Breast Cancer Update Think Tank 2006 (2)

DR JOYCE O’SHAUGHNESSY: In my practice, I don’t use AC any more as a four-cycle regimen. I’ve switched over to TC. When I’m going to use four cycles for patients with lower-risk, ER-positive, node-negative disease, I use TC.

DR DEBU TRIPATHY: TC is a reasonable non-anthracycline regimen. The US Oncology trial was a smaller study, so our level of confidence is lower, but at least everything pointed in the right direction.

Despite the limitations of being a small study, being spread out over a long period of time and having broad eligibility criteria, it did show that TC is as good or even better than AC. For patients with cardiac risk factors, it’s a reasonable regimen to use.

For patients who don’t have cardiac risk factors, I believe TC should be brought up as an option. When I consider the overall toxicity profile, it’s hard for me to figure out which was better tolerated because the spectrum of toxicities was different. The TC regimen had more hematologic toxicities and edema, whereas the AC regimen had more GI and cardiac toxicities.

Breast Cancer Update 2007 (2)

DR FRANKIE ANN HOLMES: I’ve started to incorporate the TC regimen much more frequently in my practice, especially in situations in which I have concerns about chemotherapy tolerance. However, at this time, I have not given up on the standard AC taxane regimen for my patients with node-positive disease.

AC is now recognized as a highly emetogenic regimen, and patients may experience delayed nausea and vomiting. I was once on a panel discussing emesis, and someone said, “Oh, that’s just AC.” Well, AC is associated with a lot of delayed nausea and vomiting. You find considerable hidden toxicity if you step into the shoes of a patient. It can be incapacitating. With TC, you don’t have that level of burden of emesis and nausea.

Breast Cancer Update 2007 (1)

DR JOSEPH A SPARANO: We now know that TC administered every three weeks is superior to AC administered every three weeks. Therefore, I believe that represents a reasonable evidence-based option for patients who have lower-risk, early-stage breast cancer. Before the US Oncology study, I would commonly use AC administered every two weeks, not necessarily because I thought it would be more effective — particularly in estrogen receptor-positive disease — but because the treatment was finished in a shorter period of time.

I believe the risks of cardiac toxicity with anthracycline-containing adjuvant regimens is a real complication. We can identify who’s at high risk, but we can’t identify who will develop a problem with any degree of certainty. For the patients at high risk, if we have alternatives to AC, then those options should be seriously considered.

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DR STEPHEN E JONES: Personally, I would use TC in the population of patients we studied in the US Oncology trial: Those with node-negative disease or those with one to three positive nodes. It provides a good reduction in the risk of recurrence. We don’t have many data for women with four or more positive nodes, so I probably wouldn’t pick TC in those situations, but I would for the patients with lower-risk disease or those with cardiac compromise.

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