21. The adjuvant treatment of breast cancer.
Risk of relapse of breast cancer depends largely on tumour features: size, grade and, particularly, lymph node status. Adjuvant systemic therapies reduce risk of relapse and death, as shown in several meta-analyses. Relative risk reductions are similar across different prognostic groups but the absolute benefits are greater in those with a worse prognosis. Combination chemotherapy is superior to single agent regimens but longer duration (>6 months) gives no additional benefit compared with six months of therapy. Benefits from adjuvant chemotherapy diminish with the age of the patient. CMF type regimens have been most widely used: anthracyclines can reduce risk of relapse by 12% (an absolute survival benefit of about 3%) but with greater toxicity. Early trials of taxoids look promising but benefit was seen only in those with ER- tumours. Tamoxifen is the most extensively used endocrine adjuvant therapy, and is associated with a reduction in risk of death of 26% independent of age or menopausal status but only in those with ER+ tumours. Aromatase inhibitors are effective only in postmenopausal women and, although the early results with anastrozole look promising, long-term efficacy and toxicity studies are presently lacking, so five years of tamoxifen is standard treatment for women with ER+ tumours.
Hedley Atkins Breast Unit, Guy's Hospital, London, UK.
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D000208:Acute Disease; D000328:Adult; D000367:Age Factors; D000368:Aged; D018931:Antineoplastic Agents, Hormonal / Q000009:adverse effects / Q000627:therapeutic use; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D047072:Aromatase Inhibitors; D001943:Breast Neoplasms / Q000188:drug therapy*; D017024:Chemotherapy, Adjuvant; D002908:Chronic Disease; D003520:Cyclophosphamide / Q000008:administration & dosage / Q000009:adverse effects; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D008727:Methotrexate / Q000008:administration & dosage / Q000009:adverse effects; D008875:Middle Aged; D009362:Neoplasm Metastasis; D011379:Prognosis; D013629:Tamoxifen / Q000009:adverse effects / Q000627:therapeutic use
D018931:Antineoplastic Agents, Hormonal; D047072:Aromatase Inhibitors; D013629:Tamoxifen; D003520:Cyclophosphamide; D005472:Fluorouracil; D008727:Methotrexate