Neoadjuvant therapy for newly diagnosed hormone-positive breast cancer
- Aditya Bardia, MD, MPH
Aditya Bardia, MD, MPH
- Attending Physician
- Massachusetts General Hospital Cancer Center
- Assistant Professor of Medicine
- Harvard Medical School
- J Michael Dixon, MD
J Michael Dixon, MD
- Professor of Surgery and Consultant Surgeon
- Edinburgh University
Hormone receptor (HR)-positive breast cancer is the most common subtype of breast cancer, comprising 70 to 80 percent of all breast cancers.
Neoadjuvant or presurgical therapy refers to administration of therapy before surgery and has been used for over two decades to downstage locally advanced and unresectable primary breast cancers to make them operable [1,2]. Several studies, including the landmark National Surgical Adjuvant Breast and Bowel Project (NSABP) 18 trial, have demonstrated that administration of the same chemotherapy in the neoadjuvant versus adjuvant setting is associated with similar outcomes [3-5]. While traditionally neoadjuvant chemotherapy has been used to downstage locally advanced and unresectable primary breast cancers, a number of studies have highlighted the role of neoadjuvant endocrine therapy as an alternative option to chemotherapy in HR-positive tumors, particularly for postmenopausal women.
In this topic, we will focus on the approaches and data specific to HR-positive breast cancers. For the purpose of this discussion, the anatomic staging system set forth in the eighth edition of the American Joint Committee on Cancer Staging Manual is used (table 1); however, it is recognized that the studies cited may have used previous editions of the staging system, which is a limitation of existing data. (See "Tumor, Node, Metastasis (TNM) staging classification for breast cancer".)
The rationale and general approach to neoadjuvant treatment is discussed elsewhere. (See "General principles of neoadjuvant therapy for breast cancer".)
GOALS AND INDICATIONS
The goal of neoadjuvant therapy is to improve surgical outcomes by causing tumor shrinkage and to provide effective systemic therapy. It is appropriate for many patients with locally advanced breast cancer (regardless of subtype), generally defined as stage III cancers, as well as the subset of IIB cancers with T3 disease. For those with stage II disease, either primary surgery or neoadjuvant therapy may be used, the latter being appropriate, for example, for the patient who desires breast-conserving surgery (BCS) and is not a candidate due to a high tumor size: breast size ratio. It should be recognized, however, that HR-positive, human epidermal growth factor receptor 2 (HER2)-negative cancers are less likely to respond to neoadjuvant chemotherapy than other biologic subtypes [6-10]. For patients with stage I, estrogen receptor (ER)-positive, HER2-negative disease, we generally prefer primary surgery rather than neoadjuvant therapy given that such patients are likely to have good surgical outcomes.
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- GOALS AND INDICATIONS
- THERAPEUTIC OPTIONS
- Selection of treatment
- - Premenopausal women
- - Postmenopausal women
- Medically fit
- Medically frail
- - HER2-positive cancers
- Neoadjuvant chemotherapy
- - Efficacy
- - Prognostic features
- Neoadjuvant endocrine therapy
- - Efficacy
- Premenopausal women
- Postmenopausal women
- - Choice of endocrine therapy
- - Duration of endocrine treatment
- - Investigational options
- TREATMENT AFTER NEOADJUVANT THERAPY
- Assessment of response
- Adjuvant treatment
- SUMMARY AND RECOMMENDATIONS