Meta-analysis of neoadjuvant therapy and its impact in facilitating breast conservation in operable breast cancer

BackgroundNeoadjuvant therapy (NAT) for operable breast cancer may facilitate more breast-conserving surgery (BCS). It seems, however, that this benefit is not being realized fully. MethodsA systematic review of the literature was performed. RCTs were included. The criteria for inclusion were: documentation of surgical assessment before and after NAT, surgery performed (BCS or mastectomy), and clinical and pathological responses. ResultsA total of 1452 patients from seven RCTs met the inclusion criteria. After NAT, the feasibility of BCS increased from 433 to 604 per cent (P<0001), but BCS was performed in only 518 per cent (P=004). Only 31 per cent of patients who became eligible for BCS (assessed on clinical response) underwent BCS (pooled rate ratio 031, 95 per cent c.i. 022 to 044; P<0001). Of the mastectomy candidates who achieved a pathological complete response after NAT, only 41 per cent underwent BCS (pooled rate ratio 041, 023 to 074; P=0003). The main factors that influenced the decision not to shift to BCS, even though it was feasible, were clinical assessment before NAT, multicentricity and tumour size at presentation. ConclusionBreast surgery performed after NAT does not reflect tumour response, resulting in potentially unnecessary radical surgery, especially mastectomy. The barriers to maximizing the surgical benefits of NAT need to be better understood and explored. Still unnecessary mastectomies