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This technical article discusses how an outpatient dye tracing processes sentinel lymph node biopsy. Box-plot for overall physical activity (MET-min·wk?1) of NHSBPS attendees, chemotherapy breast cancer patients and post-treatment breast cancer survivors. Percentage of participants in each physical activity category in the NHSBPS attendees, chemotherapy breast cancer patients and post-treatment breast cancer survivors.
Abstract Background: A lack of physical activity (PA) is a well-recognised risk factor in the development of breast cancer (BC) and evidence-base research on the impact of PA on BC survival is consolidating. Creative Commons Attribution License (CC BY) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Study populationThis study included 934 patients treated for metastatic breast cancer in 4 French cancer centres.
Statistical analysisThe duration of PFS is defined as the time from the beginning of first line chemotherapy treatment to the date of progressive disease or death. Progression free survival in first-line chemotherapy according to maintenance hormonal treatment status. Patient overall survival (OS) from the first line chemotherapy according to maintenance hormonal treatment status.
The search for prognostic and predictive factors that could influence the survival of patients treated for metastatic breast cancer has already been the subject of several studies.
Hortobagyi GN, Smith TL, Legha SS, Swenerton KD, Gehan EA, Tap HY, Buzdar AU, Blumenschei GR. SNLNB can provide lymph node mapping and outpatient excision for biopsy that may eliminate the need for the more invasive axillary lymph node dissection (ALND). However, evidence reveals that BC survivors have low levels of PA, suggesting the need of targeted interventions to enhance the PA behaviour of BC survivors. Physical Activity Levels in Women Attending Breast Screening, Receiving Chemotherapy and Post-Breast Cancer Treatment; A Cross-Sectional Study. MAINTENANCE HORMONAL TREATMENT IMPROVES PROGRESSION FREE SURVIVAL AFTER A FIRST LINE CHEMOTHERAPY IN PATIENTS WITH METASTATIC BREAST CANCER.
Its aim was to identify the factors which influence progression -free survival (PFS) and overall survival (OS) after the first line of chemotherapy in patients with positive tumour hormone receptor status.
World incidence was 1 050 000 cases during the year 2000 with a mortality rate of 373 000 [1]. Metastatic survival is defined as the time from the diagnosis of a metastasis to date of death or last follow-up. Figures 1 and 2 show the patients' PFS and OS from the first line of chemotherapy according to maintenance hormonal status. Unfortunately, there is lack of data from the UK about the PA behaviours of women at various stages of diagnosis and treatment of BC. The patients with early disease progression during first-line chemotherapy were not included.

Despite earlier diagnosis and improvement in adjuvant therapies some patients will present metastatic recurrence.
The hormonal treatment was tamoxifen (94), aromatase inhibitors (153), fulvestran (47) and megesterol acetate (14). The first category is related to the primary characteristics such as initial histological grade, hormonal receptor status. Therefore, the aim of the present study was to assess PA levels in women at different stages of BC pathway. In total, 560 patients who achieved a stable disease or a response to first-line chemotherapy were studied.
Because the present analysis focuses on the impact of hormonal treatment beyond first line chemotherapy, we included only patients with positive tumour hormonal receptor status established on the primary tumour.
The second category is linked to the metastatic characteristics: proliferation index reflected by the length of disease-free interval, type and number of metastatic sites involved.
The use of systemic therapies such as hormonal therapy, chemotherapy or new biological treatment is to reduce tumour masses, improve survival and preserve quality of life. When early disease progression occurs at first chemotherapy response assessment or within 3 months after the first cycle of chemotherapy in metastatic disease, one can consider that it is a failure of chemotherapy. Proportional hazards Cox model was used to identify which factors could influence the duration of PFS. On the other hand, some prognostic factors are linked to the treatments undertaken, stressing their impact on the natural outcome of the disease: type of hormonotherapy, type of chemotherapy, type of response achieved by treatment [5-12]. Whatever the initial efficacy of the treatment undertaken in metastatic setting, almost every patient will relapse.
It will not be relevant to search in this subset for factors which influence progression-free survival (PFS). The optimal duration of chemotherapy in patients who respond or have stable disease is not identified. To achieve this, the type of chemotherapy, the optimal duration of chemotherapy, the benefit of maintenance chemotherapy, the benefit of maintenance hormonal treatment are debatable. In total, 560 patients were studied to detect predictive factors to the duration of PFS after first-line chemotherapy and among those factors the impact of hormonal treatment given as maintenance therapy was analysed.
In 1987, Coates compared continuous chemotherapy (until progression or toxicity) versus intermittent chemotherapy (stop after three cycles and re-treatment at the time of disease progression) [13]. The present study was conducted to identify the factors which influence progression-free survival after the first line of chemotherapy.
Patients receiving continuous therapy had superior response rates, time to progression, and quality-of-life scores, but no improvement in survival was observed.
Among them, the present study focuses on the impact of hormonal maintenance therapy and constitutes the largest retrospective study on this subject.
A similar trial conducted by the Piedmont Oncology Association randomly assigned patients who had responding or stable disease after six cycles of CAF to either CMF or observation.

Time to progression was three times longer in patients under continuous therapy than for those with interrupted treatment (9.4 vs. Falkson et al randomly assigned 141 patients whose measurable disease showed a complete response after six cycles of CAF to receive either maintenance chemo-hormonal therapy or observation [15]. Time to disease progression was 19 months in patients who received the maintenance treatment versus 8 months in patients under observation but again the overall survival curves were similar in both groups. The French Epirubicin Study Group study, Gregory trial and Nooij study lead to the same results when they compared interrupted with prolonged chemotherapy regimen: continuous therapy tends to improve duration of response and progression-free survival without a significative impact on overall survival [16-18]. In total, a chemotherapy holiday is associated with a shorter time-to-progression but no adverse effect on survival. While in some studies, continuous chemotherapy seemed not to affect the quality of life [13, 18], several studies showed increased rates of adverse effects [14, 15, 17].
Definitively, the major limit to the use of prolonged regimens of chemotherapy is related to their toxicity, all the more so as they are cumulative (cardiac toxicity of anthracyclins, neurologic toxicity of taxanes, haematological cumulative toxicities with any chemotherapy…). The proposition to give hormonal treatment to prolong therapy in hormonal-positive tumors is another possible option.
In this phase-III trial, 90 patients with a disease controlled after 6 cycles of anthracyclin- and ifosfamide-containing regimen were randomised to receive or not maintenance therapy by medroxyprogesterone acetate. A longer median time-to-progression was reported among patients who were treated by maintenance hormonotherapy (4. Two retrospective studies found hormonal maintenance therapy as a significant factor among several prognostic factors for disease-free survival and overall survival after first line chemotherapy.
In 1997, Berruti et al analysed the factors influencing response rate and overall survival among 207 patients treated by epirubicin, followed or not by maintenance hormonotherapy [20]. The patients who received maintenance hormonotherapy survived significantly longer than those submitted to observation in uni- and multivariate analysis.
Montemurro et al studied 109 patients receiving high-dose chemotherapy and analysed the factors which improve its efficacy [21].
The maintenance hormonal treatment improved the progression-free survival from 19, 2 to 31, 1 months (p = 0, 022).The influence of the type of response achieved by first line chemotherapy is well established [11].
This benefit was observed independently of the type of response achieved by first line chemotherapy.
We cannot know whether we are observing natural history or impacting it in such a trial.Nevertheless the major impact obtained by maintenance hormonal treatment after the first line chemotherapy might indicate that this strategy should be recommended in patients with an ER or PgR positive tumour. Based on the amplitude of the benefit observed, it may be ethically debatable to conduct a prospective randomized study. Moreover, randomized trials which assess the benefit of a new chemotherapy regimen should allow the possibility to give maintenance hormonal treatment.

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