• Breast Cancer; Preoperative; Systemic Therapy

Iatrakis G (2024) Preoperative Therapy for Breast Cancer. J Prev Med Healthc 6(1): 1030.

Preoperative therapy, also known as neoadjuvant therapy (a “misleading” terminology, broadly accepted, reminding “new adjuvant”?), is the term used to describe the systemic treatment of breast cancer before final surgical surgery. The purpose of preoperative therapy is to downstage the tumour, to increase the likelihood of facilitating cosmetically acceptable operation and to estimate the reaction of the tumor to a particular regimen [1]. As such, patients who were candidates for mastectomy may become eligible for a conservative approach. Furthermore, patients with node-positive disease may become candidates for limited axillary surgery including sentinel node removal. As an example, in nodal involvement, an anthracycline based regimen increases the chance of a limited axillary surgery. Additionally, the “reaction” of the tumor provides useful information regarding response to this particular treatment and achieving a pathologic complete response at surgery is a good prognostic factor. On the other hand, the purpose of adjuvant therapy is to reduce the risk of distant metastasis. Nevertheless, preoperative treatment does not improve overall or disease-free survival and, due to the increased number of conserving surgeries, has a greater probability of local recurrence, compared with the same adjuvant therapy.

Choosing Between Chemotherapy and Endocrine

Therapy Although there is growing interest in extending the function of preoperative endocrine therapy in specific patient subgroups, preoperative treatment has traditionally taken the form of chemotherapy. Chemotherapy is the norm for patients with triple-negative illness undergoing neoadjuvant treatment. In early-stage, hormone receptor-positive, HER2-negative cases, preoperative endocrine therapy has consistently shown longterm clinical benefits [3]. Thus, preoperative endocrine therapy is an option that could have optimal results without the side-effects of chemotherapy. However, even in patients with the above characteristics, chemotherapy is the standard preoperative approach in patients with locally advanced breast cancer.

Examples of Preoperative Chemotherapy

Chemotherapeutics that can be included in preoperative therapy are doxorubicin (anthracycline) and cyclophosphamide followed by paclitaxel or docetaxel. In an informed consent approach, the patient should be informed about the dose’s schedules of neoadjuvant therapy. As an example, docetaxel (taxane) is given every 3 weeks and paclitaxel (taxane) is administered weekly.

Furthermore, Anthracycline and Cyclophosphamide (AC) can be given every two or every three weeks, without a proven superiority between the two approaches. However, anthracycline (doxorubicin) and cyclophosphamide every three weeks followed by docetaxel every three weeks was more effective than anthracycline and docetaxel every two weeks as preoperative treatment for patients with operable breast cancer [2]. Regimens including an anthracycline increase the chance of a positive response in node-positive breast cancers. However, in cases of a contraindication to anthracyclines (serious cardiac dysfunction), doxorubicin can be omitted. As an example, cyclophosphamide and docetaxel can be given without doxorubicin in the preoperative setting of the previous cases. Furthermore, in cases with a better prognosis, like those with hormone receptor positives and HER2 negative cases, the omission of an anthracycline is an option that could be discussed in the planning of preoperative therapy. On the other hand, in high-risk cases including those with nodepositive cancer and triple negative cases, an anthracycline-based regimen is necessary in most cases. Moreover, the addition of carboplatin in advanced stages (eg, Stage III) can be discussed in a multidisciplinary approach. In triple negative cases, the addition of pembrolizumab is necessary in most cases. However, considering that the latter regimen is included in immunotherapy approaches, an underlying autoimmune disorder consists a major contraindication to this kind of treatment.

Patients with clinical stage III, or IIB (T3N0), HER2 positive should take preoperative therapy consisting of transtuzumab (IV or subcutaneously in combination with pertuzumab), pertuzumab (IV or subcutaneously in combination with transtuzumab), docetaxel, and carboplatin in 3 week intervals for 6 cycles.

Furthermore, the patient should be informed for any side-effects of the treatment and any alternative approaches. As an example, for patients with an initial life-threatening hypersensitivity reaction to a taxane, it is necessary to switch to an alternative agent.

Patient Monitoring During Preoperative Treatment

A history related to symptoms and a clinical examination is necessary each month in patients receiving preoperative treatment. Imaging studies (including magnetic resonance imaging, ultrasound, computed tomography or PET-scan) are not necessary in most cases and should only be performed if disease progression is suspected based on symptoms or physical examination.

1. Kodali A, Gadi VK. Preoperative Systemic Therapy for Breast Cancer. Surg Clin North Am. 2023; 103(1): 201-217.

2. von Minckwitz G, Raab G, Caputo A, Schütte M, Hilfrich J, Blohmer JU, et al. Doxorubicin with cyclophosphamide followed by docetaxel every 21 days compared with doxorubicin and docetaxel every 14 days as preoperative treatment in operable breast cancer: the GEPARDUO study of the German Breast Group. Clin Oncol. 2005; 23(12): 2676-2685.

3. Muñoz M, Prat A. Implementing preoperative endocrine therapy in breast cancer. Lancet Oncol. 2020; 21(11): 1390-1392.