Neoadjuvant or adjuvant chemotherapy in early breast cancer?

ABSTRACT

Introduction

The administration of chemotherapy before (neoadjuvant), rather than after surgery (adjuvant) in early breast cancer has been considered an optional strategy for patients with operable breast cancer. We reviewed this concept considering recent results in the field.

Areas covered

Herein, the authors cover neoadjuvant chemotherapy with or without biologics in triple-negative and HER2-positive operable breast cancer with a focus on rates of complete pathological remission (pCR) in the breast and axilla. The impact of the CREATE X and KATERINE randomized clinical trials of post-surgical treatments in patients with residual disease after neoadjuvant chemotherapy is also discussed.

Expert opinion

The CREATE X and KATERINE clinical trials show for the first time and with methodological strengths that, in TNBC and HER2-positive breast cancer patients, post-surgical capecitabine and T-DM1, respectively, can improve prognosis when the disease persists after neoadjuvant chemotherapy. Therefore, the role of pCR as a treatment endpoint and a guide for further treatment decisions is now demonstrated. On account of these results, neoadjuvant chemotherapy becomes not an option, but rather the preferred treatment strategy for more and more TNBC and HER2-positive breast cancer patients in clinical practice.

KEYWORDS:

• Breast Cancer
• disease-free survival
• HER2-positive breast cancer
• neoadjuvant chemotherapy
• overall survival
• pathological complete remission
• prognosis
• triple-negative breast cancer

Article highlights

• The administration of systemic therapy before surgery has evolved from a contingency in patients with inoperable breast cancer 8BC), to an option in those with operable disease.

• Some of the advantages postulated in the early days of neoadjuvant chemotherapy, like a possible benefit in DFS and OS, did not hold. However, patients could benefit from tumour downstaging and less extensive surgery.

• Failing to achieve complete eradication of the disease from the breast and axilla (pCR) with neoadjuvant chemotherapy provides a negative prognostic signal, which is particularly strong in triple-negative (TNBC) and HER2 positive BC.

• Two recently randomised trials confirmed that the prognosis of patients failing to achieve pCR after neoadjuvant chemotherapy is improved by the administration of capecitabine (TNBC) and T-DM1 (HER2-positive BC).

• Based on these results, which provide strong momentum for further research in the field, neoadjuvant therapy becomes a preferred, rather than an option compared with adjuvant therapy, in patients whose tumour belongs to these breast cancer subtypes.

This box summarizes key points contained in the article.

Declaration of interest

F Montemurro reports personal fees and travel grants from Roche, and personal fees from Novartis, Eli Lilly and Company, Pfizer, and Daiichi Sankyo. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

F Montemurro is supported by AIRC IG 2016, project code 19174 and by the Ministero della Salute, Ricerca Corrente 2019.