Management of patients with locally advanced breast cancer

Increased breast health awareness has led to earlier stage distribution among breast cancer patients in the United States; however, locally advanced tumors remain a major source of morbidity and mortality. Early attempts to control this high-risk pattern of disease with surgery or radiation alone were met with disappointingly high rates of treatment failure in locoregional and distant sites. Multimodality strategies represent a major advance in management of these difficult cancers. The current standard of care is neoadjuvant chemotherapy to improve operability, followed by breast and axillary surgery (including lumpectomy for appropriately selected patients). Following surgery, decisions regarding the need for additional chemotherapy with or without locoregional irradiation are made based on stage at presentation, response to systemic therapy, and surgical-pathology findings. Recommendations for adjuvant endocrine therapy are based on hormone receptor status. Studies of these tumors have confirmed that primary response to induction therapy is an excellent surrogate marker of success in eradicating micrometastases, as patients experiencing a complete pathologic response have a statistically significant survival advantage. Ongoing investigations of locally advanced breast cancer include studies of systemic chemotherapy with or without neoadjuvant endocrine regimens that increase the complete pathologic response rate, and correlation with outcome; integration of lymphatic mapping and sentinel lymph node biopsy into clinical trials; and defining the optimal extent of locoregional irradiation in patients who experience a strong response to neoadjuvant treatment.