Chemotherapy for early-stage breast cancer: the more the better?

Breast cancer is the most common malignancy in women worldwide 1 Sung H Ferlay J Siegel RL et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021; 71: 209-249 Crossref PubMed Scopus (31371) Google Scholar and treatment de-escalation of early-stage breast cancer has been a contentious topic of discussion. Breast-conserving surgery has gradually replaced mastectomy, eliminating the need for breast surgery in patients with a pathological complete response on image-guided vacuum-assisted core biopsy after neoadjuvant systemic therapy shows highly promising results. 2 Kuerer HM Smith BD Krishnamurthy S et al. Eliminating breast surgery for invasive breast cancer in exceptional responders to neoadjuvant systemic therapy: a multicentre, single-arm, phase 2 trial. Lancet Oncol. 2022; 23: 1517-1524 Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Sentinel lymph node biopsy, rather than axillary lymph node dissection, is the standard of care for clinical node-negative breast cancer, and some patients with node-positive disease also do not need further surgery. 3 Giuliano AE Ballman KV McCall L et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) randomized clinical trial. JAMA. 2017; 318: 918-926 Crossref PubMed Scopus (862) Google Scholar Chemotherapy substantially reduces the risk of recurrence and death due to early-stage breast cancer, but it can cause short-term and long-term side-effects. Multigene assays have been used to avoid chemotherapy in patients with hormone receptor-positive tumours, human epidermal growth factor receptor 2 (HER2)-negative tumours, and a low recurrence score, in addition to individuals with nodal involvement. 4 Kalinsky K Barlow WE Gralow JR et al. 21-gene assay to inform chemotherapy benefit in node-positive breast cancer. N Engl J Med. 2021; 385: 2336-2347 Crossref PubMed Scopus (185) Google Scholar Anthracycline-containing and taxane-containing chemotherapy for early-stage operable breast cancer: a patient-level meta-analysis of 100 000 women from 86 randomised trialsAnthracycline plus taxane regimens are most efficacious at reducing breast cancer recurrence and death. Regimens with higher cumulative doses of anthracycline plus taxane provide the greatest benefits, challenging the current trend in clinical practice and guidelines towards non-anthracycline chemotherapy, particularly shorter regimens, such as four cycles of docetaxel–cyclophosphamide. By bringing together data from almost all relevant trials, this meta-analysis provides a reliable evidence base to inform individual treatment decisions, clinical guidelines, and the design of future clinical trials. Full-Text PDF Open Access