The uses of neoadjuvant chemotherapy in the setting of breast cancer have expanded widely over the past decade. Although the benefits of neoadjuvant chemotherapy in reducing tumor size appear to be well-recognized , little is known about the real-world experience with the indications and outcomes of neoadjuvant chemotherapy in developing countries, like Egypt. In this study, we aimed to present an Egyptian center experience regarding the use of neoadjuvant systemic chemotherapy for the management of women with operable, non-inflammatory, stage II and III breast cancer. Our results indicated that the neoadjuvant chemotherapy led to a notable increase in the proportion of breast cancer patients who performed breast conservative surgery. Besides, more than two-thirds of the patients, who underwent breast conservative surgery, achieved pCR. The conversion of the patients to breast conservative surgery after neoadjuvant chemotherapy did not have a negative impact on the recurrence rate as well. The comparative analysis showed that patients who responded to neoadjuvant chemotherapy were more likely to be younger, HER-2 positive, and had lower tumor grade and stage.
Breast conservative surgery is the modality of choice for early breast cancer (stage I-II) due to its comparable survival benefits and better cosmetic outcome, compared to radical surgery . In patients with more advanced carcinoma, a relatively lower proportion of the patients become eligible for breast conservative surgery, who are usually young patients with small localized tumor and favorable physical status . Neoadjuvant chemotherapy has the advantages of downstaging tumor size before surgery and assessing treatment response. In return, neoadjuvant chemotherapy can permit less-invasive surgery, better cosmetic outcomes, and less risk of postoperative lymphedema. An additional advantage of neoadjuvant chemotherapy is its ability to aid intraoperative tumor recognition and reduce the possibility of extensive residual disease [19, 20]. In light of the aforementioned benefits of neoadjuvant chemotherapy, several studies have assessed the efficacy in increasing the rate of breast cancer patients eligible for conservative surgery. In this report, we found that the use of neoadjuvant chemotherapy increased the proportion of women eligible for breast conservative surgery by 50%. In line with these findings, Debled et al. , noted that 71% of HER2-positive patients underwent breast conservative surgery after neoadjuvant chemotherapy. The same results were obtained by Semiglazov et al. , Vergine et al. , and Cho et al . In Golshan et al. , 42% of patients who were initially deemed ineligible were converted by neoadjuvant chemotherapy to breast conservative surgery. In a previous meta-analysis, the neoadjuvant chemotherapy led to breast conservative surgery in nearly 65% of the patients . However, the current literature shows controversy regarding the positive impact of neoadjuvant chemotherapy on the rate of breast conservative surgery. According to Boughey et al. , the neoadjuvant chemotherapy did not increase the rate of conservative surgery among women with invasive breast cancer.
Higher pCR can intuitively favor the decision of performing breast conservative surgery, in patients who were previously candidates for mastectomy . In this regard, the emergence of taxanes, and other novel agents, has dramatically improved the pathological response following neoadjuvant chemotherapy and, hence, improved the clinical outcomes of the patients . In this study, we found that, out of the 72 patients who underwent conservative surgery, a total of 55 (76.4%) patients were found to have pCR. Such findings may reflect that downsizing the tumor can increase the chance of performing breast-conservative surgery without compromising the oncological outcomes. Previously, it was found that patients with pCR had better survival outcomes than patients without pCR and underwent breast-conservative surgery .
Local recurrence is a major concern in patients undergoing breast-conservative surgery, previous reports indicated that up to 15% of the patients undergoing conservative surgery will develop locoregional recurrence . However, the application of neoadjuvant chemotherapy can potentially reduce the risk of recurrence. In a recent meta-analysis, the rate of recurrence in patients received neoadjuvant chemotherapy and breast-conservative surgery was 9.2%, compared to 8.3% in the mastectomy group . In the present study, we found that the 5-year local recurrence-free rate was 98%; the difference between patients who underwent breast conservative surgery and total mastectomy was not statistically significant. Our findings run in line with the results of NSABP-B18 trial  and other studies [3, 30]. The study by Ishitobi et al. , also found no significant difference in local recurrence-free rate according to type of surgery after neoadjuvant chemotherapy in patients with a planned mastectomy at the initial exam.
We acknowledge the existence of certain limitations of the present study. The current study was a retrospective chart review, with the inherited limitations of misclassifications, missing data, or recording errors. Besides, the results of genetic testing were not available for all patients, which might have affected the choice of surgery. There were no clear data regarding the causes underlying patients’ choice to undergo total mastectomy, despite being eligible for conservative surgery. The choice of surgery was based mainly on the surgeon’s decision, which may introduce biases in the decision-making process. Lastly, all patients underwent breast magnetic resonance imaging (MRI) after neoadjuvant chemotherapy, which could have increased the rate of mastectomy in the present study; previous studies reported that MRI was a major factor for the increased rate of mastectomy due to its ability to detect additional abnormalities .