Performance of general hospitals in delivering adjuvant chemotherapy to breast cancer patients. G.I.V.I.O. (Interdisciplinary Group for Cancer Care Evaluation), Italy.

Indications for and modes of delivery of adjuvant chemotherapy in early breast cancer were assessed in a group of 353 patients followed within a cohort of 1110 newly diagnosed cases in 54 Italian general hospitals. Among node-positive patients 79% pre- and 44% post-menopausal women had the treatment. Only a few node-negative women (10% pre- and 5% post-menopausal) were treated. The multidrug combination CMF was by far the most commonly employed (89%) in its two types: cCMF (the classic combination where cyclophosphamide is given orally on days 1-14 and the two other drugs i.v. on days 1 and 8 every 28 days for either 6 or 12 cycles) to 33% women and nCMF (the more recent combination where all three drugs are given i.v. on day 1 every 21 days for 12 cycles) to 63%. The mode of delivery of treatment was consistent with the Italian National Breast Cancer Task Force (F.O.N.Ca.M.) recommendations for the cCMF combination, but the lack of clear guidelines on the use of nCMF led to wide variations in the total number of cycles administered. At present, however, it is hard to establish whether this will have any impact on patients' outcome. Overall the study suggests that adjuvant chemotherapy for breast cancer has entered general practice and can be satisfactorily delivered at the community level. However, better guidelines need to specify more precisely the treatment indications (i.e. subgroups with greater expected benefits), regimen type (is nCMF still experimental or already standard?) and treatment duration, in view of the present uncertainty about what should be the standard for general practice. The paper finally discusses the feasibility of the treatment comparing general hospitals' performance with that achieved in controlled clinical trials of adjuvant chemotherapy.