Preoperative/neoadjuvant medical therapy for early breast cancer

Preoperative (neoadjuvant) medical therapy has emerged over the past decade as a new approach for the treatment of early breast cancer. Results show it has high activity, but survival is no better than with conventional adjuvant treatment. The need for mastectomy is reduced but not abolished; in some studies this effect is associated with a small increase in risk of local recurrence, but without any detriment to survival. Predictive factors for improved outcome include clinical response, and especially pathological complete remissions. However, persisting pathological axillary node involvement is associated with poor outcome. Biological changes in apoptosis or proliferation pathways may prove to be more sensitive surrogate markers than clinical or pathological responses for assessing treatment outcome. The main long-term aim of preoperative medical treatment must be to establish such surrogate predictive markers. This would lead to individualised treatment for each patient, and would allow much more rapid assessment of new drugs than is currently possible with adjuvant therapy trials.