Neoadjuvant (Preoperative) Therapy in Breast Cancer

Locally advanced breast cancer (LABC) occurs at presentation in approximately 20-25% of breast cancer patients worldwide, but significantly less in countries with implemented screening programs. LABC refers to large operable (stage IIB, IIIA) or inoperable (stage IIIB, IIIC) tumors, including inflammatory breast cancer. Patients with ipsilateral supraclavicular lymph node involvement previously considered as having metastatic disease are now also included in the category of LABC (stage IIIC). Treatment of LABC has evolved within recent decades. For a long time, mastectomy remained the mainstay of treatment in this group of patients, but long-term local control was disappointingly low, with approximately 50% local recurrences (LR) and only 2% 5-year overall survival (OS). Implementation of postoperative radiotherapy increased local control and survival, but long-term outcomes remained unsat‐ isfactory (35-55% LR and 25-45% five-year OS). Incorporating systemic therapy (be it chemo‐ therapy, hormonal therapy or both) as an adjunct to surgery and/or radiotherapy further improved results. Currently, a combination of systemic therapy with locoregional treatment (surgery and/or radiotherapy) constitutes the standard of care in LABC patients since im‐ proving locoregional control is associated with better survival. In patients with stage III breast cancer treated with induction chemotherapy followed by surgery, radiotherapy or a combination thereof, the risk of loco regional recurrence is in the range of 20%. The use of induction systemic therapy results in tumor downstaging, and in selected LABC patients even allows for breast conserving surgery (BCS). However, the safety and efficacy of this ap‐ proach in LABC have not been verified in randomized studies. Even though locoregional management is an important component of multimodality treatment in patients with LABC, the pattern of local management and factors influencing local treatment strategy in this group are not well recognized (Sinacki et al., 2011). Neoadjuvant therapy is recommended not only for locally advanced and inflammatory breast cancer but also as an option for pri‐ mary operable disease without compromising long-term outcome (Untch et al., 2011).