Primary chemotherapy for breast cancer: response to preoperative chemotherapy as prognostic factor

Preoperative (or neoadjuvant) chemotherapy, followed by the appropriate local regional treatment (either surgery or radiotherapy, or both) has become the preferred treatment for locally advanced and inflammatory breast carcinoma [1]. Primary chemotherapy has been shown to produce major objective regression of the primary lesion and regional lymph node metastasis in the majority of patients. In addition, downstaging of the primary lesion offers the possibility to treat the breast with a subtotal mastectomy, and, therefore, breast conservation. It is unclear at this point, whether preoperative chemotherapy offers a survival benefit in the context of multimodal treatment over the postoperative administration of adjuvant chemotherapy. Our first protocol of primary chemotherapy suggested that response to this treatment correlated with long-term disease-free and overall survival [2]. The clinical trial reported here was designed to confirm the prognostic implication of response to preoperative chemotherapy, and to determine whether a response to preoperative chemotherapy could be the basis for the selection of postoperative systemic treatments. More specifically, we wanted to determine whether the addition of a non-cross-resistant combination of cytotoxic agents after optimal local/regional treatment to patients with suboptimal response to preoperative chemotherapy would result in an improvement in disease-free and overall survival.