Combination chemotherapy with gemcitabine (Gem), doxorubicin (Dox), and paclitaxel (Pac) (GAT) has been considered attractive as first-line treatment in metastatic breast cancer. We compared the potential of various schedules of GAT to induce apoptosis on MDA-MB-231, MCF7, and T47D human breast cancer cell lines. The extent of apoptotic induction was analyzed by flow cytometry with 7-aminoactinomycin D (7AAD) staining. Differences between various schedules in terms of apoptotic induction were statistically significant (P < < < <0.05). The most effective apoptotic induction regimen was achieved by the sequence: Dox for 16 h followed by Pac+ + + +Gem. Schedules employing a 16-h interval between drug administrations induced higher levels of apoptosis in human breast cancer cell lines compared with schedules using a 4-h interval. The therapeutic efficacy of the experimental results shown in this paper has been clinically corroborated in a phase II trial in metastatic breast cancer patients.
Key words: Breast cancer -Gemcitabine -Doxorubicin -Paclitaxel -ApoptosisClinical trials designed to evaluate the effectiveness and safety of new treatments for patients with all stages of breast cancer are under way. Combination therapy offers exciting possibilities of enhanced antitumor efficacy. In fact, the most effective proven chemotherapeutic regimens are combinations of active antineoplastic agents. Criteria for an effective combination include use of drugs with different mechanisms of action, relative non-cross-resistance, and partially non-overlapping toxicities. Tumor heterogeneity and the presence of subsets of cells resistant to certain drugs provide a rationale for treatment with multiple non-cross-resistant drugs. Several groups have reported that the combination of doxorubicin (Dox) plus paclitaxel (Pac) produces a high response rate, including complete responses, in metastatic breast cancer, but that this effect is offset by an 18% to 20% incidence of congestive heart failure.1) Furthermore, the schedule of Pac before Dox appears more toxic than that of Dox before Pac, in that Pac has been shown to increase the myocardial concentration of Dox if there is a relatively short interval between administration of the drugs.2) Gemcitabine (Gem) has also shown a wide range of antitumor activity and moderate toxicity in metastatic breast cancer, without cross-resistance with Pac and Dox.3, 4) Thus, the combination of Gem-Dox-Pac is considered an attractive first-line treatment for these patients.It is now well documented that cytotoxic chemotherapy induces an increase in apoptosis within 24 h after the start of treatment.5) Malignant transformation of breast epithelial cells is associated with a dysregulation of proliferation/apoptosis control mechanisms. It seems that alterations in the genes involved in the apoptosis pathway play a crucial role in the process of progression and invasion in breast carcinogenesis. 6) Therefore, the study of apoptotic induction in breast tumor cells, an important underlying mechanism of th...