the clinicoradiographic response to NST. Patient
and surgeon perceptions (whether accurate or
not) about an in-breast recurrence or development
of a secondary primary breast cancer or concern
regarding radiation, with or without identification
of a deleterious germline BRCA mutation, likely
played some role in these decisions. 11-13
Suggestions for the future
Breast surgical oncologists need to appropriately convey
to patients the risks of locoregional recurrence or second
primary cancers and discuss likely cosmetic outcomes
so patients can make informed decisions regarding local
therapy. In addition, breast imaging needs to improve to
accurately determine treatment response to NST so that
interested patients can be offered BCT, if appropriate.
Despite NST successfully converting 42 percent
of patients from BCT-ineligible to BCT-eligible
and overall high rates of pCR, most NST patients
still underwent mastectomy—many without even
attempting BCT. Future NST trials should be
prospectively designed to address patient, surgeon,
and radiologic-specific factors that may influence
offering and/or successful completion of BCT. 14
If the main proven benefit of NST is to increase
BCT rates, our results are disappointing and
warrant an effort among surgical oncologists and
medical oncologists to encourage decision making
based on modern-day response to therapy. ♦
8. Carey LA, Berry DA, Cirrincione CT, et al. Molecular
heterogeneity and response to neoadjuvant human
epidermal growth factor receptor 2 targeting in
CALGB 40601, a randomized phase III trial of
paclitaxel plus trastuzumab with or without lapatinib.
J Clin Oncol. 2016; 34( 6):542-549.
9. Ollila DW, Berry DA, Cirrincione CT, et al. Impact
of neoadjuvant chemotherapy plus HER2-targeting
on breast conservation rates: Surgical results from
CALGB 40601 (Alliance). Paper presented at: 2013
American Society of Clinical Oncology Meeting,
June 2, 2013, Chicago, IL.
10. von Minckwitz G, Schneeweiss A, Loibl S, et al.
Neoadjuvant carboplatin in patients with triple-negative and HER2-positive early breast cancer
(GeparSixto; GBG 66): A randomised phase 2 trial.
Lancet Oncol. 2014; 15( 7):747-756.
11. Debled M, MacGrogan G, Breton-Callu C, et al.
Surgery following neoadjuvant chemotherapy for
HER2-positive locally advanced breast cancer. Time
to reconsider the standard attitude. Eur J Cancer.
2015; 51( 6):697-704.
12. 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. 2015; 22( 10):3184-3190.
13. McGuire KP, Hwang ES, Cantor A, et al. Surgical
patterns of care in patients with invasive breast
cancer treated with neoadjuvant systemic therapy
and breast magnetic resonance imaging: Results of
a secondary analysis of TBCRC 017. Ann Surg Oncol.
2015; 22( 1):75-81.
14. Rippy EE, Ainsworth R, Sathananthan D, et al.
Influences on decision for mastectomy in patients
eligible for breast conserving surgery. Breast.
2014; 23( 3):273-278.
ACS CLINICAL RESEARCH PROGRAM
Breast surgical oncologists need to appropriately convey to
patients the risks of locoregional recurrence or second primary
cancers and discuss likely cosmetic outcomes so patients
can make informed decisions regarding local therapy.