© 2005 Oxford University Press
CORRESPONDENCE |
Re: Neoadjuvant Versus Adjuvant Systemic Treatment in Breast Cancer: A Meta-Analysis
Affiliations of authors: Breast Unit, Royal Marsden Hospital, London SW3 6JJ
Correspondence to: Sanjay Popat, Breast Unit, Royal Marsden Hospital, London SW3 6JJ, England (e-mail: sanjay.popat{at}icr.ac.uk).
The meta-analysis by Mauri et al. (1) from nine neoadjuvant trials is important given the conflicting evidence from published studies. However, we would like to make two points that arise from this analysis.
First, to establish the benefit of neoadjuvant therapy over adjuvant therapy, treatment regimens in the two arms should be identical in terms of drugs used and in terms of scheduling. Mauri et al. acknowledge that postoperative chemotherapy was administered to patients randomly assigned to the neoadjuvant arm in approximately half of studies (2–5), representing approximately a quarter of the dataset pooled (986 patients). This sizeable proportion may have biased results in favor of adjuvant therapy. Ideally, these studies should have been excluded from pooling, but this exclusion would have resulted in pooled data available on only 2960 patients, of which a few more than half (1523 patients) would have been from a single study [National Surgical Adjuvant Breast and Bowel Project B-18 (6)]. Data from sensitivity analysis with and without the four studies (2–5) in which patients received both adjuvant and neoadjuvant chemotherapy should be obtained to assess their potential impact on the primary outcomes assessed and the robustness of the authors' conclusions.
Second, Mauri et al. focused on the inability of neoadjuvant chemotherapy to improve any of the primary outcomes assessed, compared with adjuvant therapy, but this analysis should be recognized as a success. Data presented show the clear superiority of neoadjuvant therapy in breast-conserving surgery, an important issue for many patients. Furthermore, the ability to obtain tumor tissue by core biopsy before and during neoadjuvant therapy, in addition to the surgical specimen itself, offers a major opportunity for translational research.
REFERENCES
(1) Mauri D, Pavlidis N, Ioannidis JPA. Neoadjuvant versus adjuvant systemic treatment in breast cnacer: a meta-analysis. J Natl Cancer Inst 2005;97:188–94.
(2) Semiglazov VF, Topuzov EE, Bavli JL, Moiseyenko VM, Ivanova OA,Seleznev IK, et al. Primary (neoadjuvant) chemotherapy and radiotherapy compared with primary radiotherapy alone in stage IIb-IIIa breast cancer. Ann Oncol 1994;5:591–5.
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(4) Makris A, Powles TJ, Ashley SE, Chang J, Hickish T, Tidy VA, et al. A reduction in the requirements for mastectomy in a randomized trial of neoadjuvant chemoendocrine therapy in primary breast cancer. Ann Oncol 1998;9:1179–84.
(5) Gazet JC, Ford HT, Gray R, McConkey C, Sutcliffe R, Quilliam J, et al. Estrogen-receptor-directed neoadjuvant therapy for breast cancer: results of a randomised trial using formestane and methotrexate, mitozantrone and mitomycin C (MMM) chemotherapy. Ann Oncol 2001;12:685–91.
(6) Wolmark N, Wang J, Mamounas E, Bryant J, Fisher B. Preoperative chemotherapy in patients with operable breast cancer: nine-year results from National Surgical Adjuvant Breast and Bowel Project B-18. J Natl Cancer Inst Monogr 2001;30:96–102.
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