Integration of neoadjuvant chemotherapy and surgery in the treatment of patients with breast carcinoma

The use of neoadjuvant chemotherapy has its origins in the management of inoperable locally advanced breast cancer. Several important recent trials have demonstrated that neoadjuvant chemotherapy can increase the resectability rate of primary breast cancer, can allow more patients to successfully undergo breast conservation surgery, and does not confer a survival disadvantage compared with standard, adjuvant chemotherapy. These findings indicate that neoadjuvant chemotherapy is the preferred initial treatment for patients with locally advanced or inflammatory breast carcinoma. Neoadjuvant chemotherapy may also be appropriate in some women with earlier-stage disease. If a patient is predicted to derive little advantage from chemotherapy in the adjuvant setting, it is equally unlikely that an advantage will be seen with neoadjuvant chemotherapy. However, if a woman desires conservative breast surgery and her primary tumor size precludes this approach, neoadjuvant chemotherapy should be offered regardless of clinical disease stage. Careful initial patient assessment and close monitoring of response to neoadjuvant chemotherapy through physical assessment and imaging studies of the primary tumor and nodal metastases are critical in planning breast conservation surgery and have been shown to minimize the risk of local-regional recurrence. The clinical and pathologic response of the primary breast tumor to neoadjuvant chemotherapy appears to be a surrogate marker for the response of occult micrometastases and therefore patient outcome. The most exciting aspect of neoadjuvant chemotherapy in the multidisciplinary management of breast cancer is that neoadjuvant chemotherapy allows for the potential rapid evaluation of promising novel cancer therapies in patients who are predicted to do poorly on the basis of their minimal response to standard cytotoxic regimens. This remains a fertile area for ongoing and future trials of neoadjuvant chemotherapy. By using neoadjuvant chemotherapy, not only can we advance the field of breast cancer research but we may also offer our individual patients an early chance for potentially curative therapy.