geographical area, disease stage, and hormone receptor
status. Investigators were informed of treatment allocation. A parallel cohort of 99 patients with HER2-
negative disease was included and treated with the same chemotherapy regimen. Primary endpoint was
event-free survival. Analysis was by intention to treat. This study is registered, number ISRCTN86043495.
Findings
Trastuzumab significantly improved event-free survival in patients with HER2-positive breast cancer (3-
year event-free survival, 71% [95% CI 6178; n=36 events] with trastuzumab, vs 56% [4665; n=51
events] without; hazard ratio 059 [95% CI 038090]; p=0013). Trastuzumab was well tolerated and,
despite concurrent administration with doxorubicin, only two patients (2%) developed symptomatic
cardiac failure. Both responded to cardiac drugs.
Interpretation
The addition of neoadjuvant and adjuvant trastuzumab to neoadjuvant chemotherapy should be
considered for women with HER2-positive locally advanced or inflammatory breast cancer to improve
event-free survival, survival, and clinical and pathological tumour responses.
Program for the Assessment of Clinical Cancer Tests
(PACCT-1): Trial Assigning Individualized Options for
Treatment: The TAILORx Trial