In general , single-agent chemotherapy is not recommended for the adjuvant treatment of breast cancer in any patient population .
Anthracycline-taxane-based polychemotherapy regimens are , overall , considered superior to earlier-generation regimens and have the most significant impact on patient survival outcomes .
Regimens with varying anthracycline and taxane doses and schedules are options ; in general , paclitaxel given every 3 weeks is inferior .
Evidence does not support the use of bevacizumab in the adjuvant setting ; other systemic therapy agents such as metformin and vaccines remain investigatory .
BACKGROUND The Program in Evidence -Based Care ( pebc ) of Cancer Care Ontario recently created an evidence -based consensus guideline on the systemic treatment of early breast cancer .
The evidence for the guideline was compiled using a systematic review to answer the question " What is the optimal systemic therapy for patients with early-stage , operable breast cancer , when patient and disease factors are considered ? "
The question was addressed in three parts : cytotoxic chemotherapy , endocrine treatment , and human epidermal growth factor receptor 2 (her2)-directed therapy .
Effects of the addition of gemcitabine, and paclitaxel-first sequencing, in neoadjuvant sequential epirubicin, cyclophosphamide, and paclitaxel for women with high-risk early breast cancer (Neo-tAnGo): an open-label, 2×2 factorial randomised phase 3 trial.
BACKGROUND Anthracyclines and taxanes have been the st and ard neoadjuvant chemotherapies for breast cancer in the past decade . We aim ed to assess safety and efficacy of the addition of gemcitabine to accelerated paclitaxel with epirubicin and cyclophosphamide , and also the effect of sequencing the blocks of epirubicin and cyclophosphamide and paclitaxel ( with or without gemcitabine ) . METHODS In our r and omised , open-label , 2 × 2 factorial phase 3 trial ( Neo-tAnGo ) , we enrolled women ( aged > 18 years ) with newly diagnosed breast cancer ( tumour size > 20 mm ) at 57 centres in the UK . Patients were r and omly assigned via a central r and omisation procedure to epirubicin and cyclophosphamide then paclitaxel ( with or without gemcitabine ) or paclitaxel ( with or without gemcitabine ) then epirubicin and cyclophosphamide . Four cycles of each component were given . The primary endpoint was pathological complete response ( pCR ) , defined as absence of invasive cancer in the breast and axillary lymph nodes . This study is registered with EudraCT ( 2004 - 002356 - 34 ) , IS RCT N ( 78234870 ) , and Clinical Trials.gov ( NCT00070278 ) . FINDINGS Between Jan 18 , 2005 , and Sept 28 , 2007 , we r and omly allocated 831 participants ; 207 received epirubicin and cyclophosphamide then paclitaxel ; 208 were given paclitaxel then epirubicin and cyclophosphamide ; 208 had epirubicin and cyclophosphamide followed by paclitaxel and gemcitabine ; and 208 received paclitaxel and gemcitabine then epirubicin and cyclophosphamide .  828 patients were eligible for analysis . Median follow-up was 47 months ( IQR 37 - 51 ) . 207 ( 25 % ) patients had inflammatory or locally advanced disease , 169 ( 20 % ) patients had tumours larger than 50 mm , 413 ( 50 % ) patients had clinical involvement of axillary nodes , 276 ( 33 % ) patients had oestrogen receptor (ER)-negative disease , and 191 ( 27 % ) patients had HER2-positive disease . Addition of gemcitabine did not increase pCR : 70 ( 17 % , 95 % CI 14 - 21 ) of 404 patients in the epirubicin and cyclophosphamide then paclitaxel group achieved pCR compared with 71 ( 17 % , 14 - 21 ) of 408 patients who received additional gemcitabine ( p=0·98 ) . Receipt of a taxane before anthracycline was associated with improved pCR : 82 ( 20 % , 95 % CI 16 - 24 ) of 406 patients who received paclitaxel with or without gemcitabine followed by epirubicin and cyclophosphamide achieved pCR compared with 59 ( 15 % , 11 - 18 ) of 406 patients who received epirubicin and cyclophosphamide first ( p=0·03 ) . Grade 3 toxicities were reported at expected levels : 173 ( 21 % ) of 812 patients who received treatment and had full treatment details had grade 3 neutropenia , 66 ( 8 % ) had infection , 41 ( 5 % ) had fatigue , 41 ( 5 % ) had muscle and joint pains , 37 ( 5 % ) had nausea , 36 ( 4 % ) had vomiting , 34 ( 4 % ) had neuropathy , 23 ( 3 % ) had transaminitis , 16 ( 2 % ) had acute hypersensitivity , and 20 ( 2 % ) had a rash . 86 ( 11 % ) patients had grade 4 neutropenia and 3 ( < 1 % ) had grade 4 infection . INTERPRETATION Although addition of gemcitabine to paclitaxel and epirubicin and cyclophosphamide chemotherapy does not improve pCR , sequencing chemotherapy so that taxanes are received before anthracyclines could improve pCR in st and ard neoadjuvant chemotherapy for breast cancer . FUNDING Cancer Research UK , Eli Lilly , Bristol-Myers Squibb
In general , single-agent chemotherapy is not recommended for the adjuvant treatment of breast cancer in any patient population .
Anthracycline-taxane-based polychemotherapy regimens are , overall , considered superior to earlier-generation regimens and have the most significant impact on patient survival outcomes .
Regimens with varying anthracycline and taxane doses and schedules are options ; in general , paclitaxel given every 3 weeks is inferior .
Evidence does not support the use of bevacizumab in the adjuvant setting ; other systemic therapy agents such as metformin and vaccines remain investigatory .
BACKGROUND The Program in Evidence -Based Care ( pebc ) of Cancer Care Ontario recently created an evidence -based consensus guideline on the systemic treatment of early breast cancer .
The evidence for the guideline was compiled using a systematic review to answer the question " What is the optimal systemic therapy for patients with early-stage , operable breast cancer , when patient and disease factors are considered ? "
The question was addressed in three parts : cytotoxic chemotherapy , endocrine treatment , and human epidermal growth factor receptor 2 (her2)-directed therapy .