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Rethinking neoadjuvant chemotherapy for breast cancer

BMJ 2018; 360 doi: (Published 11 January 2018) Cite this as: BMJ 2018;360:j5913
  1. Jayant S Vaidya, professor of surgery and oncology and consultant breast cancer surgeon12,
  2. Samuele Massarut, director of oncological breast surgery3,
  3. Hrisheekesh J Vaidya, medical student4,
  4. Emma C Alexander, medical student5,
  5. Thomas Richards, consultant in clinical oncology6,
  6. Jochem A Caris, senior breast surgery registrar7 ,
  7. Bhawna Sirohi, consultant medical oncologist8,
  8. Jeffrey S Tobias, professor of oncology and honorary consultant clinical oncologist6
  1. 1Division of Surgery and Interventional Science, University College London, London, UK
  2. 2Department of Surgery, Whittington Hospital, Royal Free Hospital and University College London Hospital, London, UK
  3. 3Centro di Riferimento Oncologico di Aviano, Aviano, Italy
  4. 4Imperial College School of Medicine, Imperial College London, London, UK
  5. 5GKT School of Medical Education, King’s College London, London, UK
  6. 6Department of Clinical Oncology, University College London Hospital, London, UK
  7. 7Department of Surgery, Whittington Hospital, London, UK
  8. 8Department of Medical Oncology, Barts Health NHS Trust, London, UK
  9. Correspondence to: J Vaidya

As evidence questioning the rationale behind neoadjuvant chemotherapy in breast cancer grows, Jayant Vaidya and colleagues say we must reconsider the current treatment options

Key messages

  • Neoadjuvant chemotherapy is being increasingly used for breast cancer despite higher rates of local recurrence and no evidence of survival benefit, mainly because of the immediate and dramatic pathological responses seen with newer drugs

  • The increased pathological response of the primary tumour does not translate into a survival benefit even when given in the adjuvant setting, challenging the paradigm of “window of opportunity” studies

  • We must acknowledge that neoadjuvant chemotherapy may not be beneficial to patients

  • We should consider reducing the widespread use of neoadjuvant chemotherapy

Breast cancer is the most common cancer in women worldwide. In 2014, 55 000 women in the UK were given the diagnosis of breast cancer, and 11 000 died.1 Early breast cancer is traditionally treated with surgery, plus radiotherapy and adjuvant systemic therapy as required.

Neoadjuvant chemotherapy for breast cancer is a new strategy that was introduced towards the end of the 20th century with the aim of reducing tumour size. It has four main rationales. Firstly, it should render an otherwise inoperable tumour operable or, secondly, allow more conservative surgery. Thirdly, starting systemic treatment preoperatively was hoped to lead to improved overall survival in patients with locally advanced cancers, who are at high risk of having distant disease. Finally, unlike adjuvant chemotherapy given in the absence of any measurable disease, neoadjuvant chemotherapy gives us the opportunity to observe the tumour shrink both palpably and on imaging, enabling a rapid assessment of clinical response. This could help test responses in vivo to new drug regimens, which could then be used as adjuvant therapies, in so called window of opportunity studies.

A survey of multidisciplinary teams in Australia, Germany, Italy, the UK, …

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