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Intervention Review

Sequencing of chemotherapy and radiation therapy for early breast cancer

  1. Brigid E Hickey1,*,
  2. Daniel P Francis2,
  3. Margot Lehman3

Editorial Group: Cochrane Breast Cancer Group

Published Online: 18 OCT 2006

Assessed as up-to-date: 9 MAR 2005

DOI: 10.1002/14651858.CD005212.pub2


How to Cite

Hickey BE, Francis DP, Lehman M. Sequencing of chemotherapy and radiation therapy for early breast cancer. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005212. DOI: 10.1002/14651858.CD005212.pub2.

Author Information

  1. 1

    Princess Alexandra Hospital, Mater Centre Radiation Oncology Service, South Brisbane, QLD, Australia

  2. 2

    Queensland Health, Population Health Services, Central Area Health Service, Stafford DC, QLD, Australia

  3. 3

    Princess Alexandra Hospital, Radiation Oncology Unit, Brisbane, QLD, Australia

*Brigid E Hickey, Mater Centre Radiation Oncology Service, Princess Alexandra Hospital, 31 Raymond Terrace, South Brisbane, QLD, 4101, Australia. Brigid_Hickey@health.qld.gov.au.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 18 OCT 2006

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

After surgery for localised breast cancer, adjuvant radiotherapy improves both local control and breast cancer specific survival. In patients at risk of harbouring micro-metastatic disease, adjuvant chemotherapy improves 15-year survival. However, the best sequence of administering these two types of adjuvant therapy for early stage breast cancer is not clear.

Objectives

To determine the effects of different sequencing of chemotherapy and radiotherapy for women with early breast cancer.

Search methods

We searched the Cochrane Breast Cancer Group Specialized Register (10 March 2005). Details of the search strategy and methods of coding are described in the Group's module in The Cochrane Library. We extracted studies that had been coded as 'early', 'chemotherapy' and 'radiotherapy'.

Selection criteria

Randomised controlled trials evaluating different sequencing of chemotherapy and radiotherapy were included.

Data collection and analysis

We assessed the eligibility and quality of the identified studies and extracted data from the published reports of the included studies. We derived odds ratios (OR) and risk ratios from the available numerical data. Hazard ratios were extracted directly from text. Toxicity data were extracted, where reported. We used a fixed-effect model for meta-analysis and conducted analyses on the basis of the method of sequencing of the two treatments.

Main results

Three trials reporting two different sequencing comparisons were identified. There were no significant differences between the various methods of sequencing adjuvant therapy for survival, distant metastases or local recurrence, based on 853 randomised patients in two trials. One of these two trials (647 women) provided data on toxicity. Haematological toxicity (OR 1.43, confidence interval (CI) 1.01 to 2.03) and oesophageal toxicity (OR 1.44, CI 1.03 to 2.02) were significantly increased with concurrent therapy, and nausea and vomiting were significantly decreased (OR 0.70, CI 0.50 to 0.98). Other measures of toxicity did not differ between the two types of sequencing. On the basis of one trial (244 women), radiotherapy before chemotherapy was associated with a significantly increased risk of neutropenic sepsis (OR 2.96, 95%CI 1.26 to 6.98) compared with chemotherapy before radiotherapy, but other measures of toxicity were not significantly different.

Authors' conclusions

The data included in this review, from three well conducted randomised trials, suggest that different methods of sequencing chemotherapy and radiotherapy do not appear to have a major effect on survival or recurrence for women with breast cancer if radiation therapy is commenced within 7 months after surgery.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Sequencing of chemotherapy and radiotherapy for women following surgery for early breast cancer

Both chemotherapy and radiotherapy reduce the risk of breast cancer recurring and the risk of dying from breast cancer. Generally these therapies are given after surgery but there is uncertainty about whether they should be given at the same time (concurrently) or one after the other (sequentially). If they are used sequentially, the radiotherapy or the chemotherapy could be used first and concerns have been expressed that the effectiveness of the therapy that is delayed might be reduced. However, it has also been suggested that using chemotherapy and radiotherapy at the same time will be less beneficial than keeping them separate. This review examined current evidence on the best way to administer chemotherapy and radiotherapy following breast conserving surgery. We were able to include three randomised trials. Two of these, with a total of 853 women, assessed radiotherapy and chemotherapy given at the same time versus chemotherapy given first followed by radiotherapy. The third trial randomised 244 women to radiotherapy followed by chemotherapy versus chemotherapy followed by radiotherapy. The evidence produced by these three well conducted trials suggests that recurrence of a woman's cancer and her chances of dying from breast cancer are similar regardless of the order of the treatments, provided that both radiotherapy and chemotherapy are commenced within seven months of the surgery. The trials provided limited information regarding adverse events, side effects, or quality of life associated with the different sequences of treatment, but the limited evidence available does suggest that the frequency and severity of side effects of chemotherapy and radiotherapy are similar regardless of which sequence is used. It should be noted, however, that the women in these trials were treated, on average, ten years ago. As a result the trials do not assess the modern types of radiotherapy, and newer types of chemotherapy (such as taxanes) or other drugs (such as Herceptin). We will add relevant trials which include these newer treatments to future updates of this review.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

早期乳癌化學治療與放射治療的先後順序

在局部乳癌的外科手術之後,輔助放射治療能夠改善局部控制與乳癌特定存活. 在藏有微轉移風險疾病的患者中,輔助化學治療改善15年存活. 然而,於早期乳癌中,在執行這兩種類型輔助治療的最佳次序並不是很明確.

目標

定義早期女性乳癌化學治療與放射治療不同次序的效用.

搜尋策略

我們搜尋了考科藍乳癌群組資料庫的特定登錄者(2005年3月10日). 搜尋策略還有編碼方式的細節都詳述於考科藍實證醫學的群組元件. 我們摘錄了標示為“早期”, “化學治療”, “放射治療” 的研究.

選擇標準

使用不同次序化學治療與放射治療之隨機控制(Randomised controlled trials)臨床試驗。

資料收集與分析

我們評估了所識別研究的合格性與品質並且從相關研究中摘錄已經發表的資料. 我們從大量可取得的資料中衍生出機率(odds ratios)和風險率(risk ratios). 危害率(hazard ratios)直接從本文中摘錄. 毒性資料由有報告之處摘錄. 我們使用固定效果模型(fixedeffect model)來做統合分析(metaanalysis)並且處理這些分析,所依據的是這兩種治療方法的不同次序.

主要結論

三種試驗指出兩種不同的次序比較被鑑識出來. 在853位於這兩種試驗中被隨機選取出來的患者,所觀察到的是在各式輔助治療分別於存活情況,癌症轉移以及局部復發等部份,並沒有顯著差異. 兩者其中之一的試驗(647位女性)提供了毒性的資料. 血液學毒性(OR 1.43,信賴區間(CI)1.01至2.03)與食道毒性(OR 1.44, CI 1.03至2.02)在同時使用兩種治療的情況下有顯著增加. 而且噁心與嘔吐有顯著減少. (O.70, CI 0.50至0.98). 其他毒性的量測在這兩種型態的次序就沒有差別. 以其中一個檢測為基礎(244位女性),與放射治療之前的化學治療比較,化學治療之前的放射治療其與嗜中性球過少性敗血症(neutropenic sepsis)風險的關聯性有顯著增加. (O.96,95% CI 1.26至6.98),但是其他毒性的量測並沒有顯著差異.

作者結論

從三個控制良好的隨機試驗,在這個回顧中的所有資料提出建議指出不同化學治療與放射治療的次序對於在手術後七個月內就開始放射治療的女性乳癌患者其存活與復發的情形並沒有顯示出主要影響.

翻譯人

本摘要由中山醫學大學附設醫院周英二翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

手術後女性乳癌化學治療與放射治療的次序. 化學治療與放射治療兩者都能減弱肇因於乳癌所導致的乳癌復發與死亡的風險. 一般來說這些治療通常都在外科手術之後施行,但是仍有不確定性,關於這些治療是否應該同時執行(concurrently)或是一個接一個(sequentially).如果他們是一個接一個被使用,放射治療與化學治療都可以先被使用,而也有顧慮點出被延後使用的治療其效度有可能被削弱. 然而,也有建議認為將化學治療與放射治療兩者同時使用比起將兩者分開使用,其效益將會比較低. 這篇回顧試驗了目前的證據關於乳房保守手術之後化學治療與放射治療最好的方式. 我們可以包含三種隨機試驗. 其中兩種試驗在總數為853位女性之下,評估放射治療與化學治療同時給予相較於先予以化學治療後給予放射治療. 第三種檢測是隨機取樣244位女性先接受放射治療後接受化學治療,再對比於先化學治療後放射治療. 由這三種良好進行檢測下所得的證據建議認為女性的癌症復發率與其死於乳癌的機會是相似的,無論它們接受何種次序的治療,而這兩種治療放射治療與化學治療都在手術後七個月內被執行. 這些檢測提供有限資訊關於不良反應,副作用或是生活品質與這兩種不同治療次序的關聯,但是可獲得的有限證據建議認為無論兩種治療方式的先後次序為何,他們的在副作用的頻率和嚴重度是相似的. 然而應該注意的是,在這三種試驗中受測女性平均被治療的時間都是十年以前. 以結果來說,這些試驗並沒有評估現代型態的放射治療,還有新型態的化學治療(例如taxanes)或是其他藥物(像是Herceptin). 我們在往後在更新這篇回顧文章時會加入新的試驗,包含這些較新的治療方式.