The neoadjuvant systemic treatment of early breast cancer: a narrative review
Opher Globus, Inbal Greenhouse, Tal Sella, Einav Nili Gal‐Yam
Abstract
Background and Objective: The use of neoadjuvant systemic therapy for breast cancer is on the rise. Neoadjuvant treatment is equally effective as adjuvant treatment in preventing disease recurrence and death. The role of neoadjuvant treatment is unique for each breast cancer subtype. Neoadjuvant systemic therapy can improve surgical outcomes, provide valuable prognostic information and the response can guide post operative systemic treatment decisions. There is a growing need for all disciplines involved in the treatment of early breast cancer to discuss with patients the potential role of neoadjuvant treatment for their tumor subtype. To better guide the use of neoadjuvant systemic treatment we aim to detail its unique role in the three breast cancer subtypes with a focus on patient selection, surgical and oncological benefits, and future directions. Methods: We performed a search of the PubMed, Cochrane Review, and Clinical Trials.gov databases. We used the search terms “neoadjuvant chemotherapy” AND “breast cancer” and then conducted a thorough manual review of all bibliographies and relevant studies to identify additional potentially eligible studies. Key Content and Findings: To improve surgical outcomes, neoadjuvant therapy can be considered in all patients with operable breast cancer deemed to require adjuvant systemic treatment. For patients with human epidermal growth factor receptor-2 (HER-2) positive and triple negative breast cancer (TNBC) the presence of residual tumor can prompt a postoperative treatment change. For postmenopausal women with hormone receptor (HR) positive HER-2 negative tumors neoadjuvant endocrine treatment should be considered to help facilitate breast conservation. The use of preoperative gene expression profiles can be considered to decide whether to administer neoadjuvant chemotherapy (NACT) to patients with HR positive HER-2 negative tumors who require mastectomy or axillary lymph node dissection (ALND) upfront, however the role of these tests in the neoadjuvant setting is still unclear. Neoadjuvant therapy offers a unique window of opportunity to research additional biomarkers and systemic treatments. Conclusions: The role of neoadjuvant systemic therapy in early breast cancer is continuing to develop with the likelihood that its applications will continue to expand, further emphasizing the importance of multidisciplinary communication to provide the best outcomes for our patients.