The neoadjuvant approach to treatment of breast cancer: Multidisciplinary management to improve outcomes

Over the last several decades, the treatment of breast cancer has evolved from a reliance on radical surgery to less invasive treatments incorporating systemic therapy (e.g., chemotherapy and endocrine therapy) and radiotherapy, which has allowed for breast conservation surgery and improved survival. Accordingly, the management of breast cancer today is perhaps the best example of multidisciplinary cancer care. Surgeons work closely with radiologists, medical oncologists, radiation oncologists, and other specialists to design the optimal treatment plan for their patients. This cross-disciplinary collaboration and communication is especially well-illustrated in the neoadjuvant approach to breast cancer management. Neoadjuvant therapy provides several advantages to patients with newly diagnosed early-stage breast cancer. Current neoadjuvant regimens include chemo-immunotherapy for patients with triple negative disease, chemotherapy with human epidermal growth factor-2 (HER2) targeted therapy for patients with HER2+ disease, and chemotherapy or endocrine therapy for patients with hormone receptor positive/HER2- cases. As many studies have shown, tumor biology impacts the response to neoadjuvant therapy, including rates of pathologic complete response. Neoadjuvant approaches continue to grow in complexity, calling for increased cross-specialty understanding of its indications and treatment algorithms. Therefore, in this review we discuss contemporary neoadjuvant therapy approaches, with a focus on the interplay between imaging, systemic therapy, radiotherapy, and surgical management.