The present dilemma of adjuvant chemotherapy: acceptance and risks versus benefits.

The acceptance of ACT has been very rapid since 1974 although earlier studies by Nissen-Meyer and the NSABP in the 1960's originally suggested the effectiveness of modest short-term chemotherapy [16, 17]. The current practice is to administer combination chemotherapy for at least 6 months in all node-positive women. The survival benefits are clearly established only for women who are premenopausal and who have fewer than three positive nodes. Trials in other groups of patients are highly suggestive but have lacked some or all of the rigorous standards of the randomized clinical trial. The reasons for this widespread acceptance of ACT are not clear, but both patients and physicians are able to appreciate the concepts and bear the costs in terms of money as well as toxicity. The risks of ACT are mainly short term and reversible. Long-term consequences are not so readily apparent as yet. The benefits of improved survival will only be appreciated as more time passes, either through the long-term analyses of the current trials or the overwhelming success of a new strategy. Then all the past arguments about one therapy or another will become irrelevant. At that point this new miracle treatment will be so good that none will ask whether CMF is better than surgery alone. In essence, the old standard has become the control.