Clinical quandary in adjuvant chemo: Endpoint versus toxicity

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For oncologists battling breast cancer in the clinic, one of the most difficult decisions is choosing the optimal adjuvant therapy, one that balances the fine line between efficacy and toxicity. Clifford A. Hudis, MD, Chief, Breast Cancer Medicine Service at Memorial Sloan-Kettering Cancer Center, tackled this difficult clinical discussion in an interview with ONCOLOGY.

Reporting from the 27th MBCC, ONCOLOGY spoke with Clifford A. Hudis, MD, Chief, Breast Cancer Medicine Service at Memorial Sloan-Kettering Cancer Center. Dr. Hudis, who presented a session titled, "Choosing the Optimal Adjuvant Chemotherapy Regimen, Dose, and Schedule," explained that the central purpose of adjuvant systemic therapy is to increase survival. "However, in many cases we accept disease-free survival as a surrogate endpoint, but that always raises the risk that we will make choices that ultimately do not improve overall survival," said Dr. Hudis.

The counter current concern, he stressed, is the risk of acute and chronic toxicities. "Clinicians should base their treatment choices on the results of prospective randomized trials for which their individual patients would have been qualified. In general, combination chemotherapy has been superior to single agents (although we appropriately continue to ask this question in modern trials with newer agents), anthracyclines offer benefits over non-anthracycline-containing regimens, and the taxanes add again," noted Dr. Hudis.

Dr. Hudis added, "As a consequence of regional variations in the "standard" or comparator regimens for clinical trials, there are now several state-of-the-art options. These include dose-dense AC-paclitaxel, AC followed by weekly paclitaxel, and FEC-Taxane sequences. A key unresolved issue is the global selection of patients for chemotherapy sensitivity as well as for sensitivity to specific agents."

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