In select cases, treatment with chemotherapy, targeted therapy or hormone therapy may be given before breast surgery. When treatment is given before surgery, it is called neoadjuvant (NEE-oh-A-joo-vant) therapy or preoperative therapy.
Neoadjuvant chemotherapy and hormone therapy drugs are the same as those used after surgery (called adjuvant therapy). Some neoadjuvant targeted therapy drugs are not used in the adjuvant setting though.
Before neoadjuvant therapy begins, you will have a needle biopsy to remove a small amount of tumor tissue. A radio-opaque clip is often placed in the tumor bed so the tumor can be found later when you have surgery. (This clip will be removed during surgery.)
Tests on the biopsy tissue confirm your diagnosis and identify tumor characteristics, such as hormone receptor status and HER2 status. These factors determine the type(s) of neoadjuvant therapy that will offer the most benefit.
Learn more about hormone receptor status and HER2 status.
If your treatment plan includes chemotherapy, neoadjuvant chemotherapy may be an option as a first treatment.
Chemotherapy has the same effectiveness whether it is given before surgery or after surgery. The timing of chemotherapy around surgery does not affect survival (learn more). However, for some women, neoadjuvant chemotherapy can change surgical options.
Neoadjuvant chemotherapy can shrink a larger tumor enough so that lumpectomy plus radiation therapy becomes an option to mastectomy .
Most tumors respond to neoadjuvant chemotherapy. If a tumor does not respond to one chemotherapy drug regimen, the combination of drugs may be changed or it may be best to proceed with surgery.
Learn more about chemotherapy.
Neoadjuvant chemotherapy regimens are the same as the standard regimens used after surgery. Most are anthracycline- and taxane-based therapies.
For HER2-positive tumors, neoadjuvant therapy usually includes trastuzumab (Herceptin) in combination with pertuzumab (Perjeta) (learn more).
Learn more about chemotherapy drugs.
Learn more about HER2 status.
A meta-analysis that combined the results of eight studies found no difference in rates of breast cancer recurrence or overall survival in women who had neoadjuvant chemotherapy versus those who had adjuvant chemotherapy .
One large study looked at rates of breast cancer recurrence 10 years after treatment with neoadjuvant therapy. About 10 percent of the women who were able to have lumpectomy plus radiation therapy instead of mastectomy had a recurrence compared to about 13 percent of those who had mastectomy (with no radiation therapy) .
Learn more about lumpectomy versus mastectomy and survival.
For a summary of research studies on neoadjuvant chemotherapy, visit the Breast Cancer Research Studies section.
Compared to adjuvant hormone therapy, neoadjuvant hormone therapy does not affect survival. However, for some women, it can change surgical options.
Like neoadjuvant chemotherapy, neoadjuvant hormone therapy (usually with an aromatase inhibitor) can shrink a tumor enough that lumpectomy plus radiation therapy becomes an option to mastectomy .
Neoadjuvant hormone therapy is only used to treat hormone receptor-positive (ER-positive and/or PR-positive) breast cancer.
Neoadjuvant hormone therapy is an option for some postmenopausal women, including those who cannot have chemotherapy due to health problems or advanced age. Select women with low-grade tumors or invasive lobular breast cancer may be offered neoadjuvant hormonal therapy instead of chemotherapy.
Most premenopausal women with large tumors are treated with neoadjuvant chemotherapy rather than neoadjuvant hormone therapy, even if their tumors are ER-positive.
For a summary of research studies on neoadjuvant hormone therapy, visit the Breast Cancer Research Studies section.
Learn more about hormone therapy.
Learn more about chemotherapy.
Learn more about hormone receptor status.
Learn more about tumor grade.
Learn more about lobular and ductal invasive breast cancer.
For HER2-positive breast cancers, neoadjuvant therapy usually includes trastuzumab and pertuzumab.
If you have neoadjuvant trastuzumab, you will likely also have trastuzumab after surgery (adjuvant trastuzumab). Trastuzumab is not usually given at the same time as anthracycline-based chemotherapy in either setting.
Pertuzumab is only used in neoadjuvant therapy and is not usually given after surgery . Other targeted therapy drugs are under study as neoadjuvant therapies for HER2-positive breast cancers.
Learn more about HER2 status and prognosis.
Learn more about trastuzumab.
When a person has neoadjuvant therapy, a pathologist checks the breast tissue removed during surgery for a pathologic response. Pathologic response describes how much of the tumor is left in the breast and lymph nodes after neoadjuvant therapy.
In some cases, neoadjuvant therapy will shrink the tumor so much that the pathologist can’t find any remaining cancer. This is called a pathologic complete response (pCR).
A pCR can give some information about prognosis, but it doesn’t change your treatment plan.
Although a pCR is encouraging, it doesn’t mean the cancer will never return. It’s also important to keep in mind that many people who do not have a pCR will still do very well.
pCR rates to neoadjuvant chemotherapy are highest among women with :
However, neoadjuvant chemotherapy can be effective in treating tumors of any grade and hormone receptor status.
Learn more about tumor grade.
To check the response to neoadjuvant therapy, you may have several tests, including a clinical breast exam, a mammogram, a breast MRI and/or a breast ultrasound. Then, surgery is planned much in the same way as if you did not have neoadjuvant therapy.
A sentinel node biopsy will be done either before neoadjuvant therapy begins or after neoadjuvant therapy (at the time of your breast surgery).
The sentinel node biopsy checks for cancer in the lymph nodes in the underarm area (axillary nodes).
It is unclear whether it is better to have a sentinel node biopsy before or after neoadjuvant therapy. There are pros and cons to each and the best timing is still under study [98-99]. You should discuss this with your surgeon before you start neoadjuvant therapy.
Although the exact treatment for breast cancer varies from person to person, guidelines help ensure quality care. These guidelines are based on the latest research and the consensus of experts.
The National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) are two respected organizations that regularly update and post their guidelines online. The National Cancer Institute (NCI) also has overviews of treatment options.
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* Please note, the information provided within Komen Perspectives articles is current as of the date of posting. Therefore, some information may be out of date at this time.
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