Regarding: Valero V, Buzdar AU, Hortobagyi GN. "Locally Advanced Breast Cancer," The Oncologist 1996;1:8-17

Abstract

To the Editors: I read with interest Valero et al.'s review showing a lack of any increased cure rate over surgery from use of neoadjuvant combination therapy for locally advanced breast cancer, although a definite gain from breast conservation. Missing was any mention of hormone therapy [1] despite some of the best neoadjuvant results being from the use of Tamoxifen® in the elderly [2]. Interestingly, the highest complete remission rate in Valero et al.'s review (52%) was in a regimen including Tamoxifen® [3]. In addition, Bartlett et al. have reported that hormone therapy is superior to chemotherapy as adjuvant in estrogen receptor-positive tumors [4]. With new data from the study of radiotherapy demonstrating prostate tumor cell kill to be far higher when radiation treatment follows hormone therapy rather than when given concurrently or after therapy [5], there is a need for studies to investigate whether the same applies to hormone therapy when combined with chemotherapy in breast cancer. Further support for this comes from the latest overview of the effect of menstrual cycle timing and breast cancer surgery. The greatest gain from operating on premenopausal women occurs when the operation takes place during the progestergenic phase of the menstrual cycle, particularly in advanced node-positive patients and those with high levels of progesterone pre-op attributed to high survival [6]. With increasing recognition that trauma-induced cytokine release can be a factor in tumor acceleration [7], there is a case to consider hormones followed by chemotherapy plus radiation before any major surgical interference [1], most particularly in the rare subgroup of poor-risk tumors arising during pregnancy [8]. AUTHORS' RESPONSE: We appreciate the comments of Professor Oliver regarding our review. It has been recognized for decades that breast cancer is a systemic disease. Regional and distant micro- metastases occur early, and are part of the natural history of this illness. Adjuvant chemotherapy is an integral part of the curative management of patients with primary breast cancer, including locally advanced breast cancer (LABC). The benefit derived from this therapeutic approach is well documented, and persists beyond 10 years of follow-up [1, 2]. While we recognize the paucity of studies in direct support of this statement in patients with operable LABC, a few randomized trials have been completed and published [3, 4], and the world overview of randomized trials also demonstrated this benefit [1, 2]. Several randomized studies are under way to assess the relative efficacy of primary (or neoadjuvant) versus adjuvant chemotherapy in patients with early breast cancer, as well as operable LABC. For patients with inoperable LABC the window of opportunity to perform randomized trials with local therapy only as a control arm was lost many years ago. However, the results of phase II trials compare favorably with outcomes of historical control series. We agree that adjuvant hormonal therapy is also an integral part of optimal management of selected patients with LABC (those >50 years old, and with estrogen receptor-positive tumors). The world overview demonstrated an additive effect in women treated with both systemic modalities. Therefore, for this high-risk group of patients, combined hormone and chemotherapy for those who present with hormone-responsive breast cancer might be the treatment of choice. On the other hand, the role of neoadjuvant hormonal therapy alone remains to be defined. When we last reviewed this issue [5], only limited data were available, and the results did not appear superior to local treatments without systemic therapy. We (and others) are prospectively assessing the role of neoadjuvant tamoxifen in selected patients with LABC (those who are elderly and those patients unfit for chemotherapy). Professor Oliver's comments about other important areas in breast cancer research were beyond the scope of our review.