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Statement of the Science Concerning Locoregional Treatments After Preoperative Chemotherapy for Breast Cancer: A National Cancer Institute Conference

Thomas A. Buchholz, Constance D. Lehman, Jay R. Harris, Barbara A. Pockaj, Nagi Khouri, Nola F. Hylton, Michael J. Miller, Timothy Whelan, Lori J. Pierce, Laura J. Esserman, Lisa A. Newman, Barbara L. Smith, Harry D. Bear, Eleftherios P. Mamounas

From the Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX; Department of Radiology, The University of Washington and Seattle Cancer Care Alliance, Seattle, WA; Department of Radiation Oncology, Dana-Farber Cancer Institute; Brigham and Women's Hospital, Harvard Medical School; Department of Surgery, MA General Hospital, Boston, MA; Department of Surgery, Mayo Clinic Arizona, Scottsdale, AZ; Department of Radiology and Oncology, The Johns Hopkins University, Baltimore, MD; Departments of Radiology and Surgery, The University of California, San Francisco, CA; Department of Surgery, The Ohio State University, Columbus Aultman Health Foundation and Department of Surgery, Northeastern Ohio Universities College of Medicine, Rootstown, OH; Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Departments of Radiation Oncology and Surgery, The University of Michigan, Ann Arbor, MI; and the Department of Surgery and the Massey Cancer Center, Virginia Commonwealth University, Richmond, VA

Corresponding author: Thomas A. Buchholz, MD, Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcolmbe Blvd, Unit 1202, Houston, TX 77030; e-mail: tbuchhol{at}mdanderson.org

Purpose: To review the state of the science with respect to diagnostic imaging and locoregional therapy for patients with breast cancer receiving preoperative chemotherapy.

Methods: Published data relevant to clinical staging, monitoring of tumor response, and locoregional therapy for patients with breast cancer treated with preoperative chemotherapy were reviewed.

Results: High-quality data from prospective randomized trials are limited. Available data suggest that locoregional therapy decisions should be based on both the pretreatment clinical extent of disease and the pathologic extent of the disease after chemotherapy. Accordingly, physical examination and imaging studies that accurately define the initial extent of disease are required before treatment. Sentinel lymph node biopsy can be performed either before or after preoperative chemotherapy for patients with clinical N0 disease. The success of breast conservation after preoperative chemotherapy depends on careful patient selection and achieving negative surgical margins. Adjuvant breast radiation is indicated for all patients treated with breast conservation. For patients treated with mastectomy, chest-wall and regional nodal radiation should be considered for those who present with clinical stage III disease or have histologically positive lymph nodes after preoperative chemotherapy. Additional prospective studies are needed to determine the value of postmastectomy radiation for patients with stage II breast cancer who have negative lymph nodes after chemotherapy.

Conclusion: The increased use of preoperative chemotherapy has raised new questions concerning the optimal methods to stage and monitor disease response to treatment and how to optimize locoregional treatment. The available evidence suggests that a multidisciplinary approach improves outcomes.

Presented in part at the National Cancer Institute Statement of Science Conference, March 26-27, 2007, Bethesda, MD.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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