Re: Neoadjuvant versus adjuvant systemic treatment in breast cancer: a meta-analysis.

The meta-analysis by Mauri et al. ( 1 ) from nine neoadjuvant trials is important given the confl icting evidence from published studies. However, we would like to make two points that arise from this analysis. First, to establish the benefi t of neoadjuvant therapy over adjuvant therapy, treatment regimens in the two arms should be identical in terms of drugs used and in terms of scheduling. Mauri et al. acknowledge that postoperative chemotherapy was administered to patients randomly assigned to the neoadjuvant arm in approximately half of studies ( 2 – 5 ) , representing approximately a quarter of the dataset pooled (986 patients). This sizeable proportion may have biased results in favor of adjuvant therapy. Ideally, these studies should have been excluded from pooling, but this exclusion would have resulted in pooled data available on only 2960 patients, of which a few more than half (1523 patients) would have been from a single study [National Surgical Adjuvant Breast and Bowel Project B-18 ( 6 ) ]. Data from sensitivity analysis with and without the four studies ( 2 – 5 ) in which patients received both adjuvant and neoadjuvant chemotherapy should be obtained to assess their potential impact on the primary outcomes assessed and the robustness of the authors’ conclusions. Second, Mauri et al. focused on the inability of neoadjuvant chemotherapy to improve any of the primary outcomes assessed, compared with adjuvant therapy, but this analysis should be recognized as a success. Data presented show the clear superiority of neoadjuvant therapy in breastconserving surgery, an important issue for many patients. Furthermore, the ability to obtain tumor tissue by core biopsy before and during neoadjuvant therapy, in addition to the surgical specimen itself, offers a major opportunity for translational research.