Guidelines

Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer

Published ahead of print January 28, 2021, DOI: 10.1200/JCO.20.03399
Larissa A. Korde, MD; Mark R. Somerfield, PhD; Lisa A. Carey, MD; Jennie R. Crews, MD; Neelima Denduluri, MD; E. Shelley Hwang, MD; Seema A. Khan, MD; Sibylle Loibl, MD, PhD; Elizabeth A. Morris, MD; Alejandra Perez, MD; Meredith M. Regan, ScD; Patricia A. Spears, BS; Preeti K. Sudheendra, MD; W. Fraser Symmans, MD; Rachel L. Yung, MD; Brittany E. Harvey, BS; and Dawn L. Hershman, MD

Rapid Recommendation Update

Published online February 28th, 2022

Updated Recommendation: For patients with T1cN1-2 or T2-4N0 (stage II or III), early-stage triple negative breast cancer, the Panel recommends use of pembrolizumab (200 mg every 3 weeks or 400 mg every 6 weeks) in combination with neoadjuvant chemotherapy, followed by adjuvant pembrolizumab after surgery. Adjuvant pembrolizumab may be given either concurrent with or after completion of radiation therapy. Given that immune-related adverse events (irAEs) associated with pembrolizumab therapy can be severe and permanent, careful screening for and management of common toxicities are required. The ASCO guideline for management of irAEs in patients treated with immune checkpoint inhibitor therapy offers detailed practice recommendations and should be consulted by clinicians who prescribe pembrolizumab for patients with early-stage TNBC, https://ascopubs.org/doi/full/10.1200/JCO.21.01440.

2021 Guideline Abstract

Purpose: To develop guideline recommendations concerning optimal neoadjuvant therapy for breast cancer.

Methods: ASCO convened an Expert Panel to conduct a systematic review of the literature on neoadjuvant therapy for breast cancer and provide recommended care options.

Results: A total of 41 articles met eligibility criteria and form the evidentiary basis for the guideline recommendations.

Recommendations: Patients undergoing neoadjuvant therapy should be managed by a multidisciplinary care team. Appropriate candidates for neoadjuvant therapy include patients with inflammatory breast cancer and those in whom residual disease may prompt a change in therapy. Neoadjuvant therapy can also be used to reduce the extent of local therapy or reduce delays in initiating therapy. Although tumor histology, grade, stage, and estrogen, progesterone, and human epidermal growth factor receptor 2 (HER2) expression should routinely be used to guide clinical decisions, there is insufficient evidence to support the use of other markers or genomic profiles. Patients with triple-negative breast cancer (TNBC) who have clinically node-positive and/or at least T1c disease should be offered an anthracycline- and taxane-containing regimen; those with cT1a or cT1bN0 TNBC should not routinely be offered neoadjuvant therapy. Carboplatin may be offered to patients with TNBC to increase pathologic complete response. There is currently insufficient evidence to support adding immune checkpoint inhibitors to standard chemotherapy. In patients with hormone receptor (HR)-positive (HR-positive), HER2-negative tumors, neoadjuvant chemotherapy can be used when a treatment decision can be made without surgical information. Among postmenopausal patients with HR-positive, HER2-negative disease, hormone therapy can be used to downstage disease. Patients with node-positive or high-risk node-negative, HER2-positive disease should be offered neoadjuvant therapy in combination with anti-HER2-positive therapy. Patients with T1aN0 and T1bN0, HER2-positive disease should not be routinely offered neoadjuvant therapy.

Guideline Disclaimer

The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action. The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary. ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.

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