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Recommendation
Adjuvant chemotherapy – Timing and sequencing
Ideally adjuvant chemotherapy should commence within 4 to 6 weeks of the date of surgery. If adjuvant chemotherapy and radiation therapy are indicated, the chemotherapy should be given first.
Adjuvant chemotherapy should commence within 4 weeks of the date of surgery. Patients with high-risk disease (triple negative, HER2+ or high-grade disease) appear most likely to derive benefit from quicker access to chemotherapy and should commence as soon as possible
Adjuvant systemic treatment should preferably start within 3-6 weeks after surgery (Level of evidence – I)
If adjuvant chemotherapy and radiotherapy are indicated, the chemotherapy should be given first
Body of evidence provides some support for recommendation(s), but care should be taken in its application
The desirable effects of an intervention clearly outweigh the undesirable effects (the intervention is to be put into practice), or the undesirable effects of an intervention clearly outweigh the desirable effects (the intervention is not to be put into practice)
Strong evidence for efficacy with a substantial clinical benefit, strongly recommended
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How this guidance was developed
This recommendation was adapted from three source recommendations. The period within which adjuvant chemotherapy should commence is based on a recommendation in the RACP 2017 guidelines (Australia) which was based on a systematic review of the evidence conducted in April 2014 and was graded ‘C' (using NHMRC methods) by the source guideline authors, and a recommendation in the ESMO 2019 guidelines (evidence review methods not stated), graded ‘strong’ (using ESMO methods. These two source recommendations were merged and adapted by removing the aspect of care related to patients with high-risk disease.
The second sentence from this recommendation was adopted from the KCE 2013 guidelines (Belgium). The KCE source recommendation was based on a systematic review of the evidence conducted to January 2010 and was graded ‘strong’ (using GRADE methods) by the source guideline authors. Further development of the recommendation included specification of the timing as ‘4-6 weeks from the date of surgery’. In accordance with this timing, a more recent recommendation by ESMO (2019) graded ('A') has indicated that adjuvant treatment should preferably start within 3-6 weeks after surgery.
Adjuvant chemotherapy – Timing and sequencing
Recommendation
Ideally adjuvant chemotherapy should commence within 4 to 6 weeks of the date of surgery. If adjuvant chemotherapy and radiation therapy are indicated, the chemotherapy should be given first.
Principles in action
Safe and quality care
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Multidisciplinary care
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Care coordination
Useful Links
This recommendation was adapted from three source recommendations. The period within which adjuvant chemotherapy should commence is based on a recommendation in the RACP 2017 guidelines (Australia) which was based on a systematic review of the evidence conducted in April 2014 and was graded ‘C' (using NHMRC methods) by the source guideline authors, and a recommendation in the ESMO 2019 guidelines (evidence review methods not stated), graded ‘strong’ (using ESMO methods. These two source recommendations were merged and adapted by removing the aspect of care related to patients with high-risk disease.
The second sentence from this recommendation was adopted from the KCE 2013 guidelines (Belgium). The KCE source recommendation was based on a systematic review of the evidence conducted to January 2010 and was graded ‘strong’ (using GRADE methods) by the source guideline authors. Further development of the recommendation included specification of the timing as ‘4-6 weeks from the date of surgery’. In accordance with this timing, a more recent recommendation by ESMO (2019) graded ('A') has indicated that adjuvant treatment should preferably start within 3-6 weeks after surgery.