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. 2025 Mar;51(3):109587.
doi: 10.1016/j.ejso.2025.109587. Epub 2025 Jan 7.

Long-term outcome for neoadjuvant versus adjuvant chemotherapy in early breast cancer and the prognostic impact of nodal therapy response: A population-based study

Xingrong Liu  1 , Louise Eriksson Bergman  2 , Caroline Boman  3 , Theodoros Foukakis  3 , Alexios Matikas  4
Affiliations
Free article

Long-term outcome for neoadjuvant versus adjuvant chemotherapy in early breast cancer and the prognostic impact of nodal therapy response: A population-based study

Xingrong Liu et al. Eur J Surg Oncol. 2025 Mar.
Free article

Abstract

Introduction: Although neoadjuvant systemic treatment for non-metastatic breast cancer has gained ground during the past decade, there is no compelling evidence that it improves overall survival compared to primary tumor resection and adjuvant treatment. At the same time, the approach to responders to neoadjuvant treatment in the axilla is evolving.

Materials and methods: This is a retrospective analysis of a prospectively collected population-based registry. Patients that received neoadjuvant (n = 2126) or adjuvant chemotherapy (n = 4754) for non-metastatic breast cancer during 2007-2020 in the Stockholm-Gotland region, which comprises 25 % of the entire Swedish population, were included. Overall survival of patients treated preoperatively and postoperatively was compared using inverse probability treatment weighting and landmark analysis. The prognostic impact of change between prechemotherapy clinical to postchemotherapy pathologic nodal stage (cN/pN) in women receiving neoadjuvant treatment was investigated.

Results: Median follow-up was 4.93 years. There was no difference in adjusted overall survival between adjuvant (reference) and neoadjuvant treatment in the entire population (HR = 1.38, 95 % CI 0.98-1.93, p = 0.062) or in breast cancer subtypes. Patients converting from positive clinical to negative pathologic nodal stage (cN+/pN0) had improved outcomes compared to cN0/pN0 or patients with pN0 following primary surgery. These patients had a particular disease trajectory, with early peak in risk of death followed by quick and sustained decrease.

Conclusion: There was no difference in survival of patients treated with neoadjuvant versus adjuvant systemic therapy for non-metastatic breast cancer. Patients with cN+/pN0 have excellent prognosis and represent potential candidates for de-escalation of local and systemic treatment.

Keywords: Adjuvant; Breast cancer; Neoadjuvant; Nodal stage; Population-based.

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Conflict of interest statement

Declaration of competing interest Theodoros Foukakis: institutional fees for consultancy to AstraZeneca, Gilead and Roche; personal fees for consultancy to Affibody, Pfizer, Novartis, Veracyte, Exact Sciences; honoraria from UpToDate; research funding to institution from Pfizer, AstraZeneca, Novartis and Veracyte. Alexios Matikas: speaker/consultancy (no personal fees) to Veracyte, Roche, Seagen; research funding paid to institution by Merck, AstraZeneca, Novartis, Veracyte, all unrelated to the current work. All the other authors had no potential conflicts of interest to disclose.

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