Adjuvant chemotherapy in early breast cancer

Despite living in an era of progressively improved molecular characterization of breast cancer with novel prognostic and predictive tests as well as increased use of targeted therapies, adjuvant chemotherapy is still a cornerstone in the treatment of early breast cancer. Numerous clinical trials of adjuvant chemotherapy without trastuzumab have clearly shown that the effectiveness depends not only on the mere application of new substances (e.g., taxanes) but at least equally important on the way to utilize them. At present, standard adjuvant chemotherapy should include anthracyclines, taxanes and cyclophosphamide. Docetaxel is best used in three weekly intervals, while paclitaxel should be delivered either weekly or dose-dense every two weeks with G-CSF support. In high risk breast cancer patients with more than three involved axillary lymph nodes, an intensified dose-dense and sequential approach leads to significantly improved survival. Other approaches to improve the efficacy of adjuvant chemotherapy employ the incorporation of additional substances like capecitabine. Conversely, investigators trying to de-escalate adjuvant chemotherapy implemented taxane-containing but anthracycline-free chemotherapy. Altogether, these new approaches are awaiting further confirmatory clinical trials before they should be regarded as standard of care in early breast cancer.