Systematic reviews of chemotherapy and endocrine therapy in metastatic breast cancer

Metastatic breast cancer is incurable but often responsive to treatment. There is little evidence-based consenus on when to use which treatments, in what combination and for how long. Systematic reviews were performed on 12 prospectively defined, clinically relevant research questions to support the development of evidence-based clinical practice guidelines. A comprehensive search of Medline from 1966 to 1996 identifed over 1800 controlled trials. Eligibility and data extraction were performed independently by two blinded reviewers. Trial results were summarised by ratios of median survivals (RMS) and P -values for survival curve comparisons with meta-analysis by weighted combination of these statistics. Sixty-five publications reporting 97 treatment comparisons were included. There was moderate evidence that more rather than fewer cycles of chemotherapy improved survival (RMS:1.23, P -0.01). The evidence did not support: higher rather than lower doses of chemotherapy (or of endocrine therapy); any one class of endocrine agent over all others; multiple endocrine agents over a single agent; or, combined chemotherapy and endocrine therapy over either single modality. Only six trials assessed quality of life revealing better quality of life with more rather than fewer cycles of chemotherapy and with standard rather than lower doses of chemotherapy. These systematic reviews reveal counterintuitive evidence useful to everyday practice, in particular that more rather than fewer cycles of chemotherapy lead to better quality of life and longer survival.