Sequencing of Treatment

Sequencing of Chemo and Radiation

Joint Center RT - Recht 1996 NEJM

  • adjuvant CMFAP chemo (12 weeks)
  • first survival Initial report in 1996 reported differences in first site of recurrences.
  • Time to distance recurrence was significantly different.
  • However, with 10-yr follow up all the difference disappeared.
  • Chemotherapy may delay median time to distant recurrence but does not change the overall rate of distance recurrence or survival.
  • Close and positive margins have high rate of local recurrences and should be re-resected.

Sequencing of Chemo and Surgery

Pre-op chemo NSABP-B18

  • pre-op v. post-op AC for operable tumors
  • DFS and OS is same.
  • ~ 5% more lumpectomies in large tumors (15.9% IBTR in this groups vs. 9.9% IBTR in patients who had lumpectomy as planned).
  • Pre-operative arm had non-significant increase in IBTR of 10.7% vs 7.6%.
  • No difference in DFS or OS.
  • Response to chemotherapy was prognostic of survival

Sequencing of TAM concurrent with RT

NSABP B14 (JNCI 1996;88(21);1529-42)

  • No detrimental effect to giving RT and TAM together.
  • Theoretically, TAM blocks G1 to mid-G1 transition thereby placing cells in RT resistant phase.
  • Sequencing of CT concurrent with RT
  • While not in favor there are multiple randomized trials which show local control benefit while being safe.

Haffy IJROBP 2006

Local control benefit to concurrent 92% vs 83% p < 0.01 at 10 years
Calais IJROBP 2005(abstr)
Rouesse IJROBP 2006
Bellon Cancer 2004

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