Neoadjuvant, adjuvant and postneoadjuvant strategies for escalation and de-escalation in early breast cancer treatment TNBC, HER2+and ER+/PR+/HER2-

Systemic treatment of early breast cancer is characterized by increasingly individualized, risk-adapted, and intrinsic subtype-specific strategies. In case of an indication for chemotherapy, the neoadjuvant application should be preferred, since the evaluation of treatment efficacy by the determination of the pathological complete response (pCR) offers the option of therapy escalation by postneoadjuvant treatment. For example, for the mainly neoadjuvant treated TNBC- and Her2-positive breast cancer, the postneoadjuvant application of capecitabine and T-DM1, respectively, in the case of non-pCR are well established. For luminal tumors, the risk of recurrence determines the need for chemotherapy which should also be preferably applied in a neoadjuvant setting. For this subgroup the post(neo)adjuvant escalation strategy with, for example, CDK4/6 inhibitors is also under investigation. The 5-year endocrine treatment should be given in a risk-adapted manner. For example in high-risk premenopausal patients, the addition of GnRH-agonist to tamoxifen is a valuable therapeutic escalation, while in the low-risk postmenopausal situation the omission of aromatase inhibitors for 5 years in favor of tamoxifen alone is a reasonable de-escalation strategy. An additional option for escalation in a higher risk situation is extending the adjuvant endocrine therapy for another 2-5 years.