Primary chemotherapy in operable breast cancer

The origins of primary chemotherapy lie in the experience gained more than 20 years ago in the multimodal treatment for locally advanced breast cancer. Today, primary chemotherapy followed by surgery and radiation is emerging almost all over the world as a common approach for large but resectable breast cancers. The mounting interest for this approach has resulted in increasing number of available reports on this subject. Unfortunately, there is remarkable heterogeneity among most studies as far as patient selection, locoregional treatment, drug therapy, as well as criteria of tumor response and length of follow-up are concerned. At present, the most recognized benefit of primary chemotherapy is prompt tumor shrinkage, enabling surgeons to increase the use of breast-conserving procedures. However, as clinical experience grows, it is becoming clear that the most important scope of the early use of full-dose chemotherapy is a more effective eradication of systemic micrometastases. This review summarizes the current state of knowledge about this multidisciplinary approach and outlines future prospects. In conventionally resectable breast cancer, innovative prospective controlled studies, well designed and properly conducted, are warranted to definitely assess whether the administration of primary chemotherapy can further improve the continuous relapse-free survival over classical adjuvant systemic treatments.