Breast cancer: role of neoadjuvant therapy

Breast cancer is now considered to be a systemic disease from the outset, with no correlation seen between the intensity of local treatment and survival or recurrence. Adjuvant therapy has clearly demonstrated a reduction in local and distant relapse; neoadjuvant therapy is similarly being assessed. It aims to treat occult metastases and decrease tumour bulk. Its use has demonstrated down-staging of the tumour with increased rates of breast-conserving surgery. Though neoadjuvant therapy seems to be associated with an increase in loco-regional recurrence compared to adjuvant therapy, no overall difference in survival has been demonstrated. This paper reviews several trials that compare neoadjuvant to adjuvant therapy, and the controversies around managing the axilla in the neoadjuvant setting.