The Editor
Current Oncology
24 July 2015
Locally advanced breast cancer (labc) represents an advanced stage of heterogenous breast cancers that continues to invoke great interest. Neoadjuvant chemotherapy is used in an effort to cytoreduce the tumour burden and render inoperable cancers operable (or operable cancers amenable to breast conservation), but more has to be done to improve overall survival in this cohort.
Garg and Prakash reference the definition by Mandilaras and colleagues1 of labc as tumours larger than 5 cm or those associated with bulky metastatic lymph nodes on physical examination (TNM stage T3–4 or N2–3). Although we recognize that molecular tumour phenotypes (estrogen receptor, progesterone receptor, and her2 status) and an ever-increasing list of genotypic subtypes (Ki-67Hi, anti–PD-L1+, etc.) can behave very differently clinically, treatment decisions currently continue to be made based on past trials and publications. A systematic review of labc trials and publications2 completed in 2014 demonstrated that most included T3 (even T3N0), T4, and N2–3 patients. Our 2014 locoregional labc treatment guideline therefore included those patients in our definition of labc3. It should be recognized that clinical T3N0 represents a small subset of patients, most of whom are eventually found to have pathologically node-positive disease, such that our definition of labc and that of Mandilaras et al. aligns with the U.S. National Comprehensive Cancer Network definition4. Fortunately, revised TNM staging by the American Joint Committee on Cancer, expected to include tumour phenotypes, is currently under way and is expected in early 20175.
The goal of the Mandilaras publication1 was to entice readers to rethink the standard paradigm: neoadjuvant chemotherapy with or without biologic therapies, surgery, adjuvant radiation, and hormone therapy. They proposed making every attempt to improve locoregional response by exploiting treatments used in other disease sites such as radiosensitization through concurrent neoadjuvant chemotherapy and radiation, which is increasingly being evaluated6,7.
The goal in attempting to define labc using a large umbrella is that, although physicians will see a spectrum of clinical presentations, the term “labc” will prompt them to consider that the patient in front of them could have a more aggressive-behaving tumour and might therefore benefit from participation in clinical trials, from the use of novel neoadjuvant treatment regimens, and from the use of appropriate biologic therapies as they evolve, with the hope of halting the disease before any metastatic process takes hold.
CONFLICT OF INTEREST DISCLOSURES
I have read and understood Current Oncology’s policy on disclosing conflicts of interest, and I declare that I have none.
REFERENCES
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