By including this prospective surgical sub-study in
this large, randomized NST trial, we identified that
a substantial number of patients with TNBC deemed
ineligible for BCT at presentation by the treating
surgeon could be successfully converted to BCT-eligible ( 42 percent) with NST. For those patients
who attempted BCT, the likelihood of success was
93 percent. Before NST, the breast surgeon and/or
radiologic factors most commonly cited as the reasons
a patient was BCT-ineligible were a tumor being
deemed too large and/or concern of a probable poor
cosmetic outcome. However, because most TNBC
downsize with NST, multi-centricity became the
predominant factor for non-candidacy after NST.
Our 47 percent BCT rate needs to be viewed
in the context of three other large trials on NST:
Neo-ALTTO, women with HER2-positive disease,
44 percent BCT rate; CALGB 40601, women with
HER2-positive disease, 48 percent BCT rate; and
GeparSixto, women with HER2-positive disease
and TNBC, nearly 75 percent BCT rate. 7-10
Despite the high rate of BCT in the GeparSixto
trial, the addition of carboplatin, which increased the
pCR, did not lead to an increase in BCT in that arm
of the trial. Intuitively, higher pCR rates should lead
to higher BCT rates, but, interestingly, this outcome
has not always been observed in modern trials. In an
era when drug therapies have produced remarkably
high pCR rates for TNBC, it is surprising that BCT
rates are lower than in the past when drug therapy
was less robust and pCR rates were much lower.
In CALGB 40603, many BCT-eligible patients,
regardless of whether they were always candidates
for BCT or converted to BCT candidates with
NST, ultimately did not seek breast conservation.
Instead, they opted for mastectomy regardless of
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ACS CLINICAL RESEARCH PROGRAM
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Although NST has been studied extensively, comprehensive
data on the impact of NST on converting BCT-ineligible
patients to BCT-eligible is lacking.