Neoadjuvant Chemotherapy for Early Breast Cancer in China: Practices and Perspectives

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Neoadjuvant Chemotherapy for Early Breast Cancer in China: Practices and Perspectives

For many women diagnosed with early breast cancer (EBC) in China, one of the first treatment decisions involves neoadjuvant chemotherapy—drugs given before surgery to shrink tumors. But is this approach always the best choice? A 2020 analysis from Chinese medical experts raises important questions about its overuse, risks, and whether it truly benefits all patients.

The study comes from a team of breast surgeons at the Chinese Academy of Medical Sciences and Peking Union Medical College Hospital in Beijing, including Xue-Fei Wang, Song-Jie Shen, Yan Lin, Yan Li, Xin Huang, Chang-Jun Wang, and lead author Qiang Sun. Their work challenges the automatic use of neoadjuvant therapy, even for aggressive breast cancer subtypes like HER2+ (human epidermal growth factor receptor 2-positive) or triple-negative (TNBC).

The Consensus—and Its Limits

Neoadjuvant chemotherapy is widely used to:

  • Reduce tumor size for easier surgery (e.g., enabling breast-conserving procedures instead of mastectomy).
  • Improve resection rates for locally advanced breast cancer.
  • Treat aggressive subtypes where tumor response (called pathological complete response, or pCR—no remaining cancer after treatment) is more likely.

The 2017 St. Gallen Consensus—a global guide for breast cancer care—endorsed neoadjuvant therapy for stage II/III HER2+ or TNBC, with 94% and 92% of experts supporting it, respectively. But the Chinese team warns this can go too far. As Vaidya et al. noted in a 2018 BMJ paper, poor management of neoadjuvant chemo can make surgery impossible for some patients if tumors grow or spread rapidly during treatment.

Key Concerns About Overuse

The researchers highlight four critical issues with overreliance on neoadjuvant chemotherapy for EBC:

1. pCR Isn’t the “Win” We Think It Is

Pathological complete response (pCR) is often celebrated as a sign of success, but the team argues it should not be the ultimate goal. While studies like the NSABP B-18 and B-27 trials show pCR links to better outcomes, they do not prove neoadjuvant chemo beats adjuvant therapy (drugs given after surgery) for long-term survival. Relapse can happen even with pCR—and survival, not just tumor shrinkage, should be the priority.

2. Aggressive Subtypes Don’t Justify Automatic Neoadjuvant Use

HER2+ and TNBC have higher pCR rates with neoadjuvant chemo (especially with targeted drugs like trastuzumab). But no prospective trials compare neoadjuvant to adjuvant therapy for these subtypes. Worse, some patients who don’t achieve pCR lose surgery options entirely if their tumors progress. The National Comprehensive Cancer Network (NCCN) explicitly warns about this risk.

3. Neoadjuvant Chemo Delays Cure

Neoadjuvant therapy takes months to complete, while adjuvant chemo starts just 2–3 weeks after surgery (allowing time for biopsy results and recovery). This extra time lets tumors grow or metastasize—some patients lose their chance for a cure.

4. “Internal Drug Testing” Is a Myth

A common argument for neoadjuvant therapy is that it lets doctors see how tumors respond to drugs (an “internal sensitivity test”). But two large trials—the GeparTrio (Germany) and Aberdeen studies—show switching drugs for non-responsive tumors doesn’t improve survival. Even tumors that initially respond can become resistant later, making the “test” unreliable.

Balancing Benefits and Risks

The team is clear: neoadjuvant chemotherapy helps some patients—like those with inoperable tumors or who want to avoid mastectomy. But it’s not a “one-size-fits-all” solution. Overuse can deny patients timely surgery, increase metastasis risk, and even make cure impossible.

As the authors write: “We do not deny the benefit of neoadjuvant chemotherapy for some patients. However, overuse is not in their best interest. Further research is needed to define who truly benefits.”

The original study was published in the Chinese Medical Journal in 2020. References include:

  1. Mauri D, Pavlidis N, Ioannidis JP. J Natl Cancer Inst 2005;97:188–194.
  2. Early Breast Cancer Trialists’ Collaborative Group. Lancet Oncol 2018;19:27–39.
  3. Karagiannis GS, et al. Sci Transl Med 2017;9:eaan0026.
  4. Curigliano G, et al. Ann Oncol 2017;28:1700–1712.
  5. Vaidya JS, et al. BMJ 2018;360:j5913.
  6. Rastogi P, et al. J Clin Oncol 2008;26:778–785.
  7. Cortazar P, et al. Lancet 2014;384:164–172.
  8. Fisher B, et al. Cancer Res 1989;49:2002–2004.
  9. von Minckwitz G, et al. J Natl Cancer Inst 2008;100:542–551.

doi.org/10.1097/CM9.0000000000000940

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