Two taxanes are currently available for the treatment of advanced breast cancerpaclitaxel (Taxol) and docetaxel (Taxotere). These agents have different and specific mechanisms of action, and this article will focus on the most extensively studied of them, paclitaxel. The observation that taxanes do not exhibit cross-resistance to doxorubicin (Adriamycin) underlies the international effort to bring them into the adjuvant and neoadjuvant setting. The role of taxanes, and specifically paclitaxel, in the adjuvant setting follows logically from their demonstrated activity against metastatic disease and from their lack of cross-resistance to doxorubicin. In the original series of 25 patients treated by Holmes et al, all but two had received prior doxorubicin and six were considered to be doxorubicin-resistant. two partial responses were observed in the doxorubicin-resistant patients.
In a phase II trial of heavily pretreated patients (median number of prior chemotherapy regimens 3; range 2-6), investigators at Memorial Sloan-Kettering Cancer Center gave 51 patients paclitaxel 200 mg/m² by 24-hour infusion every three weeks and observed a response rate of 28%. The same investigators subsequently studied patients who had received only one prior chemotherapy regimen for metastatic disease. After administering paclitaxel at 250 mg/m² to these patients, they observed a response rate of 48%. In both of these studies, previous resistance to anthracycline did not predict resistance to paclitaxel. As expected, in patients with newly diagnosed metastatic disease, an even higher response rate of 62% was achieved and prior use of adjuvant anthracycline therapy did not decrease the likelihood of a response.
Other studies limited to patients with anthracycline-resistant disease have confirmed the lack of cross-resistance between the two drugs. Wilson et al treated 36 metastatic breast cancer patients who had progressed after treatment with an anthracycline with paclitaxel given as a 96-hour infusion at 140 mg/m². They observed a response rate of 48%. Response rates ranging from 29% to 46% have been achieved in trials of docetaxel in patients with anthracycline-resistant disease.[5-7]
Although adjuvant doxorubicin-based chemotherapy effectively cures approximately 20% to 35% of patients with micrometastases, most patients with micrometastatic disease after surgery eventually die of progressive breast cancer. The success of the current adjuvant regimens is thus tempered by the need for more effective regimens. This need, and the encouraging results observed in the setting of anthracycline-resistant metastatic disease, have resulted in high priority trials incorporating taxanes into adjuvant treatment regimens in North America and Europe.
One of the earliest trials to use paclitaxel in the adjuvant setting was conducted by Cancer and Leukemia Group B (CALGB). CALGB 9141 was designed as a pilot study to assess the feasibility of adding paclitaxel to dose- dense doxorubicin/cyclophosphamide (doxorubicin 75 mg/m², cyclophosphamide 2,000 mg/m², given every three weeks). One hundred and seventy two node-positive patients received five cycles of AC (doxorubicin and cyclophosphamide) followed by paclitaxel 175 mg/m² every three weeks, for four cycles. Preliminary follow-up at a median of 2.4 years showed a relapse-free survival of 87%; for patients with 10 or more positive nodes, relapse-free survival was 72%.
Other studies still undergoing accrual or in follow-up are listed in Table 1. As evidenced by the wide variety of regimens in Table 1, there are many possible ways of incorporating taxanes into existing adjuvant schedules.
Taxanes may be given concurrently or sequentially with doxorubicin. In addition, paclitaxel itself may be given in a variety of doses and schedules, as shown in Table 2. Although the results of recent adjuvant trials will not be available for several years, most investigators believe they will confirm the importance of including a taxane. it may, however, be many years before the optimal regimen is defined. It is possible that the best approach will be to administer a taxane in the neoadjuvant setting followed by an anthracycline-based adjuvant regimen.
The administration of neoadjuvant chemotherapy to patients with breast cancer has been the standard of care for those with locally advanced disease (T3 or T4 tumors, or N2 or N3 nodes). At some institutions, additional chemotherapy is given following surgery. The advantages of neoadjuvant chemotherapy include the following:
1. Shrinking the tumor with chemotherapy before surgery may facilitate the removal of the tumor and permit breast-conserving surgery in patients with large tumors that would otherwise require mastectomy. The ability of neoadjuvant chemotherapy to permit breast conservation despite tumors initially too large has been well documented in clinical trials.
2. Systemic chemotherapy is administered as soon as possible after diagnosis. This has a theoretical advantageIt may prevent the emergence of drug-resistant tumor clones.
There is evidence that some primary tumors elaborate substances that inhibit the vascularization and growth of micrometastases and that surgical removal of the tumor stimulates the growth of metastases. Neoadjuvant therapy may treat micrometastases before removal of the primary tumor can stimulate their growth. Neoadjuvant therapy is given at a time when the tumors vascular bed is intact, allowing optimal drug delivery.
3. The response of the primary tumor to neoadjuvant chemotherapy can provide prognostic information. Studies have demonstrated that response to neoadjuvant chemotherapy predicts disease-free and overall survival.
The results of NSABP Trial B18, comparing neoadjuvant AC (doxorubicin and cyclophosphamide times four cycles) to adjuvant AC, were reported at the 1997 meeting of the American Society of Clinical Oncology (ASCO). There was no difference in progression-free or overall survival between the two groups. In the neoadjuvant group, however, there was significant down-staging of tumors (a 37% increase in the incidence of pathologically negative nodes) and a substantially higher rate of breast conservation (67% vs 60% in the adjuvant group).
The Buzdar Trial
Although most trials of paclitaxel in early stage breast cancer have incorporated it into postsurgical adjuvant regimens for patients at high risk of recurrence, several investigators have studied paclitaxel in the neoadjuvant setting. Buzdar et al recently reported the results of a randomized trial comparing paclitaxel alone to FAC (fluorouracil[5-FU], Adriamycin, and cyclophosphamide [Cytoxan]) given as induction therapy to patients with operable breast cancer. Paclitaxel was administered as a 24-hour infusion every three weeks at a dose of 250 mg/m². As shown in Table 3, no difference between the groups was observed in the amount of residual disease present, either in the breast or in the axilla, at the time of surgery.
Patients on the paclitaxel arm experienced significantly more febrile neutropenia (7/37 patients for paclitaxel, compared to 2/41 patients for FAC). A substantially lower incidence of neutropenia was observed in a small pilot trial of neoadjuvant therapy using the same paclitaxel dose given over three hours (grade 3 neutropenia seen in 7% of patients), reflecting the schedule dependency of paclitaxel-induced neutropenia.
The New York University Trial
At New York University, we began a trial of neoadjuvant paclitaxel for patients with palpable T2 or T3 tumors, followed by surgery, adjuvant AC (doxorubicin and cyclophosphamide) and in appropriate cases, radiation therapy. Paclitaxel is given at 200 mg/m² over three hours every two weeks. Seven patients have entered the trial. although it is too early to draw conclusions about the overall efficacy of this regimen, the neoadjuvant treatment appears to be well tolerated and all patients have demonstrated a clinical response to paclitaxel.
The Gianni Trial
Other investigators are studying paclitaxel in combination with doxorubicin in the neoadjuvant setting. Based on their experience with metastatic disease, Gianni et al conducted a pilot trial of neoadjuvant paclitaxel and doxorubicin in women with tumors greater than 3 cm or tumors otherwise locally advanced. They administered doxorubicin 60 mg/m² and paclitaxel 200 mg/m² over three hours every three weeks for four to six cycles before surgery. Their preliminary findings are summarized in Table 4. They observed grade IV neutropenia in 69% of patients, but it was of short duration and clinically manageable.
The Anelli Trial
Anelli et al have also reported on the use of combined paclitaxel and doxorubicin given neoadjuvantly. They treated 20 patients with stage IIIB breast cancer. The first 10 patients received doxorubicin 60 mg/m² and paclitaxel 135 mg/m²; the second 10 received 175 mg/m² of paclitaxel. Three cycles of therapy were given before surgery. Eighty percent of patients responded clinically, and a complete histologic response was seen in 20% of patients.
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