ADJUVANT SYSTEMIC THERAPY FOR WOMEN WITH NODE-NEGATIVE BREAST-CANCER

Objective: To assist patients with node-negative breast cancer and the ir physicians in arriving at optimal decisions regarding treatment. Ev idence: Based on systematic literature review using primarily CANCERLI T from 1983 and MEDLINE from 1980 to September 1996. Nonsystematic rev iew continued up to June 1997. Recommendations: Before deciding whethe r to use adjuvant systemic therapy, the prognosis without adjuvant the rapy should be estimated. A patient's risk for recurrence can be categ orized as low, intermediate or high on the basis of tumour size, histo logic or nuclear grade, estrogen receptor (ER) status, and lymphatic a nd vascular invasion (LVI). For each individual, the choice of adjuvan t therapy must take into account the potential benefits and possible s ide effects. These must be fully explained to each patient. Pre- and p ostmenopausal women who are at low risk of recurrence can be advised n ot to have adjuvant systemic treatment. Women at high risk should be a dvised to have adjuvant systemic therapy. Chemotherapy should be recom mended for all premenopausal women (less than 50 years of age) and for postmenopausal women (50 years of age or older) with ER-negative tumo urs. Tamoxifen should be recommended as first choice for postmenopausa l women with ER-positive tumours. For this last group of patients, it is possible that further benefit may be obtained from the addition of chemotherapy to tamoxifen. For women at intermediate risk with ER-posi tive tumours, tamoxifen should normally be the first choice. For those who decline tamoxifen, chemotherapy may be considered. For most patie nts over 70 years of age who are at high risk, tamoxifen is recommende d regardless of ER status. For some who are in robust good health, che motherapy is a valid option. There are 2 recommended chemotherapy regi mens: (1) 6 cycles of cyclophosphamide, methotrexate and 5-fluorouraci l (CMF); (2) 4 cycles of Adriamycin and cyclophosphamide(AC). Tamoxife n should normally be administered daily for 5 years. Patients should b e offered the opportunity of participating in therapeutic trials whene ver possible. Validation: The authors' original text was revised succe ssively by a writing committee, expert primary reviewers, secondary re viewers, and by The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. The final document refle cts a substantial consensus of all these contributors.