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  • Neoadjuvant chemotherapy and surgical options for women with locally advanced breast cancer

    In the past, the first step in treating newly diagnosed breast cancer was surgery. More recently, some women may have chemotherapy or other medical treatments before surgery.  This is called neoadjuvant therapy, and for some, it may be a preferred first step.  

    Chemotherapy seems to be just as effective whether it is given before or after surgery. 1 The main purpose of neoadjuvant chemotherapy is to increase the surgical options for women who would need a mastectomy if they had surgery first.  Neoadjuvant chemotherapy can sometimes shrink a large tumor enough so that a woman can have a lumpectomy instead of a mastectomy as her breast surgery.2,3  Studies have found between 16 and 26 percent of women who were candidates for mastectomy only were able to have a lumpectomy instead of a mastectomy after neoadjuvant chemotherapy.1,4,5 And, these studies found no difference in rates of breast cancer recurrence or survival in women who had neoadjuvant chemotherapy compared to women who had chemotherapy after surgery.1,4,5

    Neoadjuvant chemotherapy appears to be most effective in women with breast cancers that are grade III, hormone receptor-negative (ER- and/or PR-) or HER2/neu-positive (HER2+).  Women with HER2+ tumors are often given neoadjuvant trastuzumab (or other anti-HER2 therapy) in conjunction with neoadjuvant chemotherapy.2,3 With neoadjuvant chemotherapy, women may get all of their chemotherapy before surgery, or they may get some chemotherapy before surgery and the rest after surgery.  

    Some clinical trials are studying how to tailor neoadjuvant chemotherapy regimens to treat each woman’s breast cancer in the most effective way possible. For example, the I-SPY TRIAL 2 (Investigation of Serial Studies to Predict Your Therapeutic Response with Imaging And moLecular Analysis 2) is a novel study that is evaluating whether choosing neoadjuvant chemotherapy based upon biologic and molecular tumor characteristics improves outcomes for locally advanced breast cancer.6 (Learn more about the ISPY TRIAL 2 at http://www.ispy2.org/).  Findings from such studies can further our understanding of breast cancer and accelerate research. Women who are considering neoadjuvant chemotherapy should talk to their doctors to see if they may be eligible for a clinical trial. 

    Neoadjuvant therapy with hormone therapy is an option for women with hormone receptor-positive (ER+ and/or PR+) tumors.  However, it is used more often in older women who have relatively slow-growing tumors and might have trouble tolerating standard chemotherapy. 7

    For some women diagnosed with breast cancer, neoadjuvant chemotherapy can offer a chance to have a lumpectomy instead of a mastectomy. And, it is just as effective at treating breast cancer as chemotherapy after surgery. As with standard chemotherapy, research is ongoing to tailor neoadjuvant chemotherapy to best treat each woman’s breast cancer.  

    References                                                    

     

    1. Mieog JSD, van der Hage JA, van de Velde CJH. Neoadjuvant chemotherapy for operable breast cancer. Br J Surg. 94(10):1189-1200, 2007.  
    2. National Comprehensive Cancer Network. NCCN Clinical practices guidelines in oncology: Breast cancer. V.1.2010. http://www.nccn.org, 2010.  
    3. Kaufmann M, von Minckwitz G, Bear HD, et al. Recommendations from an international expert panel on the use of neoadjuvant (primary) systemic treatment of operable breast cancer: new perspectives 2006. Ann Oncol. 18(12):1927-34, 2007. 
    4. Wolmark N, Wang J, Mamounas E, et al. Preoperative chemotherapy in patients with operable breast cancer: nine-year results from National Surgical Adjuvant Breast and Bowel Project B-18. J Natl Cancer Inst Monogr. (30):96-102, 2001. 
    5. van der Hage JA, van de Velde CJH, Julien JP, et al. Preoperative chemotherapy in primary operable breast cancer: results from the European Organization for Research and Treatment of Cancer trial 10902. J Clin Oncol. 19(22):4224-37, 2001. 
    6. Biomarkers Consortium. I SPY 2 TRIAL (Investigation of Serial Studies to Predict Your Therapeutic Response with Imaging And moLecular Analysis 2) http://ispy2.org/, 2010. 
    7. Macaskill EJ, Dixon JM. Neoadjuvant use of endocrine therapy in breast cancer. Breast J. 13(3):243-50, 2007.