Neoadjuvant chemotherapy in women with invasive breast carcinoma: Conceptual basis and fundamental surgical issues

The use of neoadjuvant chemotherapy has its origins in the management of inoperable locally advanced breast cancer. Several important recent trials have now 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 (Table 5). If a patient is predicted to derive little advantage from chemotherapy in the adjuvant settings, it is equally unlikely that an advantage will be seen with a neoadjuvant approach. But 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 (Table 5). 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 patient outcomes. The most exciting aspect of the neoadjuvant-chemotherapy concept 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. By using neoadjuvant chemotherapy, we cannot only advance the field of breast cancer research but may also offer our individual patients an early chance for potentially curative therapy.