Analysis of NeoALTTO trial data: Too few women being offered breast-conserving treatment

Discrepancy between high pathological complete response rate following neoadjuvant therapy and breast conserving surgery

Odds ratio estimates and 95% CI of significant predictors for conservative surgery

Odds ratio estimates and 95% CI of significant predictors for conservative surgery
Credit: Dr Carmen Criscitiello
Restrictions for use: ESMO website only

A new study suggests that not enough women with breast cancer are being offered the chance to undergo breast conserving surgery after neoadjuvant chemotherapy. At the ESMO 2012 Congress of the European Society for Medical Oncology, Dr Carmen Criscitiello from the European Institute of Oncology in Milan, Italy, and colleagues report on an analysis of the different factors that may have affected the choice of surgery offered to patients in the NeoALTTO trial, which showed that the combination of paclitaxel, lapatinib and trastuzumab significantly increased the rate of pathological complete response compared to paclitaxel combined with either drug alone. The NeoALTTO trial was published in January this year.

Despite this high rate of response, the proportion of women receiving breast-conserving surgery remained around 40%, regardless of which treatment the 429 women in the study received. The study researchers observed that tumour characteristics prior to neoadjuvant therapy play a main role in deciding the type of surgery, irrespective of the response to given therapies.

This study highlights a negative attitude that may deny a large fraction of women the chance of preserving their breast, with no clinical reasons that justify this decision. One of the goals of the neoadjuvant therapy concerns increasing the rate of breast conservation, but this goal is clearly not achieved if the type of surgery is chosen according to baseline characteristics.

Dr Criscitiello and colleagues call for a clear consensus in the role of breast conserving surgery for patients responding to neoadjuvant therapy. “This will translate the progress in neoadjuvant therapies and the consequent high pathological complete response rates into higher rates of breast conservation.

Prof. Michael Gnant, a surgical oncologist from Vienna's Medical University, who was not involved in the studies, commented that Dr Criscitiello’s work is very important in a goal to further increase breast conservation rates. Particularly in biologically aggressive subtypes of breast cancer, such as HER-2/neu over-expressing disease, there is still some hesitation in applying breast-conserving surgical strategies. The abstract suggests that particularly in patients with an excellent response a more proactive approach to breast conservation can be used, given the advances in targeted therapy. While long-term confirmation on loco-regional control is awaited, according to Prof. Gnant modern breast cancer surgery should orientate its strategy around the post-treatment outcome rather than the baseline situation. When this will be implemented in more centres, even more women will benefit from the advances in multimodality treatment.

According to Prof. Gnant, advances in interdisciplinary preoperative approaches have contributed to the revolution in breast surgery that has provided huge benefits to women in the last three decades. Less invasive surgery, breast conserving approaches as standard of care, sentinel node surgery, reduced pain and hospital stays, have been achieved. Modern clinical research aims at fine-tuning and even improving these treatment strategies.

 

Caption for image: Odds ratio estimates and 95% CI of significant predictors for conservative surgery
Credit: Dr Carmen Criscitiello
Restrictions for use: ESMO website only