Surgery Seen as Adjunct to Chemo in Some Invasive Breast Cancers

CHICAGO--Because adjuvant systemic chemotherapy has led to real andmeaningful improvement in long-term disease-free and overall survival ofwomen with invasive breast cancer, "perhaps the primacy of surgeryis not sacrosanct," said David Hyams, MD, executive medical officerof the NSABP, Allegheny General Hospital, Pittsburgh.

"Perhaps we should consider whether surgery should become the adjuvantof more effective systemic management of breast cancer," he added.

Speaking at the Society of Surgical Oncology meeting, Dr. Hyams saidthat in several clinical trials, "alternative surgical techniqueshave not resulted in a survival difference" for women with invasivecarcinoma of the breast.

In NSABP protocol B18, women with operable breast cancer were randomizedto receive surgery followed by chemotherapy--doxorubicin and cyclophosphamide,with adjuvant tamoxifen (Nolvadex) for those over age 50--or chemotherapyfirst, then surgery. The trial included 1,508 women with cancer in stagesT1, T2, or T3 that was palpable and confined to the breast but not fixed.

The 748 women who underwent preoperative chemotherapy had an overallresponse rate of 79% (35%, complete response, and 44%, partial response),and another 17% had stable disease. Of the 4% whose disease continued toprogress after preoperative chemotherapy, all had operable tumors. Moreover,among the patients who had a complete clinical response, 24% showed nosigns of tumor on pathologic evaluation, and 11% had only noninvasive cancer.

Preoperative chemotherapy decreased the number of positive nodes presentat surgery by 18%, and most women (84%) had 0 to 3 positive nodes at surgery.

There are no data as yet from B18 on the effects of preoperative chemotherapyon disease-free or overall survival, Dr. Hyams said. He nevertheless believesthat findings from B18, and from another ongoing trial (B27), could provethat surgery may become adjunctive. "If we can identify those patientswho undergo a complete pathologic response, these individuals may not needsurgery at all."