Neoadjuvant chemotherapy came into vogue in the seventies and eighties, spurred on by the success of organ preservation strategies in cancers such as laryngeal and rectal cancer. It used to be thought there are two potential benefits of neoadjuvant chemotherapy: downstaging a breast tumor so lesser surgery can be performed – lumpectomy instead of mastectomy, and to potentially treat early occult metastatic disease and to improve survival. The first goal can be successfully accomplished as has has been corroborated by large randomized studies but the second goal has not been proven to be accomplished by neaodjuvant chemotnerapy. In fact, studies do not show a survival approach for a neaodjuvant versus and adjuvant chemotherapy approach. However, more recently, with improving chemotherapy effectiveness, it became appreciated that response is a predictive tool that can be used to plan farther chemotherapy. The NOAH (NeOAdjuvant Herceptin) study demonstrated that trastuzumab in addition to chemotherapy not only doubled pCR rates compared with chemotherapy alone, but it also reduced the relapse rate by half. The TECHNO (Taxol Epirubicin Cyclophosphamide(Drug information on cyclophosphamide) Herceptin Neoadjuvant) study reported a significantly more favorable disease-free and overall survival for patients who achieved a pCR compared with those who did not. On the other hand, a recent pooled analysis of the German neoadjuvant studies investigated whether the prognostic impact of pCR on long-term outcome is equal to that of neoadjuvant chemotherapy and trastuzumab for patients with hormone receptor (HR)-positive and -negative tumors. In fact, whereas in 298 patients with HER2-positive/HR-negative tumors, a pCR was associated with a significantly better disease-free survival compared with no pCR (hazard ratio [HR] = 8.7, P < .001), no difference in outcome was seen in 356 patients with HER2-positive/HR-positive tumors (HR = 1.2; P = .543). Even without having an explanation for this observation, information about pCR should be used with caution in these triple-positive tumors unless other data sets provide different evidence. However, NCCN still only recommends neoadjuvant therapy for women in stage IIA or higher and who desire breast preservation.
R. Connoly et al, A Multidisciplinary Approach to Neoadjuvant Therapy for Primary Operable Breast Cancer ONCOLOGY. Vol. 24 No. 2 2010
NCCN, Breast Cancer, BREAST-12
B . Sousa et al, Neoadjuvant treatment for HER-2-positive and triple-negative breast cancers Ann Oncol Sep 1, 2012:x237-x242
Alfredo Berruti et al, International Expert Consensus on Primary Systemic Therapy in the Management of Early Breast Cancer: Highlights of the Fourth Symposium on Primary Systemic Therapy in the Management of Operable Breast Cancer, Cremona, Italy (2010) J Natl Cancer Inst Monogr Oct 1, 2011:147-151
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