title: Preoperative chemotherapy: updates of National Surgical Adjuvant Breast and Bowel Project Protocols B-18 and B-27.
abstract: OBJECTIVE
  National Surgical Adjuvant Breast and Bowel Project (NSABP) Protocol B-18 was designed to determine whether four cycles of doxorubicin and cyclophosphamide (AC) administered preoperatively improved breast cancer disease-free survival (DFS) and overall survival (OS) compared with AC administered postoperatively. Protocol B-27 was designed to determine the effect of adding docetaxel (T) to preoperative AC on tumor response rates, DFS, and OS.
  
  
  METHODS
  Analyses were limited to eligible patients. In B-18, 751 patients were assigned to receive preoperative AC, and 742 patients were assigned to receive postoperative AC. In B-27, 784 patients were assigned to receive preoperative AC followed by surgery, 783 patients were assigned to AC followed by T and surgery, and 777 patients were assigned to AC followed by surgery and then T.
  
  
  RESULTS
  Results from B-18 show no statistically significant differences in DFS and OS between the two groups. However, there were trends in favor of preoperative chemotherapy for DFS and OS in women less than 50 years old (hazard ratio [HR] = 0.85, P = .09 for DFS; HR = 0.81, P = .06 for OS). DFS conditional on being event free for 5 years also demonstrated a strong trend in favor of the preoperative group (HR = 0.81, P = .053). Protocol B-27 results demonstrated that the addition of T to AC did not significantly impact DFS or OS. Preoperative T added to AC significantly increased the proportion of patients having pathologic complete responses (pCRs) compared with preoperative AC alone (26% v 13%, respectively; P < .0001). In both studies, patients who achieved a pCR continue to have significantly superior DFS and OS outcomes compared with patients who did not.
  
  
  CONCLUSIONS
  B-18 and B-27 demonstrate that preoperative therapy is equivalent to adjuvant therapy. B-27 also showed that the addition of preoperative taxanes to AC improves response.
authors.affiliation: University of Pittsburgh Cancer Institute/Magee Womens Hospital, 300 Halket St, Room 3524, Pittsburgh, PA 15213, USA. rastogip@upmc.edu
authors.forename: Priya
authors.initials: P
authors.lastname: Rastogi
authors.forename: Stewart J
authors.initials: SJ
authors.lastname: Anderson
authors.forename: Harry D
authors.initials: HD
authors.lastname: Bear
authors.forename: Charles E
authors.initials: CE
authors.lastname: Geyer
authors.forename: Morton S
authors.initials: MS
authors.lastname: Kahlenberg
authors.forename: André
authors.initials: A
authors.lastname: Robidoux
authors.forename: Richard G
authors.initials: RG
authors.lastname: Margolese
authors.forename: James L
authors.initials: JL
authors.lastname: Hoehn
authors.forename: Victor G
authors.initials: VG
authors.lastname: Vogel
authors.forename: Shaker R
authors.initials: SR
authors.lastname: Dakhil
authors.forename: Deimante
authors.initials: D
authors.lastname: Tamkus
authors.forename: Karen M
authors.initials: KM
authors.lastname: King
authors.forename: Eduardo R
authors.initials: ER
authors.lastname: Pajon
authors.forename: Mary Johanna
authors.initials: MJ
authors.lastname: Wright
authors.forename: Jean
authors.initials: J
authors.lastname: Robert
authors.forename: Soonmyung
authors.initials: S
authors.lastname: Paik
authors.forename: Eleftherios P
authors.initials: EP
authors.lastname: Mamounas
authors.forename: Norman
authors.initials: N
authors.lastname: Wolmark
mesh_terms: D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage*; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery; D017024:Chemotherapy, Adjuvant; D003520:Cyclophosphamide / Q000008:administration & dosage; D018572:Disease-Free Survival; D000077143:Docetaxel; D004317:Doxorubicin / Q000008:administration & dosage; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D011300:Preoperative Care; D016019:Survival Analysis; D043823:Taxoids / Q000008:administration & dosage
chemical_list: D043823:Taxoids; D000077143:Docetaxel; D004317:Doxorubicin; D003520:Cyclophosphamide