Sooner or later.

We all know systemic therapy has changed the breast cancer game. What we don’t know is whether to give it before or after surgery. But that hasn’t kept us from doing it. From 2003 to 2011 alone, rates of neoadjuvant chemo increased over 3-fold for stage IIIA cancers in the US and almost 10-fold for cT2 tumors in the Netherlands. In that context, the newest EBCTCG meta-analysis to weigh-in presents some pretty unnerving findings. The authors calculate 15-year outcomes in a combined analysis of 10 randomized trials comprising >4700 women and spanning almost 20 years of various neoadjuvant vs adjuvant chemos du jour. What did women buy with the neoadjuvant approach? The good: a higher rate of breast conservation (65% vs 49%), as expected. The bad: absolutely no advantage in rates of distant recurrence (38%) or cancer-specific (34%) or overall (41%) mortality, pretty much still expected. The ugly: a significantly higher rate of local recurrence (21% vs 16%), very much NOT expected. This, along with its reporting during a Southern snow, has us wondering if some of these tumors are melting like snowflakes rather than snowballs. After all, for surgeons tackling a treated tumor, what you see is what you get.