The American Society of Breast Surgeons (ASBrS) sought to provide an evidence-based guideline on the use of neoadjuvant systemic therapy (NST) in the management of clinical stage II and III invasive breast cancer.
A comprehensive nonsystematic review was performed of selected peer-reviewed literature published since 2000. The Education Committee of the ASBrS convened to develop guideline recommendations.
A performance and practice guideline was prepared to outline the baseline assessment and perioperative management of patients with clinical stage II–III breast cancer under consideration for NST.
Preoperative or NST is emerging as an important initial strategy for the management of invasive breast cancer. From the surgeon’s perspective, the primary goal of NST is to increase the resectability of locally advanced breast cancer, increase the feasibility of breast-conserving surgery and sentinel node biopsy, and decrease surgical morbidity. To ensure optimal patient selection and efficient patient care, the guideline recommends: (1) baseline breast and axillary imaging; (2) minimally invasive biopsies of breast and axillary lesions; (3) determination of tumor biomarkers; (4) systemic staging; (5) care coordination, including referrals to medical oncology, radiation oncology, plastic surgery, social work, and genetic counseling, if indicated; (6) initiation of NST; (7) post-NST breast and axillary imaging; and (8) decision for surgery based on extent of disease at presentation, patient choice, clinical response to NST, and genetic testing results, if performed.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Wolmark N, Wang J, Mamounas E, et al. Preoperative chemotherapy in patients with operable breast cancer: nine-year results from National Surgical Adjuvant Breast and Bowel Project B-18. J Natl Cancer Inst Monogr. 2001;(30):96–102.
Van der Hage JA, van de Velde CJ, Julien JP, et al. Preoperative chemotherapy in primary operable breast cancer: results from the European Organization for Research and Treatment of Cancer Trial 10902. J Clin Oncol. 2001;19:4224–37.
Gianni L, Baselga J, Eirmann W, et al. European Cooperative Trial in Operable Breast Cancer (ECTO): improved freedom from progression (FFP) from adding paclitaxel (T) to doxorubicin (A) followed by cyclophosphamide methotrexate and fluorouracil (CMF) (abstract 513). J Clin Oncol. 2005;23:7s.
Bear HD, Anderson S, Brown A, et al. The effect on tumor response of adding sequential preoperative docetaxel to preoperative doxorubicin and cyclophosphamide: preliminary results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2003;21:4165–74.
Gianni L, Baselga J, Eiermann W, et al. First report of the European Cooperative Trial in Operable Breast Cancer (ECTO): effect of primary systemic therapy (abstract 132). Proc Am Soc Clin Oncol. 2002;21:34a.
Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumors: revised RECIST guidelines (version 1.1). Eur J Cancer. 2009;45:228–47.
Cortazar P, Zhang L, Untch M, et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. Lancet. 2014;384(9938):164–72.
Jochelson MS, Lampen-Sachar K, Gibbons G, et al. Do MRI and mammography reliable identify candidates for breast conservation after neoadjuvant chemotherapy. Ann Surg Oncol. 2015;22:1490–5.
Choy N, Lipson J, Porter C, et al. Initial results with preoperative tattooing of biopsied axillary lymph nodes and correlation to sentinel lymph nodes in breast cancer patients. Ann Surg Oncol. 2015;22:377–82.
National Comprehensive Cancer Network. Clinical practice guidelines in oncology: breast Cancer, v2.2015. Available at: http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed 24 May 2015.
Mieog JSD, van der Hage JA, van de Velde CJH. Neoadjuvant chemotherapy for operative breast cancer. Br J Surg. 2007;94:1189–200.
Schneeweiss A, Chia S, Hickish T, et al. Pertuzumab plus trastuzumab in combination with standard neoadjuvant anthracycline-containing and anthracycline-free chemotherapy regimens in patients with HER2-positive early breast cancer: a randomized phase II cardiac safety study (TRYPHAENA). Ann Oncol. 2013;24:2278–84.
Gianni L, Pienkowski T, Im YH, et al. Efficacy and safety of neoadjuvant pertuzamab in women with locally advanced, inflammatory, or early HER2-positive breast cancer (Neosphere): a randomized multicentre, open-label, phase 2 trial. Lancet Oncol. 2012;13:25–32.
Saleh RR, Bouganim N, Hilton J, Arnaout A, Clemons M. Neoadjuvant endocrine treatment for breast cancer: from bedside to bench and back again? Curr Oncol. 2014;21:e122–e128.
Haddad TC, Goetz MP. Landscape of neoadjuvant therapy for breast cancer. Ann Surg Oncol. 2015;22:1408–15.
Caudle AS, Gonzales-Angulo AM, Hunt KK, et al. Impact of progression during neoadjuvant chemotherapy on surgical management of breast cancer. Ann Surg Oncol. 2011;18(4):932-8.
Bosch AM, Kessels AG, Beets GL, et al. Preoperative estimation of the pathological breast tumour size by physical examination, mammography and ultrasound: a prospective study on 105 invasive tumours. Eur J Radiol. 2003;48:285–92.
Weiss A, Lee KC, Romero Y, et al. Calcifications on mammography do not correlate with tumor size after neoadjuvant chemotherapy. Ann Surg Oncol. 2014;21:3310–6.
Moran M, Schnitt SJ, Giulianno AE, et al. Society of Surgical Oncology–American Society of Radiation Oncology consensus guidelines on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Int J Radiat Oncol Biol Phys. 2014;88:553–64.
Wang F, Peled AW, Garwood E, et al. Total skin-sparing mastectomy and immediate breast reconstruction: an evolution of technique and assessment of outcomes. Ann Surg Oncol. 2014;21:3223–30.
Radovanovic Z, Radovanovic D, Golubovic A, et al. Early complications after nipple-sparing mastectomy and immediate breast reconstruction with silicone prosthesis: results of 214 procedures. Scand J Surg. 2010;99:115–8.
Kelly AM, Dwamena B, Cronin P, Carlos RC. Breast cancer sentinel node identification and classification after neoadjuvant chemotherapy—a systemic review and meta-analysis. Acad Radiol. 2009;16:551–63.
Xing Y, Foy M, Cox DD, et al. Meta-analysis of sentinel lymph node biopsy after preoperative chemotherapy in patients with breast cancer. Br J Surg. 2006;93:539–46.
Mamounas EP, Brown A, Anderson S, et al. Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer: results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2005;23:2694–702.
Kuehn T, Bauerfeind I, Fehm T, et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol. 2013;14:609–18.
Boughey JC, Suman VJ, Mittendorf EA, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310:1455–61.
NSABP B-51/RTOG 1304. ClinicalTrials.gov. Identifier: NCT01872975.
Alliance A112020. ClinicalTrials.gov. Identifier: NCT01901094.
Vidal-Sicart S, Giammarile F, Mariani G, et al. Pre- and intra-operative imaging techniques for sentinel node localization in breast cancer. Imag Med. 2013;5:275–91.
Ascherman JA, Hanasono MW, Newman MI, et al. Implant reconstruction in breast cancer patients with radiation therapy. Plast Reconstr Surg. 2006;117:359–65.
Benediktsson K, Perbeck L. Capsular contracture around saline-filled and textured subcutaneously placed implants in irradiated and non-irradiated breast cancer patients: five years of monitoring of a prospective trial. J Plast Reconstr Aesthet Surg. 2006;59:27–34.
Behranwala KA, Dua RS, Ross GM, et al. The influence of radiotherapy on capsule formation and aesthetic outcome after immediate breast reconstruction using biodimensional anatomical expander implants. J Plast Reconstr Aesthet Surg. 2006;59:1043–51.
Barry M, Kelly MR. Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Res Treat. 2011;27:15–22.
Lam TC, Hsieh F, Boyages J. The effects of postmastectomy adjuvant radiotherapy on immediate two-stage prosthetic breast reconstruction: a systematic review. Plast Reconstr Surg. 2013;132:511–8.
Kronowitz SJ, Robb GL. Radiation therapy and breast reconstruction: a critical review of the literature. Plast Reconstr Surg. 2009;124:395–408.
Garvey PB, Clemens MW, Hoy AE, et al. Muscle-sparing TRAM flap does not protect breast reconstruction from postmastectomy radiation damage compared with the DIEP flap. Plast Reconstr Surg. 2014;133:223–33.
Chang DW, Wang B, Robb GL, et al. Effect of obesity on flap and donor site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction. Plast Reconstr Surg. 2000;105:1640–8.
Chang DW, Reece GP, Wang B. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg. 2000;105:2374–80.
Garg AK, Buchholz TA. Influence of neoadjuvant chemotherapy on radiotherapy for breast cancer. Ann Surg Oncol. 2015;22:1434–40.
Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15 year survival: an overview of the randomized trials. Lancet. 2005;336(9503):2087–106.
Mamounas EP, Anderson SJ, Dignam JJ, et al. Predictors of locoregional recurrence after neoadjuvant chemotherapy: results from combined analysis of National Surgical Adjuvant Breast and Bowel Project B-18 and B-27. J Clin Oncol. 2012;30:3960–6.
Buchholz TA, Katz A, Strom EA, et al. Pathologic tumor size and lymph node status predict for different rates of locoregional recurrence after mastectomy for breast cancer patients treated with neoadjuvant versus adjuvant chemotherapy. Int J Radiat Oncol Biol Phys. 2002;53:880–8.
Katz A, Strom EA, Buchholz TA, et al. Locoregional recurrence patterns after mastectomy and doxorubicin-based chemotherapy: implications for postoperative irradiation. J Clin Oncol. 2000;18:2817–27.
The authors declare no conflict of interest.
This journal article summarizes key factors that must be addressed in the care of the NST candidate. The full-length version of the guideline may be accessed at www.breastsurgeons.org.
About this article
Cite this article
Holmes, D., Colfry, A., Czerniecki, B. et al. Performance and Practice Guideline for the Use of Neoadjuvant Systemic Therapy in the Management of Breast Cancer. Ann Surg Oncol 22, 3184–3190 (2015). https://doi.org/10.1245/s10434-015-4753-3
- Sentinel Node
- Sentinel Node Biopsy
- Axillary Lymph Node Dissection
- National Comprehensive Cancer Network
- Breast Reconstruction