When and how do I use neoadjuvant chemotherapy for breast cancer?

OPINION STATEMENT: Systemic neoadjuvant chemotherapy is utilized along with surgery and radiotherapy for the management of patients with locally advanced breast cancer. The backbone of current chemotherapy regimens include anthracyclines and taxanes given either sequentially or concurrently for up to 8 cycles. Neoadjuvant treatment benefits include in vivo assessment of response to treatment with reduction in the extent of primary and regional metastases. Neoadjuvant chemotherapy for operable breast cancer is used in women who desire breast conservation surgery who are not candidates for such treatment at the time of the diagnosis. The use of neoadjuvant treatment in patients, who present with operable breast cancer, shows equivalent survival outcome compared with adjuvant breast cancer treatment. Several prospective studies have evaluated the role of trastuzumab in combination with neoadjuvant chemotherapy in patients with Her2-positive disease. The addition of trastuzumab to neoadjuvant chemotherapy is associated with improvement of the complete clinical and pathological complete response to therapy and significantly improved event-free survival and overall survival. Dual Her2 blockade is emerging as a new approach to improve pathological complete response rates and therefore survival. To date, in triple-negative breast cancer, there are no predictive markers to identify potential treatment targets. Triple-negative patients who achieve a pathological complete response have more favorable outcome compared with those with residual disease following neoadjuvant treatment. The choice of optimal chemotherapy regimen and the duration of treatment have been studied extensively in the neoadjuvant setting. No consensus has been developed thus far. Following work done with anthracycline and CMF treatments in neoadjuvant chemotherapy, recent studies in locally advanced breast cancer focus on the addition of new and target agents. All of these trials are based on well-established regimes used in the adjuvant setting. Successful use of neoadjuvant chemotherapy requires a coordinated multidisciplinary approach.