Long-term prognosis of breast cancer patients with 10 or more positive lymph nodes treated with CMF
Introduction
Although adjuvant polychemotherapy treatment for breast cancer patients has led to improvements in both event-free survival (EFS) and overall survival (OS) [1], patients with 10 or more positive lymph nodes still have a high rate of recurrence, and EFS rates after five years are below 50% 2, 3, 4. Therefore, the improvement of this poor prognosis by applying new treatment strategies, such as high-dose chemotherapy, is considered as one of the most important topics of current research in breast cancer. Several observational studies have reported EFS and OS rates after treatment with high-dose chemotherapy as being substantially larger than the corresponding rates from a retrospectively chosen control group. However, detailed information about other potential prognostic factors or possible selection criteria for the patients treated with high-dose chemotherapy is often not given [5]. This may be due to the assumption that a further separation of patients with 10 or more positive lymph nodes in subgroups of patients with different prognosis is not possible on account of the strong prognostic effect of the number of positive lymph nodes.
This may explain the limited interest in this issue in the literature. Recently, Schmoor and Schumacher [4] reported a 5-year OS rate in a group of patients with 10 or more positive nodes treated with conventional chemotherapy of approximately 40%. For this poor prognosis group, we therefore wanted to investigate the prognostic value of standard factors for 141 patients with 10 or more positive nodes with a median follow-up of approximately 10 years. These patients represent a subgroup (13%) of 1048 lymph node-positive patients who were all treated with adjuvant conventional chemotherapy (cyclophosphamide, methotrexate, and 5-fluorouracil; CMF) within two studies of the German Breast Cancer Study Group (GBSG).
Section snippets
Study design
In 1984, the GBSG started two studies (GBSG studies 2 and 3) in patients with primary histologically proven node-positive breast cancer without known distant metastatic spread to compare different adjuvant treatment regimens. Primary local treatment was a modified radical mastectomy (Patey) with en bloc axillary dissection with at least six identifiable lymph nodes in the specimen. Patients were younger than 65 years old and had a Karnofsky index of at least 60. During the recruitment period,
Results
The patient population comprised 141 patients with 10 or more positive axillary lymph nodes, who entered either GBSG trial 2 or 3 between 1984 and 1989. Patient characteristics are displayed in Table 1.
A median number of 13 positive lymph nodes was found (lower quartile=11, upper quartile=17). The median number of lymph nodes examined was 17. Since there was considerable variation in the number of lymph nodes examined (10% quantile=11, lower quartile=14, upper quartile=22, 90% quantile=27), we
Discussion
Here, we presented the long-term prognosis of breast cancer patients with 10 or more positive lymph nodes treated with a standardised, conventional dose CMF chemotherapy within two prospective studies. Existing treatment heterogeneity with respect to additional hormonal treatment or radiotherapy has been accounted for by stratification. There are only a few studies with a sufficient number of patients included and/or a long-term follow-up in this high-risk group 2, 3, 19, 20, 21 although the
Acknowledgements
This study was sponsored by the Bundesministerium für Forschung und Technologie (BMFT) and by the Deutsche Forschungsgemeinschaft (DFG).
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