In clinical practice, neoadjuvant endocrine therapy (NET) is rarely used despite being an effective treatment modality able to downstage tumors and facilitate breast-conserving surgery.
Using data from studies conducted since 2000, we provide readers with a critical in-depth review on clinical aspects related to the application of NET in the treatment of hormone receptor (HR)-positive/ERBB2 (formerly HER2)–negative breast cancer. This includes an overview of patient-selection criteria, regimen choice, treatment duration, evaluation of response by imaging, interpretation of pathology after treatment, and surgical considerations. Areas of controversy include the use of gene-expression tests for patient selection, treatment of premenopausal women, surgical management of the axilla after NET, and adjuvant systemic therapy decision-making, including the use of chemotherapy.
Conclusions and Relevance
NET is an optimal treatment modality for a considerable proportion of postmenopausal women diagnosed with HR-positive tumors. The treatment landscape for HR-positive breast cancer is evolving, with novel agents and the growing use of gene expression profiling to define treatment selection. As such, it is likely that NET use will increase and the practical considerations outlined here will become more important.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: February 24, 2021.
Published Online: September 9, 2021. doi:10.1001/jamaoncol.2021.2132
Corresponding Author: Otto Metzger-Filho, MD, Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 (email@example.com).
Author Contributions: Dr Metzger-Filho had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Sella and Weiss served as co–first authors and contributed equally to the work.
Concept and design: Sella, Weiss, King, Pilewskie, Metzger-Filho.
Acquisition, analysis, or interpretation of data: Sella, Weiss, Mittendorf, Giuliano.
Drafting of the manuscript: Sella, Weiss, Pilewskie, Metzger-Filho.
Critical revision of the manuscript for important intellectual content: Sella, Weiss, Mittendorf, King, Pilewskie, Giuliano.
Administrative, technical, or material support: Sella, Weiss, Metzger-Filho.
Supervision: Mittendorf, King, Metzger-Filho.
Conflict of Interest Disclosures: Dr Sella reported personal fees from Roche outside the submitted work, is a Goldfarb Advanced Fellow in breast oncology at the Dana-Farber Cancer Institute, and is also supported by the American Physicians Fellowship for Medicine in Israel and the Pinchas Burstein Talpiot Medical Leadership Program. Dr Weiss reported a sponsored research agreement with Myriad Laboratories Inc unrelated to the current work. Dr Mittendorf reported honoraria from Physician Education Resource; personal fees from serving on scientific advisory boards for Exact Sciences (formerly Genomic Health), Merck, and Roche/Genentech; grants from Roche/Genentech via a Stand Up to Cancer grant; funding through a sponsored research agreement from GlaxoSmithKline; uncompensated service on steering committees for Bristol Myers Squibb, Lilly, and Roche/Genentech; and additional support as the Rob and Karen Hale Distinguished Chair in Surgical Oncology. Dr King reported receiving speaker honoraria from and personal fees for serving on the advisory board for Exact Sciences (formerly Genomic Health). Dr Metzger-Filho reported institutional research funding from Pfizer, Roche/Genentech, Abbvie, the Breast Cancer Research Foundation, and the Maor Foundation, as well as funding from serving on the advisory board at GI Therapeutics, outside the submitted work. No other disclosures were reported.
Meeting Presentation: This work was presented at the San Antonio Breast Cancer Symposium; December 10, 2019; San Antonio, Texas.
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