Current status and indications for adjuvant therapy in breast cancer.

1. Modified radical mastectomy is the standard surgical procedure today in most countries. 'Lesser surgery' associated with radiotherapy emerges as an alternative for patients with T1N0 lesions. 2. The potential risk of occult micrometastases is best predicted by careful axillary staging and possibly by the ER status of the primary tumor. 3. Additional risk factors such as tumor size, patients age, menopausal status, and intramammary lymphatic or vascular invasion are less well established and need clarification. 4. Previous studies showed no significant long-term benefit of adjuvant radiotherapy and at best a marginal increase of lifespan by adjuvant castration in patients subjected to radical surgery. 5. Various types of adequately intensive adjuvant chemotherapy resulted in a significant increase of relapse-free survival and probably also overall survival 5-6 years after mastectomy in pre- and possibly also postmenopausal N+ patients. 6. Treatment intensity (full doses) of adjuvant chemotherapy seems to be more critical than treatment duration (CMF X 6 is as good as CMF X 12). 7. Adjuvant chemotherapy with drug combinations is generally more effective than single drugs. No combination so far (if adequate doses are given) is clearly superior. 8. Whether early peri-operative onset of adjuvant chemotherapy or combinations with endocrine measures or cyclic, alternating drug regimens increase effectiveness remains to be shown. 9. Adjuvant chemotherapy in N- patients, though still experimental, appears rewarding. 10. The pattern of first relapse has not been significantly altered by the use of adjuvant chemotherapy. Response rate and duration with secondary treatments are consistent with common experience in metastatic disease. 11. Up to 5-6 years median observation time there is no proof that the risk of second neoplasms is increased by currently used adjuvant chemotherapy regimens. 12. More and highly critical prospective trials are needed to assess not only effectiveness, but also patient tolerance (cost-benefit ratio) of adjuvant therapies in breast cancer.