Combined Hormone Therapy at Menopause and Breast Cancer: A Warning—Short-Term Use Increases Risk

Abstract

years is necessary. 7 Not all patients are appropriately treated with preoperative chemoradiotherapy,particularlythosewithpathologicallynegativepelvic nodes. In the German trial reported by Sauer et al, 3 18% of patients who were considered to have cT3N0 disease and underwent initial surgery without preoperative therapy actually had pT1-2N0 disease. Thosepatientswouldhavebeenovertreatedhadtheyreceivedpreoperative therapy. The subset of patients with cT3N0 disease were not reported in the NSAPB R-03 trial. 4 However, for all patients who underwent surgery first, 4% had pT1-2N0 disease and would have therefore been overtreated had they received preoperative therapy. Although not ideal, administering preoperative therapy is still preferred to performing initial surgery, because even after preoperative chemoradiotherapy (which downstages tumors) 22% of patients will have lymph node‐pathologically positive disease at time of surgery. 8 Inpatientswhoundergosurgeryalone,thisnumberisashigh as 40%. These patients will then require postoperative chemoradiotherapy, in which inferior local control, higher acute and chronic toxicity,and—whenlowanastomosiswasperformed—inferiorfunctional results were demonstrated in the CAO/ARO/AIO 94 trial, 3 compared with preoperative chemoradiotherapy. Clearly, the development of more accurate methods to identify lymph node-positive disease, including improved imaging techniques and molecular markers, is essential as more patients are treated with preoperative chemoradiotherapy.Otherinvestigatorsadvocatetheselectionofpreoperative therapy on the basis of risk of a positive circumferential identified by high-resolution magnetic resonance imaging. 9 Highresolution magnetic resonance imaging was not used in the CAO/ ARO/AIO 94 and NSABP R-03 trials. The most pressing question is notwhetherpreoperativetherapyispreferred;rather,itishowtomore