Hormone treatment for breast cancer is called neoadjuvant chemotherapy, when chemotherapy is given before surgical operation. Chemotherapy after surgical operation for breast cancer is called adjuvant therapy. Dr. Anton Titov, MD.: How to select neoadjuvant and adjuvant chemotherapy, hormone therapy protocols for treating breast cancer? Are protocols the same? So you can use neoadjuvant therapy, endocrine neoadjuvant therapy, chemotherapy, or adjuvant chemotherapy or adjuvant endocrine therapy. So you can do both. Randomized clinical trials have suggested that neoadjuvant therapy and adjuvant therapy makes no difference in survival of patients with breast cancer. So it doesn't matter enormously what you do in terms of survival. Dr. Marc Lippman, MD.: But in the neoadjuvant therapy, you have many, many, many advantages. First of all, it's easy for patients with larger tumors to downstage tumors. So a patient might not be suitable for lumpectomy and breast conservation. Almost all patients will respond to neoadjuvant chemotherapy, and most patients will respond to neoadjuvant endocrine therapy, so that tumors will shrink. One, it shows you, what breast cancer therapy will work. So it can guide breast cancer therapy once the tumors are removed. From a research point of view, we are extremely enthusiastic about neoadjuvant therapy because you have an initial biopsy of breast cancer tumor. And then, when the patient goes to surgery after the neoadjuvant therapy is completed, you can get more breast cancer tissue. And you can see what is the effect your treatment had on breast cancer. And it's a tremendously valid way to develop new breast cancer therapies. There's something called pathologic complete response. And miraculously, depending on the disease subtype, subsets of breast cancer patients will have every last cancer cell disappear from the breast when you give them neoadjuvant therapy. That's fabulous. And pathologic Complete Response (pCR) is a tremendous predictor of survival. We know that patients who have a pathologic Complete Response don't commonly need additional systemic therapy after the surgery, which is wonderful. So neoadjuvant therapy is very useful for guiding breast cancer therapy. Dr. Marc Lippman, MD.: But there is not a big survival advantage, giving [medical breast cancer therapy] before or after surgery, at this time. Neoadjuvant endocrine therapy doesn't induce complete responses as often, mostly because neoadjuvant therapy probably isn't given for long enough time. And now some wonderful new adjuvant clinical trials are going to go for six or eight months to see the effect of longer-term neoadjuvant endocrine therapies in breast cancer. I await the results of those clinical trials with tremendous interest. Finally, in the United States, we amazingly over-treat patients. It's just amazing. You see breast cancer patients in their 80s. They're infirm and not well. And doctors are talking about mastectomy and radiation therapy, and all this other treatments. Dr. Marc Lippman, MD.: But there's a lovely study done in England for women over 80 who were diagnosed with breast cancer that was ER-positive. Doctors put them on Tamoxifen, no surgery, no radiation, just a tamoxifen pill. And the majority of those women died of something else. In other words, Tamoxifen for these elderly women with indolent ER-positive breast cancer was enough to control their disease till something else got them. I think that speaks [in favor of not over-treating elderly infirm patients with breast cancer.] I mean, that's the mother of all neoadjuvant studies, because you're giving it before any therapy, and you're just not quitting. That so it's obvious that endocrine neoadjuvant therapy can be very effective. Plus, it's child's play, to follow a woman to see if you're controlling the cancer in a breast. If she's got a lump, you can feel it. It takes thumb and index finger to tell whether she's doing well or not, right? Or a simple imaging test. So there's no emergency here. So neoadjuvant therapy in infirm patients with breast cancer could be very attractive, in my mind, but it's not done so much in this country. England has led the way there. No one's tried it yet here. Well, some years ago, I hate to say how many, we first developed neoadjuvant therapy at the National Cancer Institute, when I ran the breast cancer program there. We didn't know how to do neoadjuvant chemotherapy in breast cancer. Who knew? No one had ever done neoadjuvant therapy in breast cancer before. So we took women, and we said, we don't know how long to give neoadjuvant endocrine therapy. So we'll just give it until we reach the best response and just keep giving them cycle after cycle. We don't care. And as long as we can measure what's going on, why would we stop, right? As long as the breast cancer tumor is shrinking. And interestingly, even though neoadjuvant regimens these days are usually four or six cycles of therapy, the median number of cycles to the best response, in our hands was five. It means that half the women took 7-8-9-10 cycles of neoadjuvant hormonal therapy to get to their best response. So that was very, very instructive for breast cancer treatment by endocrine therapy. So I don't think even the best way to do neoadjuvant therapy for breast cancer had been fully identified. Maybe the best way is to base neoadjuvant therapy on how the patient herself is doing, rather than on some preconceived cookbook regimen boiled for half an hour.