Advantages include being better tolerated than adjuvant treatment, higher rate of compliance, treatment of potential micrometastases at the earliest time, potential for down staging disease and increased chance of resection of primary lesion.
For breast cancer with doxorubicin and cyclophosphamide leads to a pathologic complete remission in 11.5% of cases while doxorubicin and cyclophosphamide followed by docetaxel has a pCR of 21.8%.
Neoadjuvant chemotherapy for breast cancer results of the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-27 trial showed improved outcomes with the addition of taxanes.
Complete remission of breast and regional lymph node disease after preoperative chemotherapy associated with improved disease-free and long term survival.
Neoadjuvant chemotherapy provides equivalent clinical outcomes as compared to the administration have the same regimen in the adjuvant setting.
Patients with TNBC or HER2 positive disease who achieve a pathological complete response with
have improved long-term clinical outcomes relative to those with residual disease after neoadjuvant therapy.
Only one sugroup treated with neo- adjuvant chemotherapy had a survival benefit and that group had a complete pathological response (B-18).
Pathological complete remissions for neoadjuvant chemotherapy for breast cancer is observed an approximately 19% of patients with the use of anthracyclines and taxanes, either in combination or in sequence (Bear HD, Von Minckwitz G).
Neoadjuvant chemotherapy associated with a greater percentage of complete pathological response with ER negative tumors versus ER positive tumors, even though there is a better clinical outcome for ER positive tumors.
Equivalent survival exists for chemotherapy before or after breast cancer surgery.
Neoadjuvant treatment provides equivalent disease free and overall survival compared to adjuvant therapy, and is associated with improved rates of breast conserving surgery (Mauri D).
Neoadjuvant chemotherapy for breast cancer increases the rates of breast conserving surgery, and decreases the him and him him for complete axillary lymph node dissection.
The presence of tumor associated lymphocytes in breast cancer patients is an independent predictor of response to neoadjuvant chemotherapy suggesting a pre-existing immunologic response may enhance the effects of conventional cytotoxic chemotherapy (Denkert C).
In a phase II study CHER-LOB trial stage II orII breast cancer patients HER2+ who received chemotherapy prior to surgery for stage II or III BC responded better to treatment with a combination of trastuzumab and tyrosine kinase inhibitor lapatinib then with treatment with either lapatinib or trastuzumab alone with chemotherapy: A complete pathological response was noted in 28% of patients in the trastuzumab only arm, 32% in the lapatinib only arm and 48% in the combination arm (Guarneri V et al).
Pathologic complete response after adjuvant chemotherapy for breast cancer is a short term surrogate marker correlating with long-term outcome.
Pathologic complete remission associated with improved disease free survival and overall survival in breast cancer (Wollman N).
Improved neoadjuvant chemotherapy response in breast cancer seen with:low ER expression, high Ki-67 or other proliferation index, high grade, and ductal pathology (Colleoni M).
Improved response to neoadjuvant chemotherapy and high pathologic complete response rates seen in breast cancer patients with HER2 positive lesions, or those patients that are ER negative tumors PR negative tumors and HER2 negative (Triple negative).
Patients with HER2+ disease and triple negative tumors have the highest frequency of pathologic complete remissions (pCR), but are considered almost cured when pathological complete remission is reached.
The NOAH (NeOAdjuvant Herceptin) trail demonstrated that trastuzumab plus chemotherapy doubled pCR compared to chemotherapy alone and reduced relapse rate by half on locally advanced HER2+ BC (Gianni L et al ).
Considered the initial treatment for inflammatory and large volume breast cancers.
Standard of care for stage III locally advanced breast cancer and for some stage IIA and IIB lesions.
Has not provided significant overall survival benefit in breast cancer, but this approaches me breast conservation possible in select groups of patients (Rastogi P).
Younger women under the age of 35 years have a higher response rate to neoadjuvant chemotherapy for breast cancer.
Addition of Trastuzumab to preoperative docetaxel associated with a 54% pathologic complete remission in breast cancer patients with HER2 over expression.
A multicenter phase II trial of neoadjuvant therapy with Trastuzumab, docetaxel and Carboplatin in stage II/III operable breast cancer for six cycles: resulted in 85% complete response and 10% partial response (Coudert).
The combination of trastuzumab and chemotherapy compared to chemotherapy alone resulted in a more than doubled pathologic complete response rate (Buzdar AU).
Among patients with TNBC, the percentage of patients with pathological complete response is significantly higher among patients who receive pembrolizumab plus neoadjuvant chemo therapy than among those who receive placebo plus neoadjuvant chemo therapy ( Schmidt P).
No survival benefit for patients with operable tumors but is associated with increased rate of breast conservation surgery compare to those patients receiving adjuvant chemotherapy.
Offers the earliest treatment for micrometastatic disease.
Provides regression of breast cancer to avoid mastectomy in about 80% of cases.
Lobular carcinoma tumors do not respond well to neoadjuvant therapy, as response rates are low and chance for large lesion to undergo conservative surgery is low.
For ovarian cancer alone it is insufficient as the initial management of advanced stage cancer-it is only one event in the treatment course, as it should be followed by a cytoreductive surgery.
For ovarian cancer, and the major value of neoadjuvant chemotherapy is as a preparation for aggressive cytoreductive surgery.
For ovarian cancer patients who receive neo-adjuvant chemotherapy there is a significantly greater likelihood to undergo optimum surgical cytoreduction and often have shorter operating times, less blood loss, shorter intensive care unit stays, shorter overall hospital stays, as less aggressive surgery is necessary to achieve optimum surgical site or reduction.
For ovarian cancer a meta-analysis of 22 published series indicated patients treated with platinum/Taxane regimens did better than patients with other regimens(Bristow RE).
For ovarian cancer where the Cisplatinum and paclitaxel was used as neoadjuvant chemotherapy the prognosis in patients with stage III cancer was improved, compared to Cisplatinum and cyclophosphamide(Mcguire WP).
In an ovarian cancer study carboplatin and paclitaxel given in a neoadjuvant fashion for six cycles, followed by aggressive cytoreductive surgery, compared to patients treated with conventional cytoreductive surgery followed by combination chemotherapy for six cycles: there was no difference in progression free all overall survival(Hou JY).
In the above study, approximately 33% of patients underwent conventional treatment were debulked to no residual disease, whereas 80% of patients who received neoadjuvant chemotherapy as the initial treatment, and then subsequently underwent surgery were debulked to no residual disease(HouJY).
Bladder cancer neoadjuvant therapy clinical trials revealed a 5% absolute survival benefit for muscle invasive disease: at 5 years survival up to 50%.
Patients who receive pathologic response to neoadjuvant bladder cancer chemotherapy of either a complete response or eradication of muscle invasive disease have an improved prognosis compared with those with residual muscle invasive or greater disease.
Neoadjuvant chemotherapy is recommended for patients with T2 to T4 disease.
Studies have shown clinical benefit of neoadjuvant chemo therapy versus upfront cystectomy in muscle invasive urothelial bladder cancer: most studies have cisplatinum based multi drug regimens.
Most studies suggest neoadjuvant therapy be given for muscle invasion urothelial bladder cancer with dose dense MVAC or cisplatinum/ Gemcitabine chemotherapy.