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					The influence of systemic therapy on local recurrence following breast
conservation
There is clear evidence that chemotherapy alone does not reduce local recurrence
risk after BCS (Fisher et al., 1989, 1995). The data on the inXuence of systemic
therapy in addition to adjuvant RT on local recurrence is scarce. Retrospective
series are confounded by competing risks, with those selected for systemic therapy
more likely to develop distant disease before local recurrence and thus do not have
any local recurrence recorded. In addition, there is little data on those patients
with positive margins. The JCRT have found treatment with adjuvant
chemotherapy
to be associated with reduced risk of local failure following BCS/RT and RT
(Rose et al., 1989). However this paper does not include data on the status of the
surgical margin. Randomized data from NSABP B-13 indicates that in patients
with clear margins adjuvant chemotherapy does appear to reduce risk of ipsilateral
breast recurrence from 13.4% to 2.6% at 8 years (Fisher et al., 1996). It should be
noted, however, that a tumour bed boost was not used in this trial and the total
tumour bed dose was only 50 Gy.
For patients with involved margins, a multivariate analysis of the Stanford series
found the use of concurrent adjuvant chemotherapy to be independently associated
with better local control in those with margins that were not_2 mm clear.
In the group with margins positive, indeterminate or _2 mm clear local control
was 98% compared with 86% for those who did not receive chemotherapy (Smitt
et al., 1995). However, only 81 patients received chemotherapy and only 17
patients in the whole series of 289 women had more than focally positive margins.
Other series including patients with involved margins have not found use of
adjuvant chemotherapy to be associated with reduced local recurrence risk (Ryoo
et al., 1989; Kurtz et al., 1990a; Anscher et al., 1993; Borger et al., 1994; Spivack
et
al., 1994; Touboul et al., 1999).
In answer to our third question there is, therefore, insuYcient data available to
conclude that adjuvant chemotherapy can normalize the high risk of local
recurrence
following BCS/RT and RT associated with a more than focally positive
margin. Limited data suggests that use of adjuvant chemotherapy, at least if given
either concurrently, following the radiotherapy or in a sandwich fashion, may
further reduce risk of local recurrence in those with margins that are not more
than focally positive (Rose et al., 1989; Smitt et al., 1995; Fisher et al., 1996).

				
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