Neoadjuvant systemic therapy for breast cancer: Response, subsequent treatment, and prognosis
- William M Sikov, MD, FACP
William M Sikov, MD, FACP
- Associate Professor of Medicine
- Warren Alpert Medical School of Brown University
- Section Editors
- Julie R Gralow, MD
Julie R Gralow, MD
- Section Editor — Breast Cancer
- Department of Medical Oncology
- University of Washington
- Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
- Section Editor — Breast Surgery
- Associate Professor, Department of Surgery
- Yale University School of Medicine
Neoadjuvant systemic therapy is the accepted approach for women with locally advanced breast cancer for whom immediate surgery is not feasible. It is also an option for women with operable breast cancer who desire an attempt at breast conservation but in whom mastectomy is indicated based on tumor size and location [1-4].
Response assessment during and following neoadjuvant therapy, implications for surgical management of the breast and axillary nodes, pathologic evaluation of the surgical specimen, influence of pathologic findings on prognosis, and options for adjuvant therapy following neoadjuvant treatment will be reviewed here. The rationale for neoadjuvant therapy, patient selection, pre-treatment evaluation, and treatment options are discussed separately. (See "Neoadjuvant therapy for breast cancer: Rationale, pretreatment evaluation, and therapeutic options".)
Clinical response assessment during treatment — Patients undergoing neoadjuvant systemic therapy for breast cancer should undergo periodic clinical evaluations during treatment to assess response and ensure that their tumor is not progressing.
There are no formal guidelines regarding the ideal assessment strategy during neoadjuvant treatment. Our approach is as follows:
●For patients on neoadjuvant chemotherapy (NACT), we perform a clinical examination every two to four weeks (ie, prior to each cycle of treatment). This should include evaluation of the affected breast and ipsilateral axilla.
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- TREATMENT EVALUATION
- Clinical response assessment during treatment
- Clinical response assessment after treatment
- DEFINITIVE SURGICAL TREATMENT
- Breast surgery
- Nodal evaluation
- PATHOLOGIC ASSESSMENT
- Defining efficacy
- - Chemotherapy
- - Endocrine therapy
- Re-testing of pathologic markers
- ADJUVANT THERAPY
- Radiation therapy
- HER2-directed treatment
- Endocrine therapy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS