Neoadjuvant Chemotherapy (NAC) for Breast Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Among women with operable breast cancers at the time of diagnosis:
    • Neoadjuvant chemotherapy (NAC) is increasingly used to gain information about the tumor’s response to treatment:
      • With pathologic response rates:
        • Correlating with long-term prognosis
  • The most accepted definition of pathologic complete response (pCR) includes:
    • No residual invasive disease in the breast or sampled axillary nodes:
      • Although this definition varies:
        • Residual in situ disease does not affect the risk of distant recurrence
  • Response to preoperative treatment differs by:
    • Tumor biology:
      • With hormone-receptor positive breast cancer patients having the lowest overall pCR rate
  • For some women with residual disease, including those with HER2-positive and triple-negative breast cancers:
    • This allows for use of additional adjuvant therapy that improves cancer outcomes including receipt of:
      • TDM-1 (trastuzumab emtansine, KATHERINE Trial)
      • Xeloda (CREATE-X Trial)
      • Eligibility for ongoing clinical trials
  • Notably, recent changes to the American Joint Committee on Cancer Staging System includes:
    • Pathologic stage after neoadjuvant chemotherapy as part of the updated system:
      • When pCR is achieved in both the breast and axillary nodes:
        • Survival is driven by response to chemotherapy compared to initial presenting stage
  • Choosing a NAC regimen depends on tumor biology:
    • In HER2-positive patients:
      • Chemotherapy should be combined with HER2-targeted therapies:
        • i.e., taxane + carboplatin + trastuzumab, pertuzumab (TCHP)
    • For HER2-negative patients:
      • Anthracycline-based drugs including doxorubicin and cyclophosphamide followed by a taxane
      • Higher risk HER2-negative breast cancers (node-positive hormone-receptor positive patients and triple-negative patients) typically receive anthracycline and taxane-based regimens with or without carboplatin
    • Notably, results from the CALGB40603 trial suggested that for triple-negative breast cancer:
      • The addition of carboplatin to NAC resulted in a 14% increase in eligibility for breast conservation
  • References:
    • Fayanju OM, et al. The Clinical Significance of Breast-only and Node-only Pathologic Complete Response After Neoadjuvant Chemotherapy. Annals of Surgery. 2018; 268(4): 591-601.
    • von Minckwitz, G et al. Trastuzumab Emtansine for Residual Invasive HER2-Positive Breast Cancer. NEJM. 2018; 380(7): 617-628.
    • Masuda N, et al. Adjuvant Capecitabine for Breast Cancer After Preoperative Chemotherapy. NEJM. 2017; 376:2147-59.
    • Golshan M, et al. Impact of neoadjuvant chemotherapy in stage II-III triple negative breast cancer on eligibility for breast-conserving surgery and breast conservation rates: surgical results from CALGB 40603 (Alliance). Annals of Surgery. 2015; Sep; 262(3):434-9.
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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