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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 149-150

Changing the paradigm of treatment in locally advanced breast cancers: Can we impact outcomes in resource-limited settings by improving pathological complete response?

Department of Radiation Oncology, Cancer Institute, Chennai, Tamil Nadu, India

Date of Submission17-Jan-2022
Date of Decision24-Jan-2022
Date of Acceptance25-Jan-2022
Date of Web Publication24-Feb-2022

Correspondence Address:
Priya Iyer
Department of Radiation Oncology, Cancer Institute, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/crst.crst_32_22

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How to cite this article:
Iyer P. Changing the paradigm of treatment in locally advanced breast cancers: Can we impact outcomes in resource-limited settings by improving pathological complete response?. Cancer Res Stat Treat 2022;5:149-50

How to cite this URL:
Iyer P. Changing the paradigm of treatment in locally advanced breast cancers: Can we impact outcomes in resource-limited settings by improving pathological complete response?. Cancer Res Stat Treat [serial online] 2022 [cited 2022 Aug 11];5:149-50. Available from: https://www.crstonline.com/text.asp?2022/5/1/149/341283

Breast cancer is the most common malignancy in women worldwide.[1] In low- and middle-income countries (LMICs) like India, locally advanced breast cancer (LABC) accounts for nearly 40%–50% of breast cancer cases.[1] Operability is the main goal in LABC and is essentially what led to the genesis of neoadjuvant chemotherapy (NACT). NACT is also used to facilitate breast conservation surgeries in operable LABC.

Pathological complete response (pCR) is a surrogate marker for improved disease-free survival. However, it has not been shown to impact overall survival.[2] There are certain subtypes such as triple-negative and HER2/neu-positive breast cancer, where the attainment of pCR after NACT gives valuable prognostic information.[3] However, in LMICs like India, not all patients can afford expensive anti-HER2-directed treatments. Sadly in today's world, a person's birthplace determines his or her survival.[4] Can oncologists make a difference in treatment with the available technology or resources in such a scenario?

The article by Choudhary et al. published in the previous issue of the journal used an exhaustive methodology. The study has highlighted the importance of pCR after NACT by quoting several studies.[5] However, the authors have missed a few key points and studies, which I would like to highlight.

One of the first reports on NACT and pCR in breast cancer from India was the study by Shanta et al.[6] They evaluated 1117 patients treated with neoadjuvant concurrent chemoradiotherapy; they used a simple chemotherapy regimen, as this was before the widespread use of NACT. They compensated for the lack of novel chemotherapeutic agents by using radiosensitizing chemotherapy. The study reported an impressive pCR rate of 45.1%.

A study by Iyer et al. also showed a pCR rate of 37.7% from concurrent chemoradiation in LABC. HER2/neu-positive patients who were unable to receive neoadjuvant HER2-directed treatment were included in the study. The pCR rate attained as a result of neoadjuvant chemoradiotherapy was similar to that reported in the literature for HER2-positive patients treated with neoadjuvant HER2-directed treatment.[7]

Recently, Dhanushkodi et al. published the largest series on neoadjuvant treatment and pCR in LABC in India.[8]

The above-mentioned studies focused on the use of neoadjuvant concurrent chemoradiation as a novel approach in inoperable LABC in resource-constrained settings. Neoadjuvant chemoradiation is especially useful in patients with inoperable LABC with an inadequate response to the initial NACT regimen. Neoadjuvant chemoradiation is an important option in patients who cannot afford or do not have access to novel NACT regimens.

The title of the study by Choudhary et al. suggests that the authors only included patients with LABC.[5] However, stage II patients were reported as part of the analysis. I request clarification from the authors regarding what definition of LABC they used in the study.

In conclusion, the study by Choudhary et al. reiterates the role of NACT to improve the pCR rates and discriminate responders from non-responders, which is useful for guiding further systemic therapy. However, pCR is only a surrogate marker and does not predict for superior survival in responders.[9] Hence, the need for NACT, especially in early breast cancer, should not be driven by the need to attain a pCR. Instead, it should be used as a prognostic tool in LABC to guide further treatments. Prospective multicenter trials exploring the use of neoadjuvant concurrent chemoradiation in breast cancer should be undertaken to understand its effectiveness in LABC.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.  Back to cited text no. 1
Pennisi A, Kieber-Emmons T, Makhoul I, Hutchins L. Relevance of pathological complete response after neoadjuvant therapy for breast cancer. Breast Cancer (Auckl) 2016;10:103-6.  Back to cited text no. 2
Sharma RK, Gogia A. Management of triple-negative breast cancer in the era of novel therapies: A narrative review. Cancer Res Stat Treat 2021;4:668-76.  Back to cited text no. 3
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Manuprasad A, Shenoy PK, Jones J, Vinin NV, Dharmarajan A, Muttath G. Short-course adjuvant trastuzumab in breast cancer: Experience from a tertiary cancer center in rural India. Cancer Res Stat Treat 2020;3:69-73.  Back to cited text no. 4
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Choudhary P, Gogia A, Deo SV, Sharma D, Mathur SR, Batra A, et al. Correlation of pathological complete response with outcomes in locally advanced breast cancer treated with neoadjuvant chemotherapy: An ambispective study. Cancer Res Stat Treat 2021;4:611-20.  Back to cited text no. 5
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Shanta V, Swaminathan R, Rama R, Radhika R. Retrospective analysis of locally advanced noninflammatory breast cancer from Chennai, South India, 1990-1999. Int J Radiat Oncol Biol Phys 2008;70:51-8.  Back to cited text no. 6
Iyer P, Radhakrishnan V, Balasubramanian A, Sridevi V, Krishnamurthy A, Dhanushkodi M, et al. Study of pathological complete response rate with neoadjuvant concurrent chemoradiation with paclitaxel in locally advanced breast cancer. Indian J Cancer 2020;57:428-34.  Back to cited text no. 7
[PUBMED]  [Full text]  
Dhanushkodi M, Sridevi V, Shanta V, Rama R, Swaminathan R, Selvaluxmy G, et al. Locally advanced breast cancer (LABC): Real-World Outcome of Patients From Cancer Institute, Chennai. JCO Glob Oncol 2021;7:767-81.  Back to cited text no. 8
Badwe RA, Parmar V, Nair NS. Predicting pathological complete response post neoadjuvant chemotherapy and personalizing therapy in breast cancer. Cancer Res Stat Treat 2021;4:726-7.  Back to cited text no. 9
  [Full text]  


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