Treating breast cancer before surgery

The benefits of systemic treatment of breast cancer have been recognised in Britain for over a century1; but for most of this period international medical practice has been more influenced by enthusiasm for aggressive local treatments, including radical breast surgery.2 The rise of evidence based research revived interest in medical anticancer treatment, culminating in recent confirmation of longer survival after adjuvant systemic treatments.3 In contrast, randomised trials of local breast cancer treatments failed to establish any substantive overall survival benefit.4 Happily, this failure spawned the first revolution of 20th century breast cancer treatment: the advent of conservative surgery. Hence the only intervention proved to alter the natural course of breast cancer is effective adjuvant systemic treatment. Despite this, adjuvant prescribing habits have been one of Britain's most volatile therapeutic variables in recent years.5 A new NHS report6 has invoked this variability to help explain startling survival differences (12–23% at five years) reported between specialist and non-specialist breast cancer units.7 The down side of this upbeat view of adjuvant treatment is the …