Synopsis
Select systemic treatment before surgery for defined biological and local-control goals, establish measurable baselines, and use response and residual disease to guide later care.
- Neoadjuvant treatment is systemic therapy given before surgery to treat micrometastatic risk, improve operability or conservation and reveal in-vivo treatment response.
- Secure core histology, ER, PR and HER2, axillary assessment and appropriate clinical staging before treatment; mark the breast target and any proven node that may become occult.
- Where neoadjuvant chemotherapy is indicated for HER2-positive invasive cancer, NICE says offer it within relevant commissioning criteria; pertuzumab with trastuzumab is an option for defined high-risk disease.
Investigation priorities
Confirm invasive cancer and define ER, PR and HER2 before selecting systemic treatment.
Management branches
A 43-year-old has a 45 mm HER2-positive invasive cancer and a clipped biopsy-proven axillary node; neoadjuvant chemotherapy is indicated.
- In this illustrative case, core pathology confirms a 45 mm HER2-positive invasive tumour and the sampled axillary node is metastatic. The breast target and proven node are durably marked, pretreatment clinical stage and imaging are recorded, and indicated distant staging shows no metastases.
- The oncology team confirms cardiac fitness and the relevant high-risk neoadjuvant eligibility. After the patient discusses benefits, toxicity and fertility implications, she starts the selected taxane-containing chemotherapy and trastuzumab-based HER2 treatment through the commissioned pathway.