Distant recurrence in breast cancer. Survival expectations and first choice of chemotherapy regimen

Controversial questions in recurrent breast cancer include the magnitude of the survival benefit of combination chemotherapy and the best choice of first line chemotherapy. Data from the files of the Danish Breast Cancer Cooperative Group (DBCG) show that with current systemic treatment median survival after distant recurrence is 19 months. Since historical data from the pre-chemotherapy era indicate a median survival of 12 months, the survival benefit of standard chemotherapy appears to be around 7 months in the average patient. The DBCG trial 80-R2 is the largest randomized trial of CAF (cyclophosphamide, doxorubicin, 5-fluorouracil) versus CMF (cyclophosphamide, methotrexate, 5-fluorouracil) in recurrent breast cancer. A review of this study and 6 other similar studies shows that CAF is clearly superior to CMF in terms of better tumor shrinkage, prolonged overall time to progression, and decreased need of secondary therapy. The adverse effects of the two treatments are largely comparable, but CAF causes severe alopecia and is more expensive than CMF. On balance, the existing evidence indicates that CAF rather than CMF should be chosen as first line chemotherapy in recurrent breast cancer.