Controlled trial of adjuvant chemotherapy with cyclophosphamide, methotrexate, and fluorouracil for breast cancer

Postmastectomy Radiotherapy and Concomitant Adjuvant Chemotherapy Versus Adjuvant Chemotherapy Alone in Premenopausal Breast Cancer Patients with Positive Axillary Nodes

AIMS

To evaluate the efficacy of postmastectomy radiotherapy (RT) combined with adjuvant chemotherapy compared to adjuvant chemotherapy alone as regards overall survival (OS), overall disease-free survival (ODFS), local disease-free survival (LDFS) and distant disease-free survival (DDFS).

METHODS

We reviewed retrospectively two non-randomized groups of premenopausal high-risk breast cancer patients treated from 1985 to 1990 in the following Institutions: Department of Radiation Oncology of Brescia University, "Istituto del Radio O. Alberti" (IRA), and Department of Oncology of Brescia Hospital "Beretta Foundation" (BF). A total of 163 patients was found to satisfy the criteria of the current analysis: 81 patients received adjuvant chemotherapy alone [6 cycles CMF(1-8)] at BF and 82 patients received postoperative radiotherapy and chemotherapy [8 cycles CMF(1-21)] at IRA. A modified CMF schedule was chosen at IRA to avoid the feared increase in toxicity due to the association with RT. Primary surgical treatment was modified radical mastectomy with axillary node dissection in both cases.

RESULTS

A statistically significant improvement in OS was found in systemic adjuvant therapy patients compared to those also given RT (77.6% vs 59%; P = 0.0025). No statistically significant improvement in ODFS was found in the CMF(1-8) arm compared to the RT and CMF(1-21) stm: 51.6% vs 43.6%; P = 0.46. A statistically significant improvement in LDFS at 5 years was found in irradiated patients (89.3% vs 76.2%; P <0.05). The DDFS was also improved, although without evidence of statistical significance, in the CMF(1-8) group: at 5 years 65% vs 44% (P = 0.059).

CONCLUSIONS

The study confirmed that RT reduces the risk of local recurrence but without a statistically significant reduction in mortality. The lack of a survival benefit may somehow reflect the dose reduction in CMF(1-21). The evidence that CMF(1-8) offers undoubtable advantages over the CMF(1-21) regimen in OS and, perhaps, in distant control suggests that the dose intensity of CMF in this setting may also be important. In fact, although many CMF(1-8) patients received a dose intensity lower than 100%, 95% of them received a dose intensity higher than the maximum one of the CMF(1-21) patients. Although our results should be interpreted with caution, they seem to provide further rationale for testing the association of postoperative radiotherapy and the CMF(1-8) regimen in stage II breast cancer with positive nodes and treated with demolitive surgery, as already done in the conservative management of breast cancer, also in view of the new support therapies now available (i.e. hematologic growth factors).

Performance of General Hospitals in Delivering Adjuvant Chemotherapy to Breast Cancer Patients

Indications for and modes of delivery of adjuvant chemotherapy in early breast cancer were assessed in a group of 353 patients followed within a cohort of 1110 newly diagnosed cases in 54 Italian general hospitals. Among node-positive patients 79 % pre- and 44 % postmenopausal women had the treatment. Only a few node-negative women (10 % pre- and 5 % post-menopausal) were treated. The multidrug combination CMF was by far the most commonly employed (89 %) in its two types: cCMF (the classic combination where cyclophosphamide is given orally on days 1–14 and the two other drugs i.v. on days 1 and 8 every 28 days for either 6 or 12 cycles) to 33 % women and nCMF (the more recent combination where all three drugs are given i.v. on day 1 every 21 days for 12 cycles) to 63 %. The mode of delivery of treatment was consistent with the Italian National Breast Cancer Task Force (F.O.N. Ca. M.) recommendations for the cCMF combination, but the lack of clear guidelines on the use of nCMF led to wide variations in the total number of cycles administered. At present, however, it is hard to establish whether this will have any impact on patients’ outcome. Overall the study suggests that adjuvant chemotherapy for breast cancer has entered general practice and can be satisfactorily delivered at the community level. However, better guidelines need to specify more precisely the treatment indications (i.e. subgroups with greater expected benefits), regimen type (is nCMF still experimental or already standard?) and treatment duration, in view of the present uncertainty about what should be the standard for general practice. The paper finally discusses the feasibility of the treatment comparing general hospitals’ performance with that achieved in controlled clinical trials of adjuvant chemotherapy.

A dose escalation trial of adjuvant cyclophosphamide and epirubicin in combination with 5-fluorouracil using G-CSF support for premenopausal women with breast cancer involving four or more positive nodes

BACKGROUND

Dose-dense and dose-intensive regimens have improved the outcome of breast cancer in high-risk women with operable disease.

PATIENTS AND METHODS

Sixty-three premenopausal women with Stage 2, 3 breast cancer and > or =4 positive axillary nodes were treated in three successive cohorts with 70 mg/m(2) of epirubicin, 500 mg/m(2) of 5-fluorouracil and G-CSF every 14 days for 12 cycles. Cyclophosphamide (C) was given at 700 mg/m(2), 900 mg/m(2), and 1100 mg/m(2) doses. Patients were evaluated for dose-limiting toxicities (DLTs) in the first four cycles, the primary endpoint of the trial.

RESULTS

No DLTs were seen at C 700 mg/m(2); at C 900 mg/m(2) two of 16 patients experienced febrile neutropenia and poor performance status; at C 1100 mg/m(2), 1 of 31 patients experienced poor performance status. Over 6 months, febrile neutropenia, grade 4 thrombocytopenia, grade 3 anemia and severe fatigue were observed. Clinical congestive heart failure occurred in three patients over 4 years.

CONCLUSION

A dose-intense and dose-dense regimen of cyclophosphamide, epirubicin and 5-fluorouracil was delivered with G-CSF without apparent increase in acute toxicity. Cyclophosphamide could be increased to more than twice the standard dose at the cost of more anemia and fatigue.

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.

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.

p53 immunohistochemical staining and survival after adjuvant chemotherapy for breast cancer

We have investigated the relationship between immunohistochemically determined p53 status and outcome in 277 women with node-positive primary breast cancer who, following tumour excision and axillary clearance, were randomised to receive either 6 cycles of cyclophosphamide/methotrexate/S-fluorouracil (CMF) (n = 130) or no such post-operative treatment (n = 147). Follow-up data (median = 9 years) were available on all patients. A significant association was found between p53 status and survival. Patients with p53-positive tumours had a less favourable outcome than those with p53-negative disease. Women receiving adjuvant CMF chemotherapy had a significantly more favourable outcome compared to those who did not. The effect was seen both in women with p53-positive and p53-negative tumours; multivariate analysis showed relative risks for overall survival attributable to chemotherapy of 2.3 (95% CI 1.2-4.3) for women with p53-positive tumours and of 2.1 (95% CI 1.4-3.0) for those with p53-negative tumours. Thus, adjuvant chemotherapy with CMF is associated with a survival benefit in women with node-positive breast cancer irrespective of immunohistochemically determined p53 status.

Loco-regional recurrence following mastectomy for early breast carcinoma: efficacy of radiotherapy at the time of recurrence

This study aims to define the risk factors for loco-regional relapse following mastectomy, and to assess the efficacy of radiotherapy at the time of relapse. To achieve this 272 patients with loco-regional relapse treated at a single institution with modified radical or radical mastectomy were reviewed. Tumour size, axillary node involvement and tumour grade were found to be significant risk factors for loco-regional recurrence of disease. Radiotherapy given at the time of relapse controlled disease in 61% of cases, compared with 34% of patients treated with systemic treatment only. Altogether, 146 (54%) of the 269 evaluable patients with local failure had uncontrolled disease at the same site, either at the time of death or at the date last seen. The result of this retrospective study showed that delayed radiotherapy was effective in controlling the disease in patients with developing loco-regional relapses. However, as adjuvant radiotherapy reduces the incidence of local disease recurrence it should be recommended to patients considered to be at high risk of local relapse following mastectomy; namely those with tumours bigger than 5 cm with four or more positive axillary nodes.

Meta-Analysis of the Second Collaborative Study of Adjuvant Chemoendocrine Therapy for Breast Cancer (ACETBC) in Patients with Stage II, Estrogen-Receptor-Positive Breast Cancer

The second 5-year study of postoperative adjuvant therapy in patients with breast cancer between 1985 and 1988 was performed by the Study Group for Adjuvant Chemoendocrine Therapy for Breast Canecr (ACETBC). This report describes the results of a meta-analysis of the outcome. A total of 3012 patients with stage II, estrogen-receptor-positive primary breast cancer who underwent radical surgery (total mastectomy with at least axillary dissection) were eligible for the analyses. On the day of surgery, all patients received 13 mg/m(2) of mitomycin C (MMC) intravenously. Patients were then given one of two adjuvant chemoendocrine therapies for 2 years:regimen A, consisting of tamoxifen citrate (TAM) 30 mg/day, or regimen B, consisting of TAM 30 mg/day plus tegafur (Futraful, FT)600 mg/day. The results from all eligible patients were included in a meta-analysis according to the method of Peto et al. The odds reduction rate was 12 +/-13% (log-rank test, P= 0.35)for the 5-year survival rate and 16 +/- 10% (log-rank test, P=0.093)for the 5-year non-recurrence rate. In terms of the 5-year non-recurrence rate. regimen B(with FT)yielded slightly, but not significantly, better results than regimen A. In addition, stratified analyses were carried out with respect to the 5-year non-recurrence rate. Regimen B(with FT)yielded significantly better results than regimen A in patients with four or more positive axillary nodes (log-rank test, P= 0.039) and yielded slightly, but not significantly, better results than regimen A in premenopausal patients (log-rank test, P= 0.079).

Laparoscopic oophorectomy: a prospective evaluation in pre-menopausal breast cancer with particular reference to incidence and severity of menopausal symptoms

Laparoscopic oophorectomy offers potential advantages over other methods of ovarian ablation. In this prospective study the technique, complications and side-effects have been assessed in 69 consecutive patients. Menopausal symptoms were assessed using two scoring systems - the Kupperman index and the Women's Health Questionnaire. The serum beta oestradiol levels fell rapidly post-operatively (from 540 pmol/l to 25 pmol/l within 1 month). Menopausal symptoms were mild in 75% of patients and severe in none. Complications occurred in three patients. Laparoscopic oophorectomy has an important role to play in the management of pre-menopausal breast cancer and this study confirms that is well tolerated and gives good short-term results.

A quality-adjusted survival meta-analysis of adjuvant chemotherapy for premenopausal breast cancer. International Breast Cancer Study Group

The purpose of this paper is to develop and apply a meta-analysis methodology, that does not require patient-level data, for comparing treatments in terms of quality-of-life-adjusted survival. As a motivating example, we considered adjuvant chemotherapy for breast cancer. This therapy has been shown to offer an improvement in recurrence-free and overall survival, especially for younger women, but its acute toxic effects discourage some physicians from prescribing it. To determine whether the benefit of adjuvant chemotherapy treatment outweighs its costs in terms of toxic effects, we performed a meta-analysis of quality-adjusted survival based on data from 1229 patients, 49 years of age or younger, randomized in eight clinical trials that compared chemotherapy versus no adjuvant systemic therapy. We conducted the meta-analysis by performing a quality-adjusted survival analysis known as a Q-TWiST analysis on each trial. A Q-TWiST analysis allows one to make treatment comparisons that incorporate differences in quality of life associated with various health states. In this analysis, we define as health states the periods of time patients spend: (i) with subjective toxic effects of chemotherapy; (ii) without symptoms of recurrence and toxicity, and (iii) following disease recurrence. We assigned weights to each health state which reflect their relative value in terms of quality of life and allowed them to vary in a sensitivity analysis. We then combined the individual trial results in a meta-analysis, using a multivariate regression model, in such a way that we could easily perform an overall sensitivity analysis. Individual patient-level data are not required to perform this meta-analysis methodology if the individual Q-TWiST analysis results for each trial are available.

The natural history of operable breast cancer after primary treatment

This paper aimed at reviewing information on the natural history of operable breast carcinoma after primary treatment. Breast carcinoma does not appear as a single disease entity, but as a wide variety of clinical manifestations. Primary loco-regional treatment should have a curative aim. However, the probability of early or late relapse increases according to a series of prognostic factors. The axillary node status remains the main prognostic indicator but especially in node-negative patients, an increasing number of additional morphologic and biological prognostic factors can classify patients according to a low, good or high risk categories. The natural history of the disease is influenced by loco-regional treatment as far as loco-regional control is concerned. The risk of relapse after loco-regional treatment alone differs during the first three years according to nodal status and it then tends to decrease and become more homogeneous. Adjuvant systemic therapies can decrease the probability of relapse, mainly in loco-regional but rarely in distant sites, thus limiting the absolute advantage. In any case, most women after primary treatment are not cured and are still carriers of occult disease. A timely diagnosis of first relapse after primary treatment is the direct aim of follow-up. An improvement in survival is only an indirect aim of the follow-up, and depends, if at all, on an anticipated diagnosis of recurrence, on the disease site in which this anticipated diagnosis is feasible and on application of different therapeutic strategies according to disease extension and to disease site. Follow-up could be tailored according to time after primary treatment (with more frequent examinations during the first three years than thereafter) and according to prognostic factors, mainly the axillary nodal status. Follow-up should not be considered as conceptually independent either from primary treatment or from treatment after recurrence. At time of first relapse, a new prognostic evaluation can be based on sites of disease recurrence, ER status at time of diagnosis and the time interval from primary treatment to relapse. Different therapeutic approaches could be planned according to survival expectation, including experimental treatments for patients having a dire prognosis.

Expression of sialyl-Tn predicts the effect of adjuvant chemotherapy in node-positive breast cancer

Sialyl-Tn (STn) is a carcinoma-associated carbohydrate determinant expressed on cancer-associated mucins and has the structure NANA alpha(2-6)alpha GalNAc. Expression of STn in colon and ovarian cancer is associated with a poor prognosis independent of tumour grade, stage or histological type. We have examined 237 cases of primary breast cancer for expression of this antigen using the antibody HB-STn (Dako). The frequency of STn expression was 31% in the whole group, 36% in the node-negative and 28% in the node-positive group. Survival was lower, but not significantly so, in the STn-positive group (P = 0.07), but this effect was highly significant for patients with node-positive disease (P < 0.002), the curves for node-negative disease being coincident (P = 0.31). In node-positive disease the effect was limited to those receiving adjuvant chemotherapy (P = 0.001). In a multivariate (Cox) analysis on the whole group STn staining, combined with adjuvant chemotherapy, showed a highly significant correlation with survival. In STn-negative cases, adjuvant chemotherapy improved survival (relative risk 2.3, 95% confidence intervals 1.4-3.9), whereas adjuvant chemotherapy did not influence survival in patients which expressed STn (relative risk 1.1, 95% confidence intervals 0.6-2.2). Thus, by either direct or indirect mechanisms, STn positivity appears to be a marker of resistance to adjuvant chemotherapy.

Postmastectomy radiotherapy in the management of operable breast cancer

There is a long and detailed history of radiation therapy as an adjuvant to surgery in operable breast cancer. The results of a large number of randomized clinical trials will be reviewed. They can be summarized by saying that although the trials show a reduction in local-regional failure with the use of postoperative radiotherapy, a survival advantage has not been clearly identified. Many of the older trials used techniques and radiation doses inadequate by current standards, which may have affected the results. Recent trials that used therapeutic doses of radiation, however, did demonstrate a survival advantage among patients who received postoperative radiotherapy. These trials generally have included chemotherapy and required careful integration of radiotherapy and systemic therapy. Although all trials have not demonstrated a survival benefit by the addition of radiotherapy, the ability to maintain local-regional control after mastectomy is an important goal. Administration of prophylactic chest wall and nodal radiotherapy to patients at high risk for local-regional recurrence significantly reduces the chance of a local treatment failure. Because a chest wall recurrence is a distressing event that dramatically affects quality of life, improved local-regional control with postoperative radiotherapy is a highly significant end point.

c-erbB-2 amplification in mammary carcinoma

The c-erbB-2 oncogene has been extensively studied in mammary carcinomas since Slamon and colleagues demonstrated the association between amplification and poor prognosis in 1987. Further work found that amplification was accompanied by overexpression of the protein; however, this relationship is not perfect. Recently, Hollywood and Hurst have shown increased transcription in some cell lines containing a single copy of the gene, causing mRNA accumulation in overexpressing cells. Protein expression appears to be a good indicator of various abnormalities in the c-erbB-2 gene. Fortunately, c-erbB-2 protein, unlike epidermal growth factor (EGF) receptor, survives most fixation procedures used in routine histopathology laboratories. This has enabled immunohistochemical studies to be carried out on archival material. A higher incidence of c-erbB-2 positivity occurs in ductal carcinoma in situ (DCIS) than in infiltrating carcinomas. In DCIS there is a very close association between protein expression and high grade (comedo type). This explains the very high incidence of c-erbB-2 positivity in Paget's disease of the nipple which is nearly always associated with high grade DCIS. A lower proportion of high grade infiltrating carcinomas express the protein, highlighting the difference in incidence of positivity in the two types of ductal lesion. As well as having a potential role in the biological classification of mammary carcinomas, c-erbB-2 expression has been used to predict response to treatment. There have been reports that tumors expressing c-erbB-2 fail to respond to either chemotherapy or endocrine therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of adjuvant chemotherapy on outcome after relapse for patients with breast cancer

This study examines the outcome following relapse for 176 patients who had been entered into a randomised trial comparing adjuvant cyclophosphamide, methotrexate and 5-fluorouracil (CMF) with no adjuvant therapy (controls). Relapse has occurred in 65/144 (45%) of the CMF group and 111/158 (70%) of controls (P < 0.0001). 123/176 patients received endocrine treatment after relapse with higher response rates (38 vs. 18%, P < 0.05) and longer time to progression (23 vs. 19 weeks, P = 0.03) for controls. 94/176 received chemotherapy after relapse again with higher response rates (47 vs. 23%, P = 0.05) and longer time to progression (17 vs. 9 weeks, P = 0.03) for controls. Despite this, survival after relapse was the same for the two groups (median 16 months). However, on subgroup analysis, postmenopausal patients who had received adjuvant CMF had shorter survival (P = 0.03). These results suggest that prior adjuvant therapy should be a stratification factor in clinical trials in advanced disease.

Chemotherapy-induced amenorrhea and other clinical and pathological parameters in the prognosis of breast cancer patients

147 stage II pre- and perimenopausal breast cancer patients were treated with cyclophosphamide-methotrexate-5-fluorouracil (CMF)- based adjuvant regimens. 103 (72%) patients became amenorrheic during or immediately after the end of the chemotherapy program. Univariate analyses for age, menstrual status, nodal involvement, grading, estrogen and progesterone receptor status indicated no correlation between induction of amenorrhea and a significant prolongation of overall and disease-free survival. Multivariate analyses confirmed that young age at diagnosis, increasing number of infiltrated nodes, negative progesterone receptor status and grade 3 tumors are associated with a worse prognosis. Our results suggest that no benefit is expected in women with drug induced amenorrhea after CMF adjuvant treatment.

Significance of local recurrence after mastectomy for breast cancer

In a retrospective study 678 patients who underwent (modified) radical mastectomy between 1970 and 1986 were analysed. By comparing the groups of patients who experienced local recurrence, regional recurrence or distant metastasis during follow-up with patients who remained free of disease, we have tried to gain some insight into the significance of local recurrence. By looking at the prognostic factors and the disease-free period there is hardly any difference between the patients with either a local, regional or distant recurrence. Actuarial survival of patients with local recurrence is slightly better than the survival of patients with distant metastasis (P = 0.009). From our results and from the literature we conclude that an isolated local recurrence after mastectomy for breast cancer is, in most cases, a first manifestation of metastatic disease. Probably only a minority of the local recurrences is caused by tumour cells left behind in the operation field.

Prediction of response to adjuvant chemotherapy in premenopausal lymph node positive breast cancer patients with morphometry, DNA flow cytometry and HER-2/neu oncoprotein expression. Preliminary results

The value of morphometry, DNA flow cytometry and HER-2/neu oncoprotein expression for prediction of response to adjuvant chemotherapy in premenopausal lymph node positive breast cancer patients was evaluated in a group of CMF treated patients and controls with long-term follow-up. In the treated group, the Morphometric Prognostic Index (cutpoint 1.1) was the best prognosticator (p less than 0.0001, MC = 16.9), followed by the Mitotic Activity Index, the volume percentage epithelium and the number of positive nodes. For the controls, only the % HER-2/neu oncoprotein expression revealed significant differences (p less than 0.0001, MC = 16.3). When directly comparing treated patients and controls stratified for a certain parameter, no significant differences were obtained, although a trend towards improved survival in the treated group was present for some of the subgroups for several parameters. These preliminary results indicate that morphometric features and quantitative HER-2/neu oncoprotein expression may be important factors for identifying cases that will or will not respond to adjuvant chemotherapy.

Selection of patients with breast cancer for routine follow-up bone scans

Routine radionuclide bone scans have not been considered cost-effective for the routine follow-up after treatment of primary breast cancer. However subgroups of patients exist in whom early relapse in the skeleton is likely and this study examines again the role of the bone scan in routine follow-up. Serial radionuclide bone scans were performed every 6 months during the first 2 years of follow-up of 560 patients with breast cancer. Tumor characteristics which predict early relapse in bone were identified and the scan conversion rate from negative to positive determined for each prognostic group. A total of 199 (28%) of patients have relapsed, 50 (9%) with first recurrence in bone within two years of diagnosis. All were identified on the bone scan with a median lead time of 4 months over radiological evidence of bone involvement. The overall scan conversion rate was 2.8%. This was significantly higher in poor prognosis patients with T4 tumours (6.3%), more than four involved axillary lymph nodes (6.1%) and inoperable tumours (6.5%), than in good prognosis patients with T1 tumours (1.1%), negative axillary lymph node involvement (1.2%) or well-differentiated ductal grade tumours (1.1%). We do not recommend routine bone scans in the follow-up of all patients with breast cancer. In patients with a good prognosis after primary treatment they cannot be considered cost-effective. However, in those with features which predict early recurrence in the skeleton the frequency of scan conversion is sufficient to justify serial bone scanning during the first two years of follow-up.

Adjuvant chemotherapy of breast cancer

Many women will not be cured of breast cancer by even the best early detection and surgical techniques because of micrometastases present at diagnosis. Adjuvant therapy has extended the disease-free interval for most patients and lengthens overall survival for many. Combination chemotherapy has become the standard form of adjuvant treatment for premenopausal women with breast cancer and positive lymph nodes after primary therapy. With minimal toxicity, disease-free and overall survival are improved. Results are less impressive or less clear-cut for postmenopausal women or any woman with negative lymph nodes. Long-term toxicities of adjuvant chemotherapy may include second malignancies and cardiac dysfunction. Although these complications probably are rare, they must be considered seriously when weighing chemotherapy for patients in whom its benefits may be slight. Innovations likely to become standard in adjuvant therapy decision making include risk assessment with new prognostic indicators (growth fraction, oncogene expression) and investigation of dose intensification using bone marrow growth factors and autologous stem-cell support.

Breast cancer

Breast cancer will affect 1 out of 10 women in the United States and cause 27 deaths per 100,000 women per year. The etiology remains unknown, but the incidence correlates with genetic as well as environmental factors. Screening programs have been shown to prolong the survival by early detection compared with control populations but remain underutilized by physicians and patients. Breast disease can be evaluated by physical examination and mammography and a definitive diagnosis made by needle aspiration, needle biopsy, or excisional biopsy. This allows the patient to participate in the decision regarding mastectomy vs. conservative surgery plus radiation therapy. These two approaches have equivalent survival in selected patients. Patients with locally advanced, nonmetastatic disease benefit from a multidisciplinary approach using preoperative chemotherapy and postoperative radiation therapy. This approach has allowed less disfiguring surgery and improved survival. Preinvasive carcinoma is diagnosed more frequently with the increased use of screening mammography. Local therapy options include simple mastectomy, local excision plus radiation, or local excision alone. The natural history and results of therapy in preinvasive disease are evolving as more data are accumulated. Systemic adjuvant therapy is recommended for all node-positive patients and most node-negative patients with invasive cancer. The specific modality (hormonal or cytotoxic) varies with the subgroup involved. Treatment of metastatic disease to palliate symptoms and prolong survival includes the use of local therapies (surgery and radiation) and hormonal and cytotoxic agents. Most patients benefit, but cure has been unobtainable. Newer approaches utilizing high-dose chemotherapy and bone marrow support with growth factors or autologous transplantation are currently being explored.

West Midlands Oncology Association trials of adjuvant chemotherapy in operable breast cancer: results after a median follow-up of 7 years. I. Patients with involved axillary lymph nodes

The aim of this study was to test the effectiveness of a regimen of combination chemotherapy known to be active in advanced breast cancer when given as an adjuvant treatment after mastectomy. A total of 569 patients with cancer of the breast and involvement of axillary lymph nodes were randomised, after simple mastectomy with axillary sampling, to receive either no adjuvant treatment or intravenous adriamycin 50 mg, vincristine 1 mg, cyclophosphamide 250 mg, methotrexate 150 mg and fluorouracil 250 mg (AVCMF) every 21 days for eight cycles. Randomisation was stratified according to menopausal status and tumour size. Treatment was started within 14 days of surgery in 94% of patients. Eighty-eight per cent of patients received at least seven cycles of chemotherapy with no dose reduction. The median relapse-free survival was prolonged by 14 months in patients treated with AVCMF (chi2 1 = 11.7; P = 0.0006). In the premenopausal group this period was 17 months (chi2 1 = 8.8; P = 0.003) compared with 8 months in the post-menopausal group (chi2 1 = 3.3; P = 0.07). Neither overall survival nor survival in these subgroups was significantly influenced by treatment.

Premenopausal breast cancer patients treated with conservative surgery, radiotherapy and adjuvant chemotherapy have a low risk of local failure

The use of adjuvant chemotherapy in premenopausal breast cancer patients with positive nodes is now routine, but the optimal local treatment of these patients is uncertain. To determine the effect of adjuvant chemotherapy on the likelihood of local recurrence as the first site of failure in premenopausal patients treated with conservative surgery (CS) and radiotherapy (RT), we examined the outcome of 74 patients treated with CS, RT, and adjuvant chemotherapy and compared it to the outcome in 192 patients treated with CS and RT alone. Adjuvant chemotherapy consisted of four or more cycles of either a doxorubicin-containing regimen or cyclophosphamide, methotrexate, and 5-fluorouracil. All patients were less than 50 years old, had UICC-AJCC Stage I or II breast cancer treated between 1968 and 1981, had gross excision of the primary tumor, and had a total radiation dose to the primary tumor bed of greater than or equal to 6000 cGy. Factors predicting for local recurrence, such as extensive intraductal carcinoma and age less than 35, were equivalent in the two groups. Women treated with adjuvant chemotherapy had significantly worse T- and N-stages than women treated with conservative surgery and radiotherapy alone: 61% versus 36% had T2 tumors (p = 0.0003), 34% versus 6% had clinically positive nodes (p less than 0.0001), and 97% versus 4% had pathologically positive nodes (p less than 0.0001). Despite the poorer prognosis of patients treated with adjuvant chemotherapy, within 5 years of diagnosis, 4% of patients who received adjuvant chemotherapy had their initial relapse in the breast and 24% had initial failure elsewhere, compared with 15% local failure first and 14% failure elsewhere first for those treated without chemotherapy (p = 0.01). We conclude that premenopausal patients with positive nodes treated with combined modality therapy (conservative surgery, radiation therapy, and adjuvant chemotherapy) have a low risk of local recurrence as a first site of failure. These results suggest a possible interaction between radiation therapy and chemotherapy in their effects on local tumor control.

Influence of radiotherapy on the dose of adjuvant chemotherapy in early breast cancer

399 patients with early breast cancer were randomly allocated to treatment by either modified radical mastectomy or lumpectomy and radiotherapy. 169 had histologically involved axillary nodes and were randomised to receive either adjuvant cytotoxic chemotherapy (76 patients) or no systemic adjuvant treatment (93 patients). Chemotherapy comprised a combination of oral cyclophosphamide and intravenous methotrexate and 5-fluorouracil (CMF) for 12 cycles over one year. Patients in the mastectomy group received a significantly higher percentage of the planned chemotherapy dose compared with those in the radiotherapy group (median 85% v. 71% p less than 0.05). Patients treated with radiotherapy were more frequently nauseated and developed more severe alopecia, but these differences were not statistically significant. At median follow-up of 37 months the relapse-rate and pattern of relapse were similar in both groups of patients receiving CMF.

Lessons from past experience in cancer immunotherapy and their application to cancer and AIDS treatment and prophylaxis

Passive immunotherapy which we attempted in 1957 using polyclonal antibodies from immunized donors aggravated tumor evolution: we suspected that blocking by Ig, tumor cell antigen epitopes which are necessary to enhance or even maintain the T-lymphocyte effector role in anti-cancer immunity could be the reason for this tumor aggravation by "specific" antibodies. Today the very limited results of monoclonal antibodies in cancer treatment favors this hypothesis. The aggravation of HIV by (some) antibodies suggests that the same phenomenon may also happen in this condition. In 1957, on the other hand, we described the therapeutically beneficial cytostatic targetting effect of polyclonal antibodies, an effect which has often been quoted and widely confirmed. Does the reason for the poor results of monoclonal antibody targetting in tumor treatment reside in cancer antigen heterogeneity? This is what an experiment we conducted with Olsson on AkR leukemia indicated, suggesting that several monoclonals should be simultaneously combined for most patients, to be determined by the antigenic study not only of each tumor but of each localisation. We shifted our cancer immunotherapy approach to an adoptive form in 1959; a), after establishing partial and transient, then total and permanent allogeneic marrow graft and chimerism in man; b), after describing the graft versus leukemia (GvL) action of the graft versus host (GvH) effect in leukaemic mice; c), and the same phenomenon in humans. Our observations on human allogeneic grafted bone marrow GvH and GvL were statistically confirmed in 1979 by the Seattle group. In the 1970s we attempted to induce strong GvL with weak GvH by replacing allogeneic bone marrow graft by allogeneic lymphocyte transfusions without host conditioning. Remarkable results were registered in mice, and in patients with acute leukaemia--5 complete remissions out of 7 patients who developed moderate GvH, and only 3 out of 70 in those who did not develop GvH. As we now know that CD4-, CD8+ lymphocytes are not all MHCl-restricted, we consider that the allogeneic CTL approach is worth trying as reinforcement treatment of (at least) severe hematopoietic malignancies. If it is indeed worthwhile in some severe neoplasias to include the adoptive form of immunotherapy in the multi-treatment program, the replacement of the patient's bone marrow by engrafted allogeneic stem cells has not been proven necessary, as the persistence in "ALL cured" chemotherapy patients of abnormally differentiated cells does not reduce the expectancy of cure.(ABSTRACT TRUNCATED AT 400 WORDS)

Adjuvant systemic treatment and the pattern of recurrences in patients with breast cancer

The aim was to analyze the impact of adjuvant systemic treatment (AST) on the anatomical distribution, the number, and the temporal relationship of the first metastases in 635 patients (pts) with breast cancer. These patients participated in the prospective studies of AST of the Danish Breast Cancer Cooperative Group (DBCG) 77-program. All patients had primary high-risk breast cancer (i.e. node positive or local invasion or tumor size greater than 5 cm). The initial treatment was mastectomy with axillary sampling, followed by postoperative radiotherapy. The types of AST and the number of patients with recurrence were: chemotherapy (CT), 134 pts; levamisole (LEV), 96 pts; tamoxifen (TAM), 154 pts. The pattern of recurrence in these patients was compared with the pattern of recurrence in 251 pts who did not receive AST (controls). Although CT reduced the total number of metastatic sites (P = 0.04), the incidence of liver metastases was increased compared to untreated controls (P = 0.02). The median number of metastatic sites was equal in TAM- and LEV-treated pts compared to controls. The incidence of lung metastases was increased in TAM-treated pts (P = 0.03), and LEV-treated pts had a decreased incidence of lymph node (P = 0.01) and pleural recurrences (P = 0.01) compared to controls. The results may suggest that mechanisms of clonal selection during the metastatic process involve differences in sensitivity to antineoplastic treatments of metastases at various anatomical locations.

Progesterone receptor activity and relapse-free survival in patients with primary breast cancer: the role of adjuvant chemotherapy

The prognostic significance of progesterone receptor activity (PgR) with regard to the estimated relapse-free survival (RFS) was studied in 350 one-center patients with primary breast cancer. All receptor assays were performed in one laboratory; PgR levels greater than 10 fmol/mg protein were considered positive. Univariate as well as multivariate statistical analyses were used to examine the prognostic significance of several variables. Eighty-nine of the 350 patients received adjuvant CMF chemotherapy (cyclophosphamide, methotrexate, and 5-fluorouracil). The median observation period was 69 months (range 12-125 months). In the group of 261 patients who did not receive adjuvant CMF, the PgR-status lacked prognostic significance; only the lymph node status significantly affected the RFS (p less than 0.00001). In contrast, in the CMF-treated group of patients, the PgR-status was the most powerful predictor of recurrence (p less than 0.001). Premenopausal CMF-treated patients with PgR+ tumors had a significantly longer RFS than those with PgR- tumors (p less than 0.02). The present data urge the need for a reappraisal of the prognostic significance of PgR and of the mechanism of action of adjuvant chemotherapy in primary breast cancer.

Ovarian function and adjuvant chemotherapy for early breast cancer

The effect of cyclophosphamide, methotrexate and fluorouracil (CMF) on ovarian function has been studied in 74 pre-menopausal patients with operable breast cancer. After median follow-up of 47 months, 50, 70 and 80% of 35 patients receiving CMF became permanently amenorrhoeic within 3, 6 and 12 months respectively; in contrast, only 5 in the no treatment (control) group of 39 patients became permanently amenorrhoeic within 12 months. Younger patients (less than 35 years) were more likely to retain or regain menstrual function while on or after CMF treatment. Estimation of ovarian and pituitary hormones in a subset of these women showed that CMF treatment was associated with a decrease in serum oestradiol and progesterone and an increase in serum follicle stimulating hormone and luteinizing hormone to post-menopausal levels. These hormonal changes are consistent with the induction of amenorrhoea during CMF treatment and the absence of resumption of menstrual function after completion of treatment suggests that CMF causes permanent ovarian ablation in a majority of these patients.

Psychological impact of adjuvant chemotherapy in the first two years after mastectomy

Psychological symptoms were assessed over two years in a randomised trial of three forms of treatment given to women after mastectomy for stage II breast cancer. The treatments were: three weeks' radiotherapy; one year's adjuvant chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil; and radiotherapy followed by chemotherapy. Analysis of the results on an intention to treat basis showed no substantial differences in depression or anxiety among groups at one, three, or six months after the operation. At 13 months, however, patients who had been allocated chemotherapy had significantly more symptoms, especially depression, than control patients treated with radiotherapy alone. Conditioned reflex nausea and vomiting increased considerably during the second six months of chemotherapy and persisted for up to a year afterwards. The psychological morbidity of adjuvant chemotherapy could be substantially reduced if courses of treatment were restricted to about six months.

Metastatic pattern and response to endocrine therapy in human breast cancer

The effect of endocrine therapy in 465 postmenopausal patients with advanced breast cancer who entered four consecutive, randomized trials has been related to the site of the metastases. Patients received either tamoxifen (T) alone or T in combination with medroxyprogesterone acetate, diethylstilbestrol, halotestin, or aminoglutethimide. The overall response rate was 40%. Responses were most frequently seen in patients with metastases in soft tissue, and the duration of response to endocrine therapy in these patients was longer than for those with metastases in bone or viscera (p less than 0.00001). In addition, the response rate was inversely correlated with the number of main metastatic sites in patients with soft tissue metastases, whereas the response rate was not associated with the number of metastatic sites in patients with metastases in bone and viscera. Survival after first recurrence was significantly longer in responding patients with soft tissue lesions compared to those with recurrence in bone or viscera. In contrast, survival after first recurrence was identical in patients with nonresponding disease, irrespective of dominant site of metastases. The outcome of endocrine therapy depends partially upon the dominant site of metastases. This may reflect a difference in biological characteristics of human breast cancer tumor cells that metastasize to different sites.

Mechanism of action of adjuvant chemotherapy in early breast cancer

The relation between tumour oestrogen and progesterone receptor status, menstrual status, relapse-free survival, and overall survival was analysed in 411 patients with early breast cancer randomised to receive either postoperative adjuvant chemotherapy with cyclophosphamide, methotrexate, and fluorouracil (CMF) or no additional treatment (control). Prolongation of time to recurrence and survival was seen predominantly in premenopausal patients; these effects were seen only with tumours positive for steroid receptors, particularly progesterone. Chemotherapy led to permanent amenorrhoea in 61% of premenopausal patients. The therapeutic effects of chemotherapy were seen only when CMF induced permanent amenorrhoea in premenopausal patients. These findings support the hypothesis that the effect of adjuvant chemotherapy in early breast cancer may be mediated by ovarian suppression.

Adjuvant radiotherapy and chemotherapy in breast cancer

Three hundred and twenty-two women with involvement of axillary lymph nodes following surgery for operable breast cancer were randomized to receive either postoperative radiotherapy, chemotherapy (CMF) or radiotherapy followed by chemotherapy. There was an increase in disease free interval in pre- and postmenopausal patients receiving radiotherapy and chemotherapy regardless of the number of nodes involved. However, there was a trend towards an improvement in disease related survival only in those patients with more than three nodes involved.

Long-term survival following relapse after 5-FU but not CMF adjuvant breast cancer therapy

Beginning in 1974, patients with greater than or equal to 4 nodes positive following mastectomy were randomized to receive either 5-FU i.v. weekly or CMF i.v. every 2 weeks, both given for 12 months. Median follow-up now exceeds 112 months with nine year results below: (table; see text) Early results based on relapse-free survival favored CMF, but more patients currently are alive on the 5-FU arm. As the survival curves cross at 40 months, the 20% survival advantage for 5-FU did not achieve statistical significance. For 34% of patients failing adjuvant 5-FU, use of combination chemotherapy after relapse (commonly with CMFVP or CMF) resulted in long term survival. In contrast, long-term survival for patients failing adjuvant CMF was unusual. Relapse was detected while under weekly observation in a greater proportion of patients on 5-FU (36%) compared to CMF (6%) adjuvant treatment (p less than 0.05), potentially influencing tumor burden at recurrence. Hormonal therapy or radiation therapy as initial therapy after relapse was ineffective, with no long term survivors resulting on either arm. Weight increase on adjuvant chemotherapy was commonly seen, with weight increase greater than 10 kg associated with a poor prognosis. We conclude that initial improvement in relapse-free survival may not predict long term survival in adjuvant breast cancer trials since both the specific adjuvant therapy given pre-relapse as well as the type of salvage therapy given post-relapse may influence ultimate patient outcome.