Summary:A single high-dose cycle of chemotherapy can produce response rates in excess of 50%. However, disease-free survival (DFS) is 15-20% at 5 years. The single most important predictor of prolonged DFS is achieving a complete response (CR). Increasing the proportion of patients who achieve a complete response may improve disease-free survival. Women with metastatic breast cancer and at least a partial response (PR) to induction chemotherapy received three separate high-dose cycles of chemotherapy with peripheral blood progenitor support and G-CSF. The first intensification was paclitaxel (825 mg/m 2 ), the second melphalan (180 mg/m 2 ) and the third consisted of cyclophosphamide 6000 mg/m 2 (1500 mg/m 2 /day ؋ 4), thiotepa 500 mg/m 2 (125 mg/m 2 /day ؋ 4) and carboplatin 800 mg/m 2 (200 mg/m 2 /day ؋ 4) (CTCb). Sixty-one women were enrolled and 60 completed all three cycles. Following the paclitaxel infusion most patients developed a reversible, predominantly sensory polyneuropathy. Of the 30 patients with measurable disease, 12 converted to CR, nine converted to a PR*, and five had a further PR, giving an overall response rate of 87%. The toxic death rate was 5%. No patient progressed on study. Thirty percent are progression-free with a median follow-up of 31 months (range 1-43 months) and overall survival is 61%. Three sequential high-dose cycles of chemotherapy are feasible and resulted in a high response rate. The challenge continues to be maintenance of response and provides the opportunity to evaluate strategies for eliminating minimal residual disease. Keywords: stem cell transplant; breast cancer; multicycle chemotherapy; tandem transplants Advanced breast cancer continues to be a highly treatable, albeit ultimately deadly disease, with a median survival of 2 to 2.5 years. 1 New cytotoxics and biologics may lengthen survival in the order of 1 to 5 months. However, long-term disease-free survival is rare. [2][3][4] The research interest in very high-dose chemotherapy sprang from the observation of a linear-log relationship between dose and tumor cell kill. Early clinical studies determined that 15 to 20% of women who achieved a complete response as a consequence of a single high-dose cycle of chemotherapy as consolidation for responding metastatic breast cancer maintained this response for longer than 5 years -in contrast to less than 5% observed in previous studies. 2 However, that the observation of improved survival might be due to selection bias is suggested in a retrospective review of a large database. 5 There are five randomized trials assessing high-dose chemotherapy with autologous stem cell support as a component of overall therapy in patients with metastatic breast cancer. Two of these trials demonstrate equivalence of a single high-dose cycle of chemotherapy with stem cell support to maintenance chemotherapy. 6,7 Survival was doubled in the small French trial, a difference that was not statistically significant. 8 The two Duke University trials compare a single high-dose cycle of chemothe...