HOW SHOULD WE INTRODUCE HIGH-DOSE CHEMOTHERAPEUTIC STRATEGIES INTO THE ADJUVANT MANAGEMENT OF HIGH-RISK BREAST-CANCER IN AUSTRALIA

Background: Development of bone marrow support techniques has altered the standard chemotherapeutic management of haematological malignancie s, and these techniques are now being increasingly utilized in solid r umours. In breast cancer, survival benefits have resulted from convent ional dose adjuvant chemotherapy, but outcomes remain poor in many wom en with high-risk disease. Improved response rates with high-dose chem otherapy (HDC) ill metastatic disease have led to the investigation of these techniques in adjuvant therapy of high-risk localized disease. Tn some high-risk patient subgroups survival is extremely poor. with 5 -year rates below 30%. Improved adjuvant strategies for patients in th ese subgroups are therefore urgently required. In Australasia, oncolog y departments are currently considering accrual of women with high-ris k disease into the International Breast Cancer Study Group (IBCSG) 15- 95 Trial investigating HDC/stem cell transplantation. Methods: The pre sent paper reviews the available data on the efficacies and toxicities of currently available high-dose chemotherapeutic strategies; discuss ing methodological considerations relevant to their introduction and s afe use in the adjuvant setting in Australia and New Zealand. Results: Although response rates with, HDC iii metastic disease are encouragin g the clinical effectiveness of current HDC regimens in adjuvant manag ement has not been established and is limited by significant toxicity. Conclusions: The introduction of HDC strategies for high-risk breast cancer in Australia encounters difficulties both iii trial design and potential clinical practice.