Preoperative Radio(Chemo)Therapy in Breast Cancer: Time to Switch the Perspective?

Abstract

Aim: Radiation therapy represents, together with surgery and systemic treatment, the triad on which the current management of patients with breast cancer is based, achieving high control and survival rates. In recent years we have witnessed a (r)evolution in the conception of breast cancer treatment. The classic scheme of surgery followed by systemic treatment and radiotherapy is being subverted and it is becoming more and more frequent to propose the primary administration of systemic treatment before surgery, seeking to maximize its effect and favoring not only the performance of more conservative surgeries but also, in selected cases, increasing the rates of disease-free survival and overall survival. Radiotherapy is also evolving toward a change in perspective: considering preoperative primary administration of radiotherapy may be useful in selected groups. Advances in radiobiological knowledge, together with technological improvements that are constantly being incorporated into clinical practice, support the administration of increasingly reliable, precise, and effective radiotherapy, as well as its safe combination with antitumor drugs or immunotherapy in the primary preoperative context. In this paper, we present a narrative review of the usefulness of preoperative radiotherapy for breast cancer patients and the possibilities for its combination with other therapies.

Preoperative Radiotherapy Does Not Change the Existing Treatment Paradigm in Stage III Breast Cancer

“…Explicitly preoperative RT had no advantage of OS in our study with stage III. More trials have supported preoperative radio (chemo) therapy [37], but PCR did not improve relative to neoadjuvant chemotherapy. Therefore, the most important aspect for patients is the effectiveness of systemic treatment, which can also be seen in our results.…”

Technical consideration for breast reconstruction in patients requiring neoadjuvant or adjuvant radiotherapy: a narrative review

“…Traditionally indicated in a patient with locally advanced breast cancer ( 24 , 38 , 39 ), NART is now a feasible therapeutic option in early-stage breast cancer cases (I, IIA and IIB, and IIIA) in which the disease has not extended beyond the axilla) ( 8 ) avoiding ART’s drawbacks and displaying a low toxicity profile ( 40 , 41 ). Although NART has not been proven to decrease overall patients’ survival ( 42 ), the benefits have been demonstrated by the improvement in DFS in estrogen receptor-positive tumors ( 42 ).…”

“…In most aggressive cases (stage IIIA–C), the combination of NART and chemotherapy, followed by mastectomy and IBR, has demonstrated a 78.3% 5-year recurrence-free survival and 88.4% 5-year OS rate ( 44 ). Similarly, Ciérvide et al ( 41 , 45 ), evaluated the feasibility and tolerability of primary concurrent radio-chemotherapy in breast cancer patients with localized triple-negative (TN) or HER2 + tumors. The treatment combined three strategies simultaneously: fractionated RT in 15 sessions, tailored computed tomography (CT) based on tumor phenotype, and local planning using positron emission tomography (PET) imaging.…”

“…The surge of clinical trials focused on combining NART with immunotherapy has consolidated the future implementation of radiation before surgery ( 41 ). These studies, based on immunotherapy, have enabled the identification of potentiation of the tumor-specific immune response ( 54 , 55 ).…”

The Coming of Age of Breast Radiotherapy

“…By harnessing data from five large prospective randomized trials, they provided a perspective on cardiotoxicity while defining the high-risk patients for whom IMN RT might offer not only the advantage of disease-free survival but also overall survival. One more iconoclastic worldview was presented by Montero and Ciervide [11], who dared to posit the role of pre-operative radiotherapy instead of that of the conventional sequence used to integrate the respective modalities prescribed by oncologists.…”