engleski

Neoadjuvant treatment of breast cancer according to subtypes

Neoadjuvant therapy (NAT) in breast cancer (BC), also called presurgical systemic therapy (PST), refers to systemic therapy administered prior to definitive surgery. In this review we’ll discuss historical, current and future perspective of NAT in BC. It was developed for patients with locally advanced, inoperable BC with the intention of downstaging unresectable tumors, or decreasing the extent of surgical intervention to replace radical mastectomy. These indications were mainly reffered to neoadjuvant chemoterapy (NACT). For patients with inflammatory BC, NACT is considered a standard of care. Nowadays, with advances in the molecular characterization of BC, NACT is being widely used for operable tumors and hold particular relevance in aggressive subtypes like triple negative BC (TNBC) and HER2-positive (HER2+) BC. Combination of anthracycline and taxane-based chemotherapy with pertuzumab and trastuzumab has become a standard NAT regimen for HER2+ disease. Postneoadjuvant treatment for those with residual disease after NACT was also a metter of research with positive KATHERINE trial with trastuzumab emtanzine given postneoadjuvant. In contrast, role of NACT in hormone receptor positive (HR+) HER2– BC is still metter of the debate, mainly due to low rates of pathological complete response (pCR) and lower accuracy of pCR as a surrogate predictor of long-term outcome. Neoadjuvant endocrine therapy (NET) still remains an unused potential in the management of HR+HER2– subtype, with key issues concerning the optimal treatment length, appropriate comparisons with NACTand its use in premenopausal patients. It has gained a central role as a platform to test new drug combinations in treatment naive patients or in „window of opportunity“ trials. Currently, the standard NACT for early-stage TNBC is anthracycline and taxane-based chemotherapy. Several new strategies have been investigated in the NAT of TNBC in order to individualize treatment and achieve higher proportion of pCR. According to the recent trials with checkpoint inhibitors, KEYNOTE-522 and IMpassion 031, the proportion of patients with pCR was significantly higher among those who received pembrolizumab or atezolizumab plus NACT. Strategies without chemo with single agent talazoparib are also under the spot-light for BRCA1/2 mutated tumors.

neoadjuvant therapy ; breast cancer ; surrogate subtypes

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