Who Should Not Receive Chemotherapy? Data From American Databases and Trials

Abstract

The demonstration of the effectiveness of chemotherapy in both premenopausal and postmenopausal women, regardless of estrogen receptor (ER) status, raises the question of whether all breast cancer patients should receive chemotherapy. Several patient groups with such a favorable longterm prognosis that they will obtain an extremely small benefit from chemotherapy can be identified. They include patients with lymph node-negative tumors of 1 cm or less in size, those with grade 1 tumors between 1.1 and 2.0 cm in size, and those with tumors of favorable histologic type (tubular and mucinous) up to 3 cm in size. A patient subgroup in which it is not clear that the benefits of chemotherapy routinely exceed the risks is postmenopausal women with ER-positive, lymph node-negative cancers receiving tamoxifen. There is a wide variation in prognosis in this group, and chemotherapy should be reserved for those at high risk of recurrence. Finally, no benefit for chemotherapy in women aged 70 years and older has been identified. The high rate of death from causes other than breast cancer may negate small survival benefits, and after adjustment for quality of life, the duration of treatment exceeds the gain in life expectancy. [J Natl Cancer Inst Monogr 2001;30:109-13]The Oxford Overview Analysis (1) has clearly demonstrated that adjuvant systemic chemotherapy reduces the risk of mortality for women with both lymph node-positive and lymph node-negative breast cancer and is effective in both premenopausal and postmenopausal women. In light of the proven benefit of chemotherapy, it is reasonable to ask whether there are any groups of breast cancer patients who should not receive this treatment. Potential patient groups who will not achieve a net benefit from chemotherapy include women with an extremely favorable prognosis, where the reduction in mortality from chemotherapy translates to an absolute survival difference of only a few percent; patients in whom the potential risks of chemotherapy outweigh the benefits; and patient subsets for which chemotherapy has not been proven to have a survival benefit. This article will discuss breast cancer patient groups who meet these criteria. FAVORABLE PROGNOSIS SUBGROUPSSubsets of lymph node-negative breast cancer patients with a favorable prognosis have usually been defined on the basis of tumor size or histologic subtype. The use of screening mammography has resulted in the increasingly frequent identification of cancers of 1 cm or less in size. Several large datasets (2-6) confirm that tumors of this size have an extremely favorable prognosis. The Breast Cancer Detection Demonstration Project (BCDDP) was one of the earlier studies to report on the favorable outcome of patients with tumors less than 1 cm in size (2). In the BCDDP, the 880 patients with stage I cancer had an 8-year survival rate of 90%, and for those with tumors less than 1 cm in size, the survival rate was 96%. This favorable prognosis was observed for both the interval and screen-detected cancers, where the survival ra...

Phase II study of preoperative sequential FEC and docetaxel predicts of pathological response and disease free survival

“…This trend was similar to previous studies using AC followed by paclitaxel regimens, though the therapeutic situations are different [10,12,27,28]. According to recent meta-analyses of post-operative adjuvant therapy, chemotherapy including cyclophosphamide/methotrexate/5FU (CMF)-type regimens, anthracycline-containing regimens and anthracycline followed by paclitaxel are more effective for hormone receptor negative tumors than for hormone receptor positive tumors [10][11][12][27][28][29][30][31][32]. However, while hormone receptor negative tumors may be more responsive to preoperative regimens, a survival benefit can be observed regardless of receptor status [2].…”

Elevated expression of chemokine C-C ligand 2 in stroma is associated with recurrent basal-like breast cancers

“…Breast cancers diagnosed as invasive ductal carcinomas during this period received a common regimen of chemotherapy and antihormonal therapies. 41 Development of high grade toxicity, 41,42 owing in part to combination treatment chemotherapy to tamoxifen, was shown to be associated with poor patient prognosis. 41 Obesity is another factor affecting chemotherapeutic efficacy and patient outcome; obese patients tend to be undertreated.…”

“…41 Development of high grade toxicity, 41,42 owing in part to combination treatment chemotherapy to tamoxifen, was shown to be associated with poor patient prognosis. 41 Obesity is another factor affecting chemotherapeutic efficacy and patient outcome; obese patients tend to be undertreated. 43,44 Recent studies also show that another factor affecting the association between chemotherapy and survival is how early these patients received chemotherapy after surgical intervention.…”