Traditionally, we have performed surgery first, followed by chemotherapy for breast cancer. Neoadjuvant treatment was limited to patients with contraindications to surgery. However, according to the latest ASCO guidelines (1), only patients with T1aN0 and T1bN0 HER2-positive disease should not be routinely offered neoadjuvant therapy. Should we now reverse our therapeutic approach?
1. Korde, L. A., Somerfield, M. R., Carey, L. A., Crews, J. R., Denduluri, N., Hwang, E. S., Khan, S. A., Loibl, S., Morris, E. A., Perez, A., Regan, M. M., Spears, P. A., Sudheendra, P. K., Symmans, W. F., Yung, R. L., Harvey, B. E., & Hershman, D. L. (2021). Neoadjuvant chemotherapy, endocrine therapy, and targeted therapy for breast cancer: ASCO Guideline. Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 39(13), 1485-1505. https://doi.org/10.1200/JCO.20.03399
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Neoadjuvant therapy has become more popular in recent years as there are several benefits including tumour shrinkage so for example some people will only need breast conserving surgery instead of mastectomy. However, you also have to think about it from a patient´s perspective: they have a tumour and they want to get rid of it as quickly as possible - they don´t want to wait and be given drugs first. This is why some patients refuse neoadjuvant therapy. A few meta-analyses have now been performed comparing adjuvant therapy alone with neoadjuvant, and mostly there doesn´t seem to be a massive difference in DFS or OS overall, although it depends on what studies were included and what factors were taken into consideration.
The decision is based on the stage, and the tumour classification. For T1N0M0 tumour, neoadjuvant systemic therapy is only applied to HER2 over-expression or triple negative disease. Because if there is a residual tumour post-surgically for these type of tumours, the treatment plan will be changed for those patients (HER2 & Triple negative), and they would be considered high-risk patients. For luminal breast cancer (hormonal positive HER2 negative) it’s different. Still you can go for surgery first as long as there’s no contraindications, such as T3 or more tumours or relatively small breast for instance.
In our oncological multidisciplinary meeting, the indications of neoadjuvant chemotherapy are: over expression of Her2 neu, triple negative biotype of Saint gallen colleage. Other indications is the desire to perform a breast conservative surgery and N2 status to facilitate the axillary lymph node dissection. But this approach need a logistical means as marquage of the tumor or any suspicious node, before the beginning of chemotherapy.
Yes, neoadjuvant systemic therapy is now considered standard practice for following subsets of breast cancer patients:
1. Inflammatory breast cancer
2. cT4 disease
3. cN2 or cN3 disease
4. Operable breast cancer with triple negative or HER2 +ve molecular subtype with cT2/N+ or higher disease stage
5. Large primary tumor relative to breast size, or when cN+ likely to become cN0 with neoadjuvant systemic therapy to facilitate breast conservation
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