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Neoadjuvant Therapy

Neoadjuvant therapy is systemic therapy given BEFORE surgery. There are two types of neoadjuvant therapy: chemotherapy and endocrine (anti-estrogen) therapy. The purpose of preoperative therapy is to potenially downstage the tumor, optimize surgical outcomes, and reduce the risk of breast cancer recurrence.

When diagnosed with breast cancer, understandably the first reaction is: get the cancer out. There are times, however, when initiating systemic therapy (chemotherapy or endocrine therapy) may actually be a more appropriate initial treatment. It is very important to know the options. Neoadjuvant therapy may be best.

Who Is Appropriate For Neoadjuvant Therapy?

 

Neoadjuvant therapy is typically used in the face of high risk breast cancers.  High risk breast cancers are those with a high rate of distant spread and mortality with the use of modern local and systemic therapies.

 

 

Katherine Trial HER2 pos

Neoadjuvant systmic therapy may be considered for any patient for whom adjuvant systemic therapy is indicated.  The use of neoajduvant therapy is a multidisciplinary decision – specific goals should be outlined.

 

Potential long term benefits

  • Assess effectiveness of therapy
  • Allow for less surgery/treatment
    • Downsize Tumor
    • Downstage Axilla
    • Lumpectomy instead of Mastectomy
  • Allow for genetic testing results that may affect surgical decision
  • Initiates most “important” treatment (systemic) first
  • Determine who may need additional systemic therapy (see below)

Potential candidates for neoadjuvant therapy

  • Larger tumors in a smaller breast
  • Node positive at presentation
  • HER2 postive tumors
  • ‘Triple Negative’ tumors

Who is inappropriate for neoadjuvant therapy

  • Patients who present with a definitive indication for chemotherapy
  • Patients motivated to preserve their breast and avoid mastectomy
  • Patients with a ‘need’ to delay surgery

The latest: Katherine Trial

  • Study of 1,486 patients with HER2 positive cancers who had residual disease found on surgial pathology
  • Those with residual disease were randomized to traditional treatment or T-DM1 (trastuzumab emtansine)
  • Risk of recurrence or death was 50% lower in T-DM1 group