Changes in Management Strategy and Impact of Neoadjuvant Therapy on Extent of Surgery in Invasive Lobular Carcinoma of the Breast: Analysis of the National Cancer Database (NCDB)

Background: Given reports of low response rates to neoadjuvant chemotherapy (NAC) in invasive lobular carcinoma (ILC), we evaluated whether use of alternative strategies such as neoadjuvant endocrine therapy (NET) is increasing. Additionally, we investigated whether NET is associated with more breast conservation surgery (BCS) and less extensive axillary surgery in those with ILC.

Patients and methods: We queried the NCDB from 2010 to 2016 and identified all women with stage I-III hormone receptor positive, human epidermal growth factor receptor-2 negative (HR+/HER2-) ILC who underwent surgery. We used Cochrane-Armitage tests to evaluate trends in utilization of the following treatment strategies: NAC, short-course NET, long-course NET, and primary surgery. We compared rates of BCS and extent of axillary surgery stratified by clinical stage and tumor receptor subtype for each treatment strategy.

Results: Among 69,312 cases of HR+/HER2- ILC, NAC use decreased slightly (from 4.7 to 4.2%, p = 0.007), while there was a small but significant increase in long-course NET (from 1.6 to 2.7%, p < 0.001). Long-course NET was significantly associated with increased BCS in patients with cT2-cT4 disease and less extensive axillary surgery in clinically node positive patients with HR+/HER2- tumors.

Conclusions: Primary surgery remains the most common treatment strategy in patients with ILC. However, NAC use decreased slightly over the study period, while the use of long-course NET had a small increase and was associated with more BCS and less extensive axillary surgery.