1-phenylalanine mustard (L-PAM) in the management of premenopausal patients with primary breast cancer: lack of association of disease-free survival with depression of ovarian function. National Surgical Adjuvant Project for Breast and Bowel Cancers

Gasotransmitters in the tumor microenvironment: Impacts on cancer chemotherapy (Review)

Nitric oxide, carbon monoxide and hydrogen sulfide are three endogenous gasotransmitters that serve a role in regulating normal and pathological cellular activities. They can stimulate or inhibit cancer cell proliferation and invasion, as well as interfere with cancer cell responses to drug treatments. Understanding the molecular pathways governing the interactions between these gases and the tumor microenvironment can be utilized for the identification of a novel technique to disrupt cancer cell interactions and may contribute to the conception of effective and safe cancer therapy strategies. The present review discusses the effects of these gases in modulating the action of chemotherapies, as well as prospective pharmacological and therapeutic interfering approaches. A deeper knowledge of the mechanisms that underpin the cellular and pharmacological effects, as well as interactions, of each of the three gases could pave the way for therapeutic treatments and translational research.

Using post-column infused internal standard assisted quantitative metabolomics for establishing prediction models for breast cancer detection

RATIONALE

Breast cancer is one of the most common cancers among women and its associated mortality is on the rise. Metabolomics is a potential strategy for breast cancer detection. The post-column infused internal standard (PCI-IS)-assisted liquid chromatography/tandem mass spectrometry (LC/MS/MS) method has been demonstrated as an effective strategy for quantitative metabolomics. In this study, we evaluated the performance of targeted metabolomics with the PCI-IS quantification method to identify women with breast cancer.

METHODS

We used metabolite profiling to identify 17 dysregulated metabolites in breast cancer patients. Two LC/MS/MS methods in combination with the PCI-IS strategy were developed to quantify these metabolites in plasma samples. Detection models were built through the analysis of plasma samples from 176 subjects consisting of healthy volunteers and breast cancer patients.

RESULTS

Three isotope standards were selected as the PCI-ISs for the metabolites. The accuracy was within 82.8-114.16%, except for citric acid and lactic acid at high concentration levels. The repeatability and intermediate precision were all lower than 15% relative standard deviation. We have identified several metabolites that indicate the presence of breast cancer. The area under the receiver operating characteristics (AUROC) curve, sensitivity and specificity of the linear combinations of metabolite concentrations and age with the highest AUROC were 0.940 (0.889-0.992), 88.4% and 94.2% for pre-menopausal woman, respectively, and 0.828 (0.734-0.922), 73.5% and 85.1% for post-menopausal women, respectively.

CONCLUSIONS

The targeted metabolomics with PCI-IS quantification method successfully established prediction models for breast cancer detection. Further study is essential to validate these proposed markers.

Nitrogen Mustards as Anticancer Chemotherapies: Historic Perspective, Current Developments and Future Trends

Nitrogen mustards, a family of DNA alkylating agents, marked the start of cancer pharmacotherapy. While traditionally characterized by their dose-limiting toxic effects, nitrogen mustards have been the subject of intense research efforts, which have led to safer and more effective agents. Even though the alkylating prodrug mustards were first developed decades ago, active research on ways to improve their selectivity and cytotoxic efficacy is a currently active topic of research. This review addresses the historical development of the nitrogen mustards, outlining their mechanism of action, and discussing the improvements on their therapeutic profile made through rational structure modifications. A special emphasis is made on discussing the nitrogen mustard prodrug category, with Cyclophosphamide (CPA) serving as the main highlight. Selected insights on the latest developments on nitrogen mustards are then provided, limiting such information to agents that preserve the original nitrogen mustard mechanism as their primary mode of action. Additionally, future trends that might follow in the quest to optimize these invaluable chemotherapeutic medications are succinctly suggested.

Today's Adjuvant Therapy in Breast Cancer: Who Should Receive What?

Breast cancer remains a major public health problem. Prospective randomized trials comparing therapies are essential to improve current therapy but, for those women unable or unwilling to participate in clinical trials, treatment plans are needed. Treatment recommendations can be based on available information from individual trials and from a large collaborative overview. This information will be reviewed with treatment recommendations presented for subpopulations of breast cancer patients.

Hypothalamic-Pituitary-Ovarian Axis in Women with Operable Breast Cancer Treated with Adjuvant CMF and Tamoxifen

The effect of adjuvant CMF (cyclophopshamide, methotrexate, and 5-fluorouracil) and tamoxifen (TM) on hypothalamic-pituitary-ovarian function was studied in 120 women with stage I-II operable breast cancer. Sixty patients were premenopausal, of whom 25 were treated with CMF for 9 cycles, 25 with CMF for 9 cycles + TM for 2 years, started concurrently, and 10 with TM alone for 2 years. Sixty patients were postmenopausal and they were all treated with TM alone for 2 years. In all groups treatment was started within 4 weeks of mastectomy. Plasma levels of estrone (E1), estradiol-17β (E2), follicle-stimulating hormone, luteinizing hormone (LH), prolactin (Prl), testosterone (T) and thyroid-stimulating hormone (TSH) were determined in all patients before surgery and again at 3-month intervals from initiation of the adjuvant therapy. In ten patients of each treatment group FSH-LH and Prl-TSH release was determined following stimulation with releasing hormones. CMF and CMF + TM therapy resulted in amenorrhea in 42/50 premenopausal patients with decrease of E1 + E2 (p < 0.001) and elevation of FSH (p < 0.001) and LH (p < 0.01) plasma concentration to postmenopausal levels. In premenopausal women treated with TM a marked increase of E1 + E2 (p < 0.001) was observed with unaltered FSH-LH plasma concentration. A significant fall of Prl also occurred in these patients. In postmenopausal women and premenopausal patients with CMF-induced amenorrhea TM produced a marked fall of FSH-LH and a decrease of Prl plasma level. Plasma TSH and T were not affected in any patient by any of the treatment regimens. The results of the stimulatory tests are in agreement with the hormonal changes observed under basal conditions and indicate that, whereas CMF suppresses the ovary and does not alter hypothalamic-pituitary function, TM induces profound changes of the hypothalamic-pituitary-ovarian axis.

Properties and reactivity of nucleic acids relevant to epigenomics, transcriptomics, and therapeutics

Developments in epigenomics, toxicology, and therapeutic nucleic acids all rely on a precise understanding of nucleic acid properties and chemical reactivity. In this review we discuss the properties and chemical reactivity of each nucleobase and attempt to provide some general principles for nucleic acid targeting or engineering. For adenine-thymine and guanine-cytosine base pairs, we review recent quantum chemical estimates of their Watson-Crick interaction energy, π-π stacking energies, as well as the nuclear quantum effects on tautomerism. Reactions that target nucleobases have been crucial in the development of new sequencing technologies and we believe further developments in nucleic acid chemistry will be required to deconstruct the enormously complex transcriptome.

Mechanisms of chemotherapy-induced ovarian damage in breast cancer patients

Fertility preservation in breast cancer patients is an increasingly relevant topic. In the present paper we review available data on the mechanism of ovarian damage caused by anticancer agents currently used for the treatment of breast cancer. We also describe current methods to preserve fertility including oocytes or ovarian tissue freezing and administration of LH-RHa during chemotherapy. The aim of the paper is to provide clinical oncologists with an adequate knowledge of the subject to enable them to give a correct counselling to young women that must receive chemotherapy and want to increase their possibilities of maintaining fertility.

Review : Infertility after chemotherapy: A review of the risks and strategies for prevention

Purpose. Infertility as a late complication of cancer chemotherapy, focusing on specific drug-related ef fects, effects observed in the treatment of certain malignancies, and strategies for prevention is re viewed.

Data Sources. A MEDLINE search of articles from 1966 to present was conducted using the terms infertility, antineoplastics, amenorrhea, azospermia, oogenesis, and spermatogenesis. Additional refer ences were identified using review articles and phar macology textbooks.

Study Selection. All human studies reported in English language were included. Animal studies were included when human data were insufficient or un available.

Data Synthesis. Data on the infertility effects of individual antineoplastic agents are difficult to inter pret for several reasons, including small sample sizes, lack of prechemotherapy fertility assessment, inade quate long-term follow-up, and use of regimens in cluding multiple agents. In general, the incidence and severity of antifertility effects are dependent on the total dosage delivered, duration of therapy, and age at exposure. The alkylating agents have the most signif icant effects on fertility. Fertility outcomes have been reported for several different malignancies, especially in patients cured of Hodgkin's disease and testicular cancer. Information on specific antineoplastic agents and cancers are reviewed. Several methods have been employed to decrease gonadotoxic effects, but none have been effective.

Conclusions. Infertility is a common late com plication of cancer chemotherapy that is receiving increasing attention as the number of cancer survi vors increases. Health care professionals should be aware of infertility risks associated with antineoplastic agents and certain malignancies, and patients should be informed of these risks as treatment decisions are made.

Prognostic Value of Chemotherapy-Induced Amenorrhea in Breast Cancer: a Meta-Analysis

BACKGROUND

There is still a great deal of controversy with regard to the prognostic role of chemotherapy- induced amenorrhea (CIA) in breast cancer patients. To confirm whether CIA can serve as a useful factor in predicting clinical effects of systemic adjuvant chemotherapy, we performed this meta-analysis.

MATERIALS AND METHODS

Relevant studies were identified using PubMed, and Embase databases. Eligible study results were pooled and summary hazard ratios (HRs) with corresponding confidence intervals (CIs) were calculated. Subgroup analyses and an assessment of publication bias were also conducted.

RESULTS

A total of 8,333 patients from 11 published studies were identified through searching the databases. The pooled HRs for disease-free survival (DFS) suggested that CIA was associated with a significant reduction in the risk of recurrence, especially in patients with hormone receptor-positive lesions (overall HR=0.65, 95%CI 0.53-0.80, I2= 41.3%). When the five studies reporting the HR for overall survival (OS) were pooled (n=4193), a favorable trend was found (HR=0.69, 95%CI 0.52-0.91, I2= 51.6%). No publication bias was observed in this study.

CONCLUSIONS

This meta-analysis suggests that CIA predicts a better outcome in premenopausal hormone receptor-positive breast cancer patients.

A combined experimental and computational study on the interaction of nitrogen mustards with DNA

In the present work, we suggest that the role of water in the reaction of nitrogen mustards with DNA is more than what was thought before. Nitrogen mustards become activated when they are hydrated by water.

Risks associated with premature ovarian failure in Han Chinese women

In this retrospective study, the relationship between demographic characteristics, past medical history, general lifestyle habits and susceptibility of premature ovarian failure (POF) in Han Chinese population was investigated. Five hundred and fifty-three patients with POF and 400 women with normal ovarian function were recruited. A questionnaire was designed to gather information from responders. Logistic regression was carried out to calculate odds ratios (OR), 95% confidence intervals (95% CI) and P-values. History of pelvic surgery, mumps, having relatives with menstrual abnormalities and exposure to chemical agents were significantly associated with increased risk of POF (OR 5.53 [2.15 to 14.23]; 3.26 [2.38 to 4.47]; 28.12 [8.84 to 89.46]; 4.47 [2.09 to 9.58]). Vegetarian diet, tea and mineral water consumption reduced the risk of POF (OR 0.27 [0.19 to 0.37]; 0.04 [0.03 to 0.07]; 0.63 [0.47 to 0.85], respectively). Heredity, pelvic surgery, mumps and exposure to chemical agents were identified as risk factors for POF, whereas vegetarian diet, tea consumption and mineral water drinking were protective. Therefore, genetic consultation could help those women whose relatives manifested an early or premature menopause to avoid the consequences of possible premature ovarian function cessation. Avoidance of exposure to endocrine disrupters and flavonoids intake should be considered.

Functional vesicles formed by anticancer drug assembly

In this Letter, a new type of nitrogen mustard conjugate vesicles is developed to improve the stability and efficiency of anticancer drug. Benzoic acid nitrogen mustard-peptide (AAAK) conjugate was designed and synthesized, which was found to self-assemble into vesicles in water. The formation of the vesicles was confirmed by dynamic light scattering (DLS), transmission electron microscopy (TEM) and circular dichroism (CD). The degradation data revealed that the benzoic acid nitrogen mustard peptide (AAAK) conjugate vesicles are more stable than the parent drug in aqueous solution. Furthermore, MTT assay revealed that the free drug conjugate has similar antitumor activity against MCF-7, Hela, HepG-2 cell lines compared with the parent drug. The benzoic acid nitrogen mustard-peptide conjugate vesicles may have potential in the treatment of cancers.

Preservation of fertility in females treated for cancer

Advancements of diagnosis and treatment have substantially improved cancer survival rates in the last few decades. The increasing number of survivors focuses attention on long-term effects caused by cancer treatment and its impact on quality of life. Ovarian failure is one of the major sequelae of cytotoxic chemotherapy and/or radiotherapy in female children and reproductive-age women. Oncologists should address the patients about fertility preservation options before therapy. Embryo cryopreservation is the only well-established method for females in preserving fertility; however other strategies including ovarian suppression, ovarian transposition and cryopreservation of oocytes and ovarian tissue are still experimental. Patients need advice and to know which are the most practical options for them. This article reviews the available fertility preservation methods in women, and the related issues including normal physiology of the ovary, effect of anticancer therapy on fertility, role of the oncologist and ethics. We performed a MEDLINE search from 1971 to 2011 in a similar way as Jensen et al. 2011, using the following MeSH terms: antineoplastic agents; ovarian failure; premature; infertility, female; fertility preservation; child and cancer; reproductive technologies, assisted.

The mechanism of guanine alkylation by nitrogen mustards: a computational study

The thermodynamics and kinetics for the monofunctional binding of nitrogen mustard class of anticancer drugs to purine bases of DNA were studied computationally using guanine and adenine as model substrates. Mechlorethamine and melphalan are used as model systems in order to better understand the difference in antitumor activity of aliphatic and aromatic mustards, respectively. In good agreement with experiments that suggested the accumulation of a reactive intermediate in the case of mechlorethamine, our model predicts a significant preference for the formation of corresponding aziridinium ion for mechlorethamine, while the formation of the aziridinium ion is not computed to be preferred when melphalan is used. Two effects are found that contribute to this difference. First, the ground state of the drug shows a highly delocalized lone pair on the amine nitrogen of the melphalan, which makes the subsequent cyclization more difficult. Second, because of the aromatic substituent connected to the amine nitrogen of melphalan, a large energy penalty has to be paid for solvation. A detailed study of energy profiles for the two-step mechanism for alkylation of guanine and adenine was performed. Alkylation of guanine is ∼6 kcal mol(-1) preferred over adenine, and the factors contributing to this preference were explained in our previous study of cisplatin binding to purine bases. A detailed analysis of energy profiles of mechlorethamine and melphalan binding to guanine and adenine are presented to provide an insight into rate limiting step and the difference in reactivity and stability of the intermediate in both nitrogen mustards, respectively.

Incidence and time course of bleeding after long-term amenorrhea after breast cancer treatment: a prospective study

BACKGROUND

The incidence of chemotherapy-induced amenorrhea (CIA) and the time to subsequent menstrual bleeding in premenopausal breast cancer patients treated with current standard chemotherapy regimens was examined.

METHODS

Four hundred sixty-six women ages 20 to 45 years at the time of diagnosis of a stage I to III breast cancer were recruited between January 1998 and July 2002. Patients completed monthly bleeding calendars from the time of study recruitment. Updated medical history data were obtained at 6-month intervals.

RESULTS

Most women received doxorubicin and cyclophosphamide (AC); doxorubicin, cyclophosphamide, and paclitaxel (ACT); or cyclophosphamide, methotrexate, and 5-fluorouracil (CMF). Approximately 41% of women experienced an initial 6 months of CIA, and an additional 29% had at least 1 year of CIA. Approximately half of the women with 6 months of CIA and 29% of those with 1 year of CIA resumed bleeding within the subsequent 3 years, usually in the year after their amenorrheic episode. Resumption of bleeding differed significantly by treatment regimen after 6 months of CIA (P = .002; 68% with AC, 57% with ACT, and 23% with CMF), but not after 1 year of CIA (P = .5). Of the 23% of women who experienced an initial 2-year period of CIA, 10% resumed bleeding within the ensuing 3 years after their amenorrheic episode, but none had regular menses.

CONCLUSIONS

A considerable proportion of women treated with chemotherapy will experience periods of CIA, but many will resume bleeding. Newer treatment regimens such as ACT appear to have a higher resumption of bleeding compared with CMF. This finding may have implications for choice of anti-estrogen treatment and for future potential pregnancies/fertility.

The effect of endocrine responsiveness on high-risk breast cancer treated with dose-intensive chemotherapy: results of International Breast Cancer Study Group Trial 15-95 after prolonged follow-up

BACKGROUND

The role of adjuvant dose-intensive chemotherapy and its efficacy according to baseline features has not yet been established.

PATIENTS AND METHODS

Three hundred and forty-four patients were randomized to receive seven courses of standard-dose chemotherapy (SD-CT) or three cycles of dose-intensive epirubicin and cyclophosphamide (epirubicin 200 mg/m(2) plus cyclophosphamide 4 mg/m(2) with filgrastim and progenitor cell support). All patients were assigned tamoxifen at the completion of chemotherapy. The primary end point was disease-free survival (DFS). This paper updates the results and explores patterns of recurrence according to predicting baseline features.

RESULTS

At 8.3-years median follow-up, patients assigned DI-EC had a significantly better DFS compared with those assigned SD-CT [8-year DFS percent 47% and 37%, respectively, hazard ratio (HR) 0.76; 95% confidence interval 0.58-1.00; P = 0.05]. Only patients with estrogen receptor (ER)-positive disease benefited from the DI-EC (HR 0.61; 95% confidence interval 0.39, 0.95; P = 0.03).

CONCLUSIONS

After prolonged follow-up, DI-EC significantly improved DFS, but the effect was observed only in patients with ER-positive disease, leading to the hypothesis that efficacy of DI-EC may relate to its endocrine effects. Further studies designed to confirm the importance of endocrine responsiveness in patients treated with dose-intensive chemotherapy are encouraged.

Effects of cancer treatment on ovarian function

Causes of primary ovarian failure are reviewed, focusing specifically on cancer treatment-related modalities. Strategies and future directions for protection of the ovaries during cancer therapy, including ovarian transposition, and conformal radiation techniques are presented.

Amenorrhea in premenopausal women after adjuvant chemotherapy for breast cancer

Chemotherapy and ovarian ablation both independently improve survival in premenopausal women with hormone-sensitive breast cancer. Amenorrhea is a well-recognized occurrence after chemotherapy. The rate of chemotherapy-induced amenorrhea varies with patient age and chemotherapy regimens administered. However, the impact of chemotherapy-induced amenorrhea on prognosis is still being defined. Older studies in premenopausal women argue that the benefit with chemotherapy is a result of direct cytotoxicity alone. However, studies that restrict outcome analysis to hormone receptor-positive tumors suggest that chemotherapy has a dual mechanism in women with hormone-responsive tumors; indirect endocrine manipulation secondary to chemotherapy-induced ovarian suppression and direct cytotoxicity. The significant health ramifications involved with the induction of premature menopause as well as potential benefits necessitate a comprehensive evaluation of chemotherapy-induced amenorrhea. This review will discuss the incidence of amenorrhea with commonly-used adjuvant chemotherapeutic regimens, the possible benefits of chemotherapy-induced amenorrhea, and the challenges of interpreting the existing data in breast cancer trials.

Ovarian tissue cryopreservation and transplantation: a review

The review covers current options for ovarian tissue cryopreservation and transplantation and provides a systematic review of the existing literature from the last 10 years, taking into account all previously published reviews on the subject. The different cryopreservation options available for fertility preservation in cancer patients are embryo cryopreservation, oocyte cryopreservation and ovarian tissue cryopreservation. The choice depends on various parameters: the type and timing of chemotherapy, the type of cancer, the patient's age and the partner status. The different options and their results are discussed, as well as their putative indications and efficacy. The review concludes that advances in reproductive technology have made fertility preservation techniques a real possibility for patients whose gonadal function is threatened by premature menopause, or by treatments such as radiotherapy, chemotherapy or surgical castration.

Tamoxifen after adjuvant chemotherapy for premenopausal women with lymph node-positive breast cancer: International Breast Cancer Study Group Trial 13-93

PURPOSE

The value of adjuvant tamoxifen after chemotherapy for premenopausal women with breast cancer has not been adequately assessed.

PATIENTS AND METHODS

Between 1993 and 1999, International Breast Cancer Study Group Trial 13-93 enrolled 1,246 assessable premenopausal women with axillary node-positive, operable breast cancer. All patients received chemotherapy (cyclophosphamide plus either doxorubicin or epirubicin for four courses followed by immediate or delayed classical cyclophosphamide, methotrexate, and fluorouracil for three courses), which was followed by either tamoxifen (20 mg daily) for 5 years or no further treatment. The primary end point was disease-free survival (DFS). Tumors were classified as estrogen receptor (ER) -positive (n = 735, 59%) if immunohistochemical (IHC) or ligand-binding assays (LBA) were clearly positive. The ER-negative group included all other tumors (n = 511, 41%). A subset of the ER-negative group was defined as ER absent (n = 108, 9%) if IHC staining was none or if the LBA result was 0 fmol/mg cytosol protein. The median follow-up time was 7 years.

RESULTS

Tamoxifen improved DFS in the ER-positive cohort (hazard ratio [HR] for tamoxifen v no tamoxifen = 0.59; 95% CI, 0.46 to 0.75; P < .0001) but not in the ER-negative cohort (HR = 1.02; 95% CI, 0.77 to 1.35; P = .89). Tamoxifen had a detrimental effect on patients with ER-absent tumors compared with no tamoxifen in an unplanned exploratory analysis (HR = 2.10; 95% CI, 1.03 to 4.29; P = .04). Patients with ER-positive tumors who achieved chemotherapy-induced amenorrhea had a significantly improved outcome (HR for amenorrhea v no amenorrhea = 0.61; 95% CI, 0.44 to 0.86; P = .004), whether or not they received tamoxifen.

CONCLUSION

Tamoxifen after adjuvant chemotherapy significantly improved treatment outcome in premenopausal patients with endocrine-responsive disease, but its use as adjuvant therapy for patients with ER-negative tumors is not recommended.

Incidence, time course, and determinants of menstrual bleeding after breast cancer treatment: a prospective study

PURPOSE

To assess ovarian function using the surrogate of monthly bleeding after breast cancer treatment in premenopausal women.

PATIENTS AND METHODS

Five hundred ninety-five US women age 20 to 45 years were accrued from January 1998 to July 2002 within 8 months of diagnosis with stages I to III breast cancer (median follow-up 45 months). Daily bleeding records were obtained prospectively, as well as extensive clinical, demographic, quality of life, and treatment data. Repeated measures logistic regression was used to assess which variables were predictive of monthly bleeding.

RESULTS

Significantly different proportions of women had monthly bleeding depending on their age (P < .001), chemotherapy program (P < .001), and time since treatment regimen. In the month after the standard course of doxorubicin and cyclophosphamide (AC), whether or not followed by paclitaxel or docetaxel, approximately 16% had monthly bleeding compared with the cyclophosphamide, methotrexate, fluorouracil (CMF) group, in which 48% bled (P < .001). Following any AC regimen, there was a slow recovery phase of about 9 months followed by a plateau, during which almost half continued monthly bleeding for the remainder of the follow-up period compared with after CMF in which there was no recovery phase and a continual decline in monthly bleeding to approximately 18% of women at study end (P < .001). Tamoxifen use decreased bleeding between months 12 and 24 after chemotherapy with 15% fewer women having bleeding.

CONCLUSION

Using daily menstrual bleeding records, it is demonstrated that age, the specific chemotherapy regimen received, and tamoxifen use impact ovarian function.

Adjuvant Chemotherapy Followed by Goserelin Versus Either Modality Alone for Premenopausal Lymph Node-Negative Breast Cancer: A Randomized Trial

BACKGROUND

Although chemotherapy and ovarian function suppression are both effective adjuvant therapies for patients with early-stage breast cancer, little is known of the efficacy of their sequential combination. In an International Breast Cancer Study Group (IBCSG) randomized clinical trial (Trial VIII) for pre- and perimenopausal women with lymph node-negative breast cancer, we compared sequential chemotherapy followed by the gonadotropin-releasing hormone agonist goserelin with each modality alone.

METHODS

From March 1990 through October 1999, 1063 patients stratified by estrogen receptor (ER) status and radiotherapy plan were randomly assigned to receive goserelin for 24 months (n = 346), six courses of "classical" CMF (cyclophosphamide, methotrexate, 5-fluorouracil) chemotherapy (n = 360), or six courses of classical CMF followed by 18 months of goserelin (CMF --> goserelin; n = 357). A fourth arm (no adjuvant treatment) with 46 patients was discontinued in 1992. Tumors were classified as ER-negative (30%), ER-positive (68%), or ER status unknown (3%). Twenty percent of patients were aged 39 years or younger. The median follow-up was 7 years. The primary outcome was disease-free survival (DFS).

RESULTS

Patients with ER-negative tumors achieved better disease-free survival if they received CMF (5-year DFS for CMF = 84%, 95% confidence interval [CI] = 77% to 91%; 5-year DFS for CMF --> goserelin = 88%, 95% CI = 82% to 94%) than if they received goserelin alone (5-year DFS = 73%, 95% CI = 64% to 81%). By contrast, for patients with ER-positive disease, chemotherapy alone and goserelin alone provided similar outcomes (5-year DFS for both treatment groups = 81%, 95% CI = 76% to 87%), whereas sequential therapy (5-year DFS = 86%, 95% CI = 82% to 91%) provided a statistically nonsignificant improvement compared with either modality alone, primarily because of the results among younger women.

CONCLUSIONS

Premenopausal women with ER-negative (i.e., endocrine nonresponsive), lymph node-negative breast cancer should receive adjuvant chemotherapy. For patients with ER-positive (i.e., endocrine responsive) disease, the combination of chemotherapy with ovarian function suppression or other endocrine agents, and the use of endocrine therapy alone should be studied.

Breast cancer in the very young patient: a multidisciplinary case presentation

A case is presented that exemplifies many issues and controversies in the diagnosis and treatment of breast cancer in the very young. This woman was 22 years of age at diagnosis; she initially underwent breast-conservation therapy and adjuvant chemotherapy, retained fertility, had a subsequent uncomplicated pregnancy and delivery, and 7 years later developed a local recurrence in the breast. The discussion addresses risk factors, diagnosis, and treatment of breast cancer in the young; the impact of treatment on fertility; implications regarding pregnancy, and the management of local recurrence after breast conservation.

Preservation of fertility and ovarian function and minimalization of chemotherapy associated gonadotoxicity and premature ovarian failure: the role of inhibin-A and -B as markers

BACKGROUND

Following the improved long term survival in young women with lymphoma and leukemia undergoing chemotherapy, the preservation of future fertility has been the focus of recent interest. The investigational endeavors of ovarian cryopreservation awaits the clinical experience of in-vitro maturation of thawed primordial follicles, their in-vitro fertilization and ET. Although promising, this experience is not available yet. Moreover, the risk of possible reimplantation of malignant stem cells with the thawed cryopreserved ovary has been raised, following experimental animal observations. Therefore, until these innovative endeavors prove successful, and in parallel to them we attempted to minimize the gonadotoxic effect of chemotherapy by the co-treatment with a GnRH agonistic analogue to induce a temporary prepubertal milieu. Whereas, inhibin-B concentrations in serum may reflect the ovarian granulosa cell compartment, inhibin-A reflects luteal function. The immunoreactive inhibin-A and -B in these patients, before, during, and following the gonadotoxic chemotherapy were measured.

METHODS

A prospective clinical protocol was undertaken in 55 women with lymphoma, aged 15-40 years, ten with leukemia and eight undergoing chemotherapeutic treatments for non malignant diseases such as systemic lupus erythematosus (SLE) or other autoimmune diseases. A monthly injection of depot D-TRP6-GnRH-a was administered from before starting the chemotherapy until its conclusion, up to a maximum of 6 months. Hormonal profile (FSH, LH, E2, T, P4, IGF-1, IGF-BP3, and PRL) was taken before starting the GnRH-a/chemotherapy co-treatment, and monthly thereafter, until resuming spontaneous ovulation. This group was compared with a control group of 55 women who have been treated with similar chemotherapy. Inhibin-A and -B immunoactivity was measured by an ELISA commercial kit (Serotec).

RESULTS

Whereas, all but three (40- and 36-year-old) of the surviving patients with GnRH-a/chemotherapy co-treatment group resumed spontaneous ovulation and menses within 12 months, less than half of the patients in the control group (chemotherapy without GnRH-a co-treatment) resumed ovarian function and regular cyclic activity (P<0.05). The remaining 56% experienced premature ovarian failure (POF). Temporary increased FSH concentrations were experienced by about a third of the patients resuming cyclic ovarian function, suggesting a reversible ovarian damage in a larger proportion of women than those experiencing POF. Inhibin-A and -B decreased during the GnRH-a/chemotherapy co-treatment but increased to normal levels in patients who resumed regular ovarian cyclicity, and/or spontaneously conceived, as compared with low levels in those who developed POF.

CONCLUSIONS

If these preliminary data are consistent in a larger group of patients, inhibin-A or -B concentrations may serve as prognostic factors for predicting the resumption of ovarian function, in addition to the levels of FSH, LH and E2. The GnRH-a co-treatment should be considered in every woman in the reproductive age receiving chemotherapy, in addition to ART, and to the investigational attempts of ovarian cryopreservation for future in-vitro maturation, autotransplantation, or xenotransplantation.

Prognostic effect of amenorrhoea and elevated serum gonadotropin levels induced by adjuvant chemotherapy in premenopausal node-positive breast cancer patients

The purpose of the study was to determine the correlation between prognosis and chemotherapy induced amenorrhoea or elevated gonadotropin levels in node-positive breast cancer patients. Since we have previously found a better prognosis in patients with more profound leucopenia induced by adjuvant chemotherapy, we examined whether this effect was mediated through more efficient induction of amenorrhoea. The study population consisted of 126 premenopausal, primarily operable, node-positive breast cancer patients treated with cyclophosphamide, methotrexate and 5-fluorouracil (CMF) adjuvant chemotherapy at the Department of Oncology, Helsinki University Central Hospital between 1990 and 1993. 12 months after the beginning of adjuvant chemotherapy, the patients were divided into groups with respect to their menstrual function (regular menstruation, irregular menstruation or amenorrhoea). Information about menstruation status and serum concentration of follicle stimulating hormone (FSH) and oestradiol were recorded at 12 and 24 months from the beginning of adjuvant chemotherapy. Median follow-up time was 72 months. Women who experienced amenorrhoea or had irregular menstruation after chemotherapy had a significantly better 5-year disease-free survival (DFS) in univariate analysis than women who continued to menstruate (P = 0.02). Amenorrhoea and irregular menstruation were associated with a better DFS among patients with oestrogen receptor (ER) positive primary tumours (P = 0.007), whereas no such association was found in ER negative cases (P = 0.86). 5-year overall survival (OS) in univariate analysis was also better in patients who experienced amenorrhoea (81%) or who had irregular menstruation (90%) after chemotherapy as compared with patients with regular menstruation (68%; 81 versus 68%, P = 0.05). The serum FSH level did not correlate significantly with outcome irrespective of the cut-off point chosen. Nodal status, tumour size and menstruation status after chemotherapy were also significantly associated with DFS in a multivariate analysis. The menstruation status after chemotherapy lost its significance for OS in a multivariate analysis whilst the number of affected lymph nodes, tumour size and oestrogen/progesterone receptor status retained their impact. There was no association between the degree of leucopenia and induction of amenorrhoea by CMF. Chemotherapy-induced ovarian function suppression (amenorrhoea/irregular menstruation) after chemotherapy had a favourable effect on DFS in premenopausal breast cancer patients. The post-chemotherapy menstruation status is a clinically usable marker for sufficient endocrine effect of chemotherapy in ER/PR-positive patients in all premenopausal age groups. FSH level seemed to be a less reliable indicator of the castration effect of adjuvant chemotherapy in this study.

Tamoxifen in high-risk premenopausal women with primary breast cancer receiving adjuvant chemotherapy. Report from the Danish Breast Cancer co-operative Group DBCG 82B Trial

Following modified radical mastectomy, pre- and perimenopausal (amenorrhoea for < 5 years) patients with stage II or III breast cancer received CMF (cyclophosphamide 600, methotrexate 40, 5-fluorouracil 600 mg/m2 intravenously (i.v.) every 4 weeks, 9 cycles). The effect on recurrence-free survival (RFS) and overall survival (OS) of the addition of adjuvant tamoxifen (TAM) to adjuvant chemotherapy was examined by randomisation either to no additional treatment (n = 314), or concurrently TAM 30 mg daily for 1 year (n = 320). 40% had positive, 12% negative and 48% unknown receptor status. One year after surgery 21% versus 35% (CMF + TAM versus CMF) were still menstruating (P < 0.01). With a median follow-up of 12.2 years there was no difference in RFS (10-year RFS 34% versus 35%, P = 0.81) or OS (45% versus 46%, P = 0.73). In a Cox proportional hazards model, tumour size, number of metastatic lymph nodes, frequency of metastatic nodes in relation to total number of nodes removed, degree of anaplasia, age, and menostasia within the first year after operation were significant independent prognostic factors for RFS, and the same factors except age for OS. No significant interactions with TAM were seen. Thus, in this group of pre- and perimenopausal high-risk early breast cancer patients with heterogeneous receptor status given CMF i.v., concurrent TAM for 1 year did not improve the outcome. These results do not exclude that receptor positive patients may benefit from adjuvant TAM for longer periods given sequentially to chemotherapy.

Fertility maintenance and 5-fluorouracil timing within the mammalian fertility cycle

The mammalian fertility cycle is responsible for tight coordination of molecular, biochemical and cellular events. We have investigated whether timing of 5-fluorouracil (5-FU) chemotherapy within this cycle affects its reproductive toxicology. When this very short half-life, largely S-phase active cytotoxic antimetabolite is administered during the estrous phase (immediate postovulatory) of the fertility cycle, female mice suffer greater subsequent loss of fertility (decreased successful pregnancy rate) than those mice receiving 5-FU during the metestrous, diestrous, or proestrous stages. Pups subsequently born to mothers given 5-FU during the estrous and metestrous stages are of lower weight compared with those born to mothers treated with 5-FU during diestrus or proestrus. Acute lethality is similarly affected by the fertility cycle timing of 5-FU administration. Treatment during estrus is associated with the greatest overall lethal toxicity. This finding indicates that the 5-FU susceptibility of nonreproductive tissues, the integrity of which is essential for survival, may also be coordinated by the mammalian fertility cycle. It is concluded that optimizing the fertility cycle timing of 5-FU (e.g., during the periovulatory, proestrous stage) diminishes the frequency and severity of long-term reproductive damage.

The risk of premature menopause induced by chemotherapy for early breast cancer

The objectives of this retrospective case series were to determine the prevalence and timing of menstrual abnormalities in early-stage breast cancer patients undergoing adjuvant methotrexate or anthracycline-based chemotherapy and to more fully assess the possible mechanism of the amenorrhea reported after chemotherapy. One hundred forty-two premenopausal patients undergoing adjuvant chemotherapy were analyzed for patient age, breast cancer stage, type of chemotherapy, and menstrual abnormalities before, during, and after chemotherapy completion. A 24-month minimum follow-up after chemotherapy completion was available for all patients. One hundred nine of 142 patients were evaluable. Sixty-nine patients (46 node negative, 23 node positive) received methotrexate-based chemotherapy, 33 patients (3 node negative, 30 node positive) received anthracycline-based chemotherapy, and 7 patients received both treatments (all node positive). Amenorrhea occurred in about a third of patients during chemotherapy (methotrexate groups 31%, anthracycline group 33%), and a higher proportion were amenorrheic 1 year after chemotherapy was completed (methotrexate group 45%, anthracycline group 46%). Abnormalities were more likely to occur in older premenopausal patients (Chi square = 6.18, p < 0.05), although 28% of patients under age 35 developed persistent abnormal menses. In some amenorrheic patients, follicle-stimulating hormone (FSH) levels were decreased within 6 months of chemotherapy (24.4 IU). The levels tended to be higher after chemotherapy (59.1 IU), suggesting ovarian failure. Menstrual abnormalities and menopause will frequently occur in premenopausal early-stage breast cancer patients, with 30% of all patients amenorrheic 1 year after chemotherapy.

Subclinical depletion of primordial follicular reserve in mice treated with cyclophosphamide: clinical importance and proposed accurate investigative tool

Studies have shown that ovarian failure is a common side-effect of chemotherapy treatment; however, continuation of regular menses post-treatment does not necessarily imply that the ovaries have escaped damage. This animal study measures directly the primordial follicle (PMF) loss following exposure to chemotherapy and evaluates reproductive outcome following significant destruction of the PMF population. Inbred Balb/c mice aged 5-6 weeks were administered different doses of an alkylating agent, cyclophosphamide, and the total number of PMF remaining in both ovaries was counted. Results show that cyclophosphamide causes PMF destruction in proportion to increasing dose (P = 0.0001). Reproductive performance was assessed after exposure to 75 mg/kg cyclophosphamide, a dose which destroys approximately 50% of PMF reserve, by evaluation of ovulation, mating and pregnancy rates. Reproductive potential of treated mice was not affected compared with controls despite the significant loss of PMF. Our results indicate that reproductive performance is not an accurate parameter for assessing ovarian injury. Rather, histological counting of PMF number more directly reflects the damage caused by chemotherapy to the ovary. This method can be used as a sensitive, inexpensive tool to gauge the damage to fertility caused by new chemotherapy agents or protocols.

Long-term consequences following conservative management of epithelial ovarian cancer in an infertile patient

A 35-year-old woman with primary infertility underwent an ovarian cystectomy for a 5 x 4 cm left adnexal mass. There was no macroscopic evidence of metastatic disease. The final pathology report revealed a poorly differentiated serous cystadenocarcinoma. Because the patient desired to retain child-bearing capacity, she refused a surgical staging of her ovarian cancer. She elected to receive combination chemotherapy. This was then followed by a negative reassessment laparotomy. The patient was diagnosed with recurrent, metastatic ovarian carcinoma 10 years later.

Hormone replacement therapy and breast cancer

The use of hormone replacement therapy by postmenopausal women with a history of breast cancer is a subject of considerable controversy. There are no scientific studies that have appropriately examined the issue, and current practice is often based on inferences from indirect evidence, anecdotal experience, and personal bias. Our understanding of the effects of exogenous, as well as endogenous, hormones on normal and neoplastic breast tissue provides some insights but is not an appropriate basis for clinical practice. The effects of exogenous hormone replacement on the overall health of postmenopausal women, including psychosocial issues, cardiovascular risks, and the morbidity of osteoporosis, must be understood before patients can be counseled appropriately. Treatment of patients must be individualized. The rapidly expanding area of nonhormonal therapies for the treatment of postmenopausal health risks and the treatment of symptomatic complaints in postmenopausal women has already led to a reevaluation of the use of exogenous hormones among all women. A prospective randomized trial that examines the effects of hormone replacement on women with a history of breast cancer is currently underway and will provide valuable data to address these issues. The aim of this review is to outline the scientific basis for the association between estrogen and breast cancer and to provide a framework in which individualized recommendations concerning the use of hormone replacement therapy can be made for patients with breast cancer.

GnRH analogues and ovarian ablation: their integration in the adjuvant strategy

Ovarian ablation, either by surgery or radiation, has been clearly shown to be an effective adjuvant therapy for pre-menopausal women following breast cancer surgery. The 1995 Oxford Overview confirmed this effect in trials of ovarian ablation compared to no other systemic adjuvant therapy. In trials of chemotherapy plus ovarian ablation compared to the same chemotherapy alone, however, the addition of ovarian ablation, although tending to add benefit, did not achieve a statistically significant positive effect. Data exist from a variety of randomized trials of adjuvant chemotherapy suggesting that pre-menopausal women who become amenorrhoeic after chemotherapy achieve a better outcome than those who continue to menstruate. These data are not consistent among all trials, however. There are few trials that compare ovarian ablation directly to chemotherapy, but those few that exist, as well as indirect comparisons, suggest that the effects of ovarian ablation, particularly in estrogen-receptor-positive women, are similar in magnitude to those of chemotherapy. Several large trials comparing chemotherapy to the LH-RH analogue Zoladex (goserelin) and studying the addition of Zoladex to adjuvant chemotherapy will be available by 1999 or 2000 and will provide considerable additional information on this matter.

Dose and dose intensity as determinants of outcome in the adjuvant treatment of breast cancer. The Cancer and Leukemia Group B

BACKGROUND

Both total dose and dose intensity of adjuvant chemotherapy are postulated to be important variables in the outcome for patients with operable breast cancer. The Cancer and Leukemia Group B study 8541 examined the effects of adjuvant treatment using conventional-range dose and dose intensity in female patients with stage II (axillary lymph node-positive) breast cancer.

METHODS

Within 6 weeks of surgery (radical mastectomy, modified radical mastectomy, or lumpectomy), 1550 patients with unilateral breast cancer were randomly assigned to one of three treatment arms: high-, moderate-, or low-dose intensity. The patients received cyclophosphamide, doxorubicin, and 5-fluorouracil on day 1 of each chemotherapy cycle, with 5-fluorouracil administration repeated on day 8. The high-dose arm had twice the dose intensity and twice the drug dose as the low-dose arm. The moderate-dose arm had two thirds the dose intensity as the high-dose arm but the same total drug dose. Disease-free survival and overall survival were primary end points of the study.

RESULTS

At a median follow-up of 9 years, disease-free survival and overall survival for patients on the moderate- and high-dose arms are superior to the corresponding survival measures for patients on the low-dose arm (two-sided P<.0001 and two-sided P = .004, respectively), with no difference in disease-free or overall survival between the moderate- and the high-dose arms. At 5 years, overall survival (average +/- standard error) is 79% +/- 2% for patients on the high-dose arm, 77% +/- 2% for the patients on the moderate-dose arm, and 72% +/- 2% for patients on the low-dose arm; disease-free survival is 66% +/- 2%, 61% +/- 2%, and 56% +/- 2%, respectively.

CONCLUSION

Within the conventional dose range for this chemotherapy regimen, a higher dose is associated with better disease-free survival and overall survival.

Chemotherapy for gestational trophoblastic tumours hastens menopause by 3 years

Chemotherapy may induce acute ovarian failure, but in women who retain gonadal function throughout chemotherapy, the late effects upon ovarian function are unknown. A retrospective controlled survey was performed to ascertain whether chemotherapy for gestational trophoblastic tumours (GTT) results in premature menopause. Questionnaires were sent to 1,489 women diagnosed between 1971 and 1990 with GTT, including 1089 who had received chemotherapy and 400 who had not received chemotherapy (controls). Responses were obtained from 972 chemotherapy-treated patients and 327 controls. 124 women were not evaluable for menopause date as they had undergone hysterectomy as part of the treatment for GTT or had developed permanent amenorrhoea during chemotherapy. Overall, 172 women reported that they were postmenopausal, including 157 women who had received chemotherapy. The median age at menopause for the evaluable population was 50 years (range 25-56 years). The age at menopause was significantly earlier in the treated arm (median 50, range 25-56 years) than in the controls (median 53, range 40-57 years) (logrank test chi 2 = 12.6, P = 0.0004). Menopause occurred significantly earlier in women treated with combination chemotherapy (median 49, range 25-56 years) compared with single agent methotrexate (median 51, range 25-56 years) (logrank test chi 2 = 8.3, P = 0.004). However, the age at completion of chemotherapy in the treated arm did not influence the age of menopause (proportional Hazards chi 2 = 1.99, P = 0.16). Chemotherapy for GTT induces menopause 3 years earlier than it occurs in women with GTT who do not receive chemotherapy. Although the difference is statistically significant, the magnitude is modest and most women can be reassured that neither fertility nor postmenopausal osteoporosis will be greatly affected.

Prognostic impact of amenorrhoea after adjuvant chemotherapy in premenopausal breast cancer patients with axillary node involvement: results of the International Breast Cancer Study Group (IBCSG) Trial VI

Adjuvant chemotherapy-induced amenorrhoea has been shown to be associated with reduced relapses and improved survival for premenopausal breast cancer patients. Amenorrhoea was, therefore, studied to define features of chemotherapy (i.e. duration and timing) and disease-related factors which are associated with its treatment effects. We reviewed data from IBCSG Trial VI, in which accrual was between July 1986 and April 1993. 1196 of the 1475 eligible patients (81%) were evaluable for this analysis. The median follow-up was 60 months. Women who experienced amenorrhoea had a significantly better disease-free survival (DFS) than those who did not (P = 0.0004), although the magnitude of the effect was reduced when adjusted for other prognostic factors (P = 0.09). The largest treatment effect associated with amenorrhoea was seen in patients assigned to receive only three initial CMF courses (5-yr DFS: 67% versus 49%, no amenorrhoea; hazard ratio, 0.55; 95% confidence interval, 0.38 to 0.81; P = 0.002). DFS differences between amenorrhoea categories were larger for patients with ER/PR positive tumours (hazard ratio, 0.65; 95% confidence interval, 0.53 to 0.80; P = 0.0001). Furthermore, patients whose menses returned after brief amenorrhoea had a DFS similar to those whose menses ceased and did not recover (hazard ratio, 1.10; 95% confidence interval, 0.75 to 1.62; P = 0.63). The effects associated with a permanent or temporary chemotherapy-induced amenorrhoea are especially significant for node-positive breast cancer patients who receive a suboptimal duration of CMF chemotherapy. Cessation of menses, even for a limited time period after diagnosis of breast cancer, might be beneficial and should be prospectively investigated, especially in patients with oestrogen receptor-positive primaries.

Pilot study of bone mineral density in breast cancer patients treated with adjuvant chemotherapy

The objective of this cross-sectional study was to determine lumbar spine bone mineral density (BMD) in breast cancer patients previously treated with adjuvant chemotherapy. Sixteen of 27 patients who received adjuvant chemotherapy became permanently amenorrheic as a result of chemotherapy. BMD was measured at the lumbar spine using dual energy X-ray absorptiometry (DEXA). Chemotherapy drugs and dosages along with a history of risk factors for reduced bone density including activity level, tobacco and/or alcohol use, metabolic bone disease, family history, and hormone exposure were identified. Results showed that women who became permanently amenorrheic as a result of chemotherapy had BMD 14% lower than women who maintained menses after chemotherapy. Chemotherapy-treated women who maintained ovarian function had normal BMD. This study suggests that women who have premature menopause as a result of chemotherapy for breast cancer are at increased risk of bone loss and may be at risk for early development of osteoporosis. Women who maintain menses do not appear to be at risk for accelerated trabecular bone loss.

Combined chemo-endocrine adjuvant therapy for patients with operable breast cancer: still a question?

Adjuvant systemic treatment delays relapse and prolongs survival in patients with operable breast cancer. However, the relative wealth of available agents and the heterogeneity of the target population contribute to considerable uncertainty about the optimal approach to particular patient groups. Systematic review and meta-analysis of the results of trials testing polychemotherapy have clearly established the value of such treatment. Endocrine treatment with tamoxifen was to be especially useful in patients with hormone-receptor positive tumours. Research in recent years has therefore concentrated on secondary questions, such as scheduling, dose intensity and new combinations of chemotherapeutic agents. Combined chemo-endocrine treatments, using polychemotherapy plus tamoxifen, ovarian ablation or both, have been compared with either modality alone. Other endocrine agents such as fluoxymesterone acetate, medroxyprogesterone acetate and, recently, LH-RH analogues have also received attention. The systematic review presented here suggests that combined cytotoxic and endocrine therapies might be the most effective use of available treatments for most, if not all, patients, and highlights the unresolved questions requiring further research.

Mechanism and management of treatment-related gonadal failure in recipients of high dose chemoradiotherapy

For the last two decades, the use of bone marrow transplantation for leukaemia, and most recently for lymphomas and other cancers, has increased dramatically and all of the systemic chemotherapy or radiotherapy used in these patients has a potential for causing infertility. This review describes the normal reproductive function of relevance to patients at risk of chemotherapy- or radiotherapy-induced infertility. The mechanism by which fertility may be affected by these agents is also described and therapeutic strategies for reducing or preventing these problems are outlined. The treatment of men and women who are infertile after chemotherapy or radiotherapy is addressed, as are the ethical and legal aspects of assisted fertilization.

Late injury of cancer therapy on the female reproductive tract

The purpose of this article is to review the late effects of cancer therapy on the female reproductive tract. The anatomic sites detailed are the vulva, vagina, cervix, uterus, fallopian tubes, and ovaries. The available pathophysiology is discussed. Clinical syndromes are presented. Tolerance doses of irradiation for late effects are rarely presented in the literature and are reviewed where available. Management strategies for surgical, radiotherapeutic, and chemotherapeutic late effects are discussed. Endpoints for evaluation of therapeutic late effects have been formulated utilizing the symptoms, objective, management, and analytic (SOMA) format. Late effects on the female reproductive tract from cancer therapy should be recognized and managed appropriately. A grading system for these effects is presented. Endpoints for late effects and tolls for the evaluation need to be further developed.

Long-term effects of adjuvant chemotherapy in breast cancer

Late effects of adjuvant chemotherapy (ACT) may include second malignant neoplasms (SMN), cardiotoxicity and ovarian suppression. Effects on the biology of residual tumour may be important in protocol design. Studies of SMN need large and reliable data sets. The leukaemia risk with current ACT is likely to be less than a five-fold increase. Leukaemia is predominantly a result of alkylating agents and peaks before 10 years. Solid SMN result also from radiotherapy and this risk continues after 10 years. Cardiotoxicity can be caused by anthracyclines but should not be a problem with current ACT regimens. It can be reduced by careful monitoring and by the cardioprotector ICRF-187. Amenorrhoea is a crude marker of ovarian suppression which may explain conflicting data on its relationship to outcome after ACT. Ovarian suppression following ACT is more likely and more permanent in older premenopausal women, but only explains a part of the ACT effects on outcome. Effects of early ACT on residual tumour are important for planning retreatments and combined modality protocols.