[Neoadjuvant endocrine therapy for locally advanced breast cancer]

The use of neoadjuvant chemotherapy in the treatment of locally advanced breast cancer is now well established. However, endocrine therapy can be a valid alternative to primary chemotherapy in the treatment of hormone-sensitive tumors, particularly in post-menopausal women. Tamoxifen (TAM) was initially used in older or frail patients who were not candidates for chemotherapy. Response rate of 49% to 68% were observed. These encouraging results prompted subsequent randomized phase III studies demonstrating the superiority of surgery in comparison to TAM as primary treatment. The successful use of aromatase inhibitors (AI) in the metastatic and adjuvant setting has encouraged studies that compare these agents with tamoxifen in the neoadjuvant setting. In terms of response rates, anastrozole and exemestane did not differ from TAM, while letrozole was superior. Nevertheless, all the AI were found to be superior to TAM as far as breast conserving surgery is concerned. The Americal College of Surgeons Oncology Group (ACOSOG) has recently activated a neoadjuvant randomized trial comparing anastrozole, letrozole and exemestane in postmenopausal patients with estrogen receptor positive tumors. Hopefully, this study will clarify which of these agents is more effective as primary endocrine therapy. In the meantime, neoadjuvant hormonal treatment should be considered in elderly patients with inoperable tumors or tumors not amenable to conservative surgery, with highly expressed estrogen receptors and contraindication to chemotherapy.