Neoadjuvant therapy – Indications (Practice Point)
In patients with large tumours (who might not be candidates for breast-conserving surgery), consider the use of neoadjuvant systemic therapies to reduce tumour size and potentially enable breast-conserving surgery instead of mastectomy.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process.
Neoadjuvant therapy – Role of imaging before and after therapy (Practice Point)
In patients with breast cancer who are treated with neoadjuvant systemic therapy, use imaging prior to the commencement of therapy and at the completion of therapy, to assist with surgical planning. The type of imaging (ultrasound or MRI) will be dependent on the histopathology of the breast lesion. In addition, use localisation techniques in the breast lesion and in any biopsy-proven positive lymph nodes before therapy is commenced.
How this guidance was developed
No evidence-based source recommendation relevant to the current Australian healthcare context was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process. Specification of the type of imaging to be used was avoided as this should be individualised to the patient as judged by the radiologist.
Neoadjuvant therapy – Role of imaging during therapy
In patients with breast cancer who are treated with neoadjuvant systemic therapy, consider using imaging for assessment of response after initiation of therapy to allow treatment modification.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process.
Neoadjuvant therapy – Timing (Practice Point)
Neoadjuvant systemic therapy should start as soon as diagnosis and staging is completed (ideally within 2-4 weeks).
How this guidance was developed
This recommendation was adopted from the ESMO 2019 breast cancer guidelines (Europe). The source recommendation was based on a non-systematic review of the evidence (date not stated). The source recommendation was graded ‘A’ (based on adapted Infectious Diseases Society of America-United States Public Health Service Grading System) by the source guideline authors.
Neoadjuvant chemotherapy – Indications (Recommendation)
Consider neoadjuvant chemotherapy for suitable patients with breast cancer whose disease type is likely to show rapid response to chemotherapy and whose disease burden as assessed preoperatively indicates a need for chemotherapy. Suitable patients may include those with triple negative breast cancer, HER2-positive breast cancer, or luminal B hormonal cancer.
How this guidance was developed
This recommendation was adapted from three source recommendations in the NICE 2018 guidelines (UK). The source recommendations were based on a systematic review of the evidence conducted up to September 2017. Two of the source recommendations used wording (‘Offer’) indicative of a ‘strong’ recommendation and one used wording (‘Consider’) indicative of a conditional recommendation (using GRADE methods) by the source guideline authors. The source recommendations were merged, and the guidance was made less directive by replacing 'offer' with 'consider' for all indications.
Neoadjuvant chemotherapy – Decision-making (Recommendation)
Discuss the benefits and risks of neoadjuvant chemotherapy, including toxicity (with consideration of regulatory status), and effects on breast conservation rate, pathological complete response rate, and survival.
How this guidance was developed
This recommendation was adapted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted up to September 2017 and used wording ('Discuss') indicative of the need for shared decision-making by the source guideline authors. The source recommendation was adapted by making the discussion applicable to all neoadjuvant chemotherapy, not just consideration of a platinum-based agent.
Neoadjuvant chemotherapy – Regimens (Recommendation)
Suitable neoadjuvant chemotherapy regimens include those used for adjuvant chemotherapy. Consider the addition of a platinum-based agent for patients with triple negative cancer.
How this guidance was developed
This recommendation was adapted from two source recommendations, one from SIGN (2013) and one from the NICE 2018 guidelines (UK). The NICE source recommendation was based on a systematic review of the evidence conducted to September 2017 and used wording ('Consider') indicative of a conditional recommendation (using GRADE methods) by the source guideline authors. The SIGN recommendation was not graded. The source recommendations were merged and simplified, including removal of the specification of ‘anthracycline-taxane regimens’ and inclusion, instead, of a link to eviQ.
Neoadjuvant endocrine therapy – Indications (Recommendation)
Consider neoadjuvant endocrine therapy for postmenopausal women with ER-positive breast cancer as an option to reduce tumour size if there is no definite indication for chemotherapy.
How this guidance was developed
This recommendation was adopted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted to September 2017 and used wording ('Consider") indicative of a conditional recommendation (using GRADE methods) by the source guideline authors. The source recommendation was accepted with no changes.
It is noted that ESO-ESMO 2017 and ESO-ESMO 2020 indicate that ‘Neoadjuvant ET should not be routinely recommended for young women outside of clinical trials’.
