Abstract
Maintenance treatment is generally administered to patients without progression after an initial chemotherapy regimen of standard duration, with the aim of increasing the time to progression of disease. The aims of this strategy include prolongation of survival with good quality of life and symptom control. The duration of the treatment is generally based on patient responsiveness and individual tolerability as well as physician preferences. As breast cancer is a heterogeneous disease with different biological characteristics, the strategy of maintenance therapy may be adapted accordingly. Metronomic chemotherapy has been investigated particularly in advanced hormone receptor negative breast cancer and resulted as an interesting and valid alternative for maintenance therapy in this setting of patients. Recent results of a meta-analysis of randomized trials with maintenance chemotherapy showed a slight benefit in the overall survival and a more significant benefit in the progression free survival. However, this benefit should be balanced with toxicities and the use of the regimen with the best risk-benefit ratio should be preferred. Communication between the oncologist and the patient may help to determine the appropriate treatment choice and the correct duration of the treatment on an individual basis.
Similar content being viewed by others
References
Gatenby RA. A change of strategy in the war on cancer. Nature. 2009;459(7246):508–9.
Sánchez-Muñoz A, Pérez-Ruiz E, Ribelles N, Márquez A, Alba E. Maintenance treatment in metastatic breast cancer. Expert Rev Anticancer Ther. 2008;8(12):1907–12.
Stockler MR, Wilcken NJC, Coates AS. Chemotherapy for advanced breast cancer: How long should it continue? Breast Cancer Res Treat. 2003;81(suppl 1):S49–52.
Cardoso F, Costa A, Norton L, et al. 1st International consensus guidelines for advanced breast cancer (ABC 1). Breast. 2012 Jun;21(3):242–52.
Pasquier E, Kavallaris M, André N. Metronomic chemotherapy: new rationale for new directions. Nat Rev Clin Oncol. 2010;7:455–65.
Munzone E, Bertolini F, Colleoni M. Part III. Clinical activity of metronomic chemotherapy: Breast cancers. In: Giulio F, Bocci G, editors. Metronomic Chemotherapy: pharmacology and clinical applications. :Springer; 2014. (in press).
Coates A, Gebski V, Bishop JF, et al. Improving the quality of life during chemotherapy for advanced breast cancer. A comparison of intermittent and continuous treatment strategies. N Engl J Med. 1987;317(24):1490–5.
Harris AL, Cantwell BM, Carmichael J, et al. Comparison of short-term and continuous chemotherapy (mitozantrone) for advanced breast cancer. Lancet. 1990;335(8683):186–90.
Muss HB, Case LD, Richards F, et al. Interrupted versus continuous chemotherapy in patients with metastatic breast cancer. The Piedmont Oncology Association. N Engl J Med. 1991;325(19):1342–8.
Ejlertsen B, Pfeiffer P, Pedersen D, et al. Decreased efficacy of cyclophosphamide, epirubicin and 5-fluorouracil in metastatic breast cancer when reducing treatment duration from 18–6 months. Eur J Cancer. 1993;29A(4):527–31.
Gregory RK, Powles TJ, Chang JC, Ashley S. A randomised trial of six versus twelve courses of chemotherapy in metastatic carcinoma of the breast. Eur J Cancer. 1997;13:2194–7.
Falkson G, Gelman RS, Pandya KJ, et al. Eastern Cooperative Oncology Group randomized trials of observation versus maintenance therapy for patients with metastatic breast cancer in complete remission following induction treatment. J Clin Oncol. 1998;5:1669–76.
Nooij MA, de Haes JC, Beex LV, Wildiers J, Klijn J, Becquart D, Jassem J, Engelsman E, Duchateau L. EORTC Breast Cancer Group. Continuing chemotherapy or not after the induction treatment in advanced breast cancer patients. Clinical outcomes and oncologists’ preferences. Eur J Cancer. 2003;5:614–21.
Gennari A, Amadori D, De Lena M, et al. Lack of benefit of maintenance paclitaxel in first-line chemotherapy in metastatic breast cancer. J Clin Oncol. 2006;24(24):3912–8.
Alba E, Ruiz-Borrego M, Margeli M, et al. Maintenance treatment with pegylated liposomal doxorubicin versus observation following induction chemotherapy for metastatic breast cancer: GEICAM 2001–01 study. Breast Cancer Res Treat. 2010;122(1):169–76.
Park YH, Jung KH, Im S-A, et al. Phase III, multicenter, randomized trial of maintenance chemotherapy versus observation in patients with metastatic breast cancer after achieving disease control with six cycles of gemcitabine plus paclitaxel (KCSG-BR07–02) as first-line chemotherapy. J Clin Oncol. 2013;31:1732–9.
Martín M, López-Tarruella S. Chemotherapy: Maintenance therapy in breast cancer—many questions remain. Nat Rev Clin Oncol. 2013;10,370–2.
Gennari A, Stockler M, Puntoni M, Sormani M, Nanni O, Amadori D, Wilcken N, D’Amico M, DeCensi A, Bruzzi P. Duration of chemotherapy for metastatic breast cancer: a systematic review and meta-analysis of randomized clinical trials J Clin Oncol. 2011;9(16):2144–9.
Lim S, Lee S, Han J, Park BW, Kim S, Park S, Kim JH, Choi HJ, Sohn J. Prolonged clinical benefit from the maintenance hormone therapy in patients with metastatic breast cancer. Breast. 2013;22(6):1205–9.
Dufresne A, Pivot X, Tournigand C, et al. Maintenance hormonal treatment improves progression free survival after a first line chemotherapy in patients with metastatic breast cancer. Int J Med Sci. 2008 May 5;5(2):100–5.
Fabi A, Russillo M, Ferretti G, Metro G, Nisticò C, Papaldo P, De Vita F, D’Auria G, Vidiri A, Giannarelli D, Cognetti F. Maintenance bevacizumab beyond first-line paclitaxel plus bevacizumab in patients with Her2-negative hormone receptor-positive metastatic breast cancer: efficacy in combination with hormonal therapy. BMC Cancer. 2012;12:482.
Colleoni M, Rocca A, Sandri MT, et al. Low-dose oral methotrexate and cyclophosphamide in metastatic breast cancer: antitumor activity and correlation with vascular endothelial growth factor levels. Ann Oncol. 2002;3(1):73–80.
Orlando L, Cardillo A, Rocca A, et al. Prolonged clinical benefit with metronomic chemotherapy in patients with metastatic breast cancer. Anti-Cancer Drugs. 2006;17:961–7.
Wang Z, Lu J, Leaw S, et al. An all-oral combination of metronomic cyclophosphamide plus capecitabine in patients with anthracycline- and taxane-pretreated metastatic breast cancer: a phase II study. Cancer Chemother Pharmacol. 2012;69(2):515–22.
Munzone E, Di Pietro A, Goldhirsch A, et al. Metronomic administration of pegylated liposomal-doxorubicin in extensively pre-treated metastatic breast cancer patients: a mono-institutional case-series report. Breast. 2010;19(1):33–7.
Addeo R, Sgambato A, Cennamo G, et al. Low-dose metronomic oral administration of vinorelbine in the first-line treatment of elderly patients with metastatic breast cancer. Clin Breast Cancer. 2010;10(4):301–6.
Goss PE, et al. Late extended adjuvant treatment with letrozole improves outcome in women with early-stage breast cancer who complete 5 years of tamoxifen. J Clin Oncol. 2008;26(12):1948–55.
Cuzick J, et al. Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 10-year analysis of the ATAC trial. Lancet Oncol. 2010;11(12):1135–41.
Davies C, et al. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. Lancet. 2013;381(9869):805–16.
Gray RG, Rea D, Handley K, et al. ATTom: long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years in 6953 women with early breast cancer. J Clin Oncol. 2013;31((suppl) abstr 5): .
Levine MN, Gent M, Hryniuk WM, et al. A randomized trial comparing 12 weeks with 36 weeks of adjuvant chemotherapy in stage II breast cancer. J Clin Oncol. 1990;8:1217–25.
Senn HJ, Jungi WF. Swiss adjuvant trials with LMF ( + BCG) in N- and N + breast cancer patients. In: Salmon SE, editor. Adjuvant therapy of cancer IV. Orlando: Grune & Stratton; 1984; pp 261–70.
Falkson HC, Gray R, Wolberg WH, Gillchrist KW, Harris JE, Tormey DC, Falkson G. Adjuvant therapy of post-menopausal women with breast cancer: an ECOG phase III study. J Clin Oncol. 1989;8:599–607.
Conflict of interest
The authors declare that there are no actual or potential conflicts of interest in relation to this article.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Munzone, E., Colleoni, M. The role of maintenance strategies in breast cancer. memo 7, 152–156 (2014). https://doi.org/10.1007/s12254-014-0159-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12254-014-0159-3