In select cases, chemotherapy or hormone therapy may be given before breast surgery. When treatment is given before surgery, it is called neoadjuvant therapy. These chemotherapy and hormone treatments are the same as those used after surgery (called adjuvant therapy).
Neoadjuvant therapy does not increase survival, but rather changes surgical options [71-72]. Sometimes, neoadjuvant therapy can shrink a tumor enough so that lumpectomy becomes an option to mastectomy.
What to expect before neoadjuvant therapy
If you are a candidate for neoadjuvant therapy, 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 that the tumor can be found later when you have surgery.
Tests on the biopsy tissue confirm your diagnosis and identify tumor characteristics, such as hormone receptor status and HER2/neu status. These factors determine the type(s) of neoadjuvant therapy that will offer the most benefit.
Learn more about hormone receptor status and HER2/neu status.
Neoadjuvant chemotherapy
If you are a candidate for adjuvant (after surgery) chemotherapy, neoadjuvant chemotherapy may be an option as a first treatment [66]. The main advantage over adjuvant chemotherapy is that neoadjuvant chemotherapy can shrink a larger tumor enough so that a lumpectomy (instead of a mastectomy) becomes a breast surgery option [71].
Response rates to neoadjuvant chemotherapy are highest among women with:
- High grade tumors
- Hormone receptor-negative (estrogen and/or progesterone receptor-negative) tumors
- HER2-positive tumors (when treatment plan includes trastuzumab)
However, neoadjuvant chemotherapy can be effective in treating tumors of any grade and hormone receptor status.
If a tumor does not respond to one neoadjuvant chemotherapy regimen, the combination of drugs can be changed or it may be best to proceed with surgery.
Find more on chemotherapy.
Find more on hormone receptor status.
Find more on tumor grades.
Find more on lobular and ductal invasive breast cancer.
Find more on subtypes of breast cancer.
Types of neoadjuvant chemotherapy regimens
Neoadjuvant chemotherapy regimens are the same as standard adjuvant chemotherapy. Most are anthracycline- and taxane-based therapies.
Learn more about chemotherapy drugs.
Recurrence and survival with neoadjuvant chemotherapy
A meta-analysis 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 [72].
Although still under study, women who are able to have lumpectomy instead of mastectomy after neoadjuvant treatment may have a higher rate of recurrence compared to those who choose mastectomy [71-72]. However, even if the risk of breast cancer recurrence is slightly higher among those who have lumpectomy instead of mastectomy, it does not mean that survival rates are lower [72].
Learn more about lumpectomy versus mastectomy and survival.
Neoadjuvant hormone therapy
Neoadjuvant hormone therapy (with tamoxifen or an aromatase inhibitor) is an option for women with hormone receptor-positive (estrogen and/or progesterone receptor-positive) breast cancer [66,71]. Like neoadjuvant chemotherapy, neoadjuvant hormone therapy can shrink a tumor enough that a lumpectomy (instead of a mastectomy) becomes an option [73].
Neoadjuvant hormone therapy is not often given in the U.S. However, it may have a role in the treatment of women who are not candidates for chemotherapy due to other health problems or advanced age. It may also be an option for women with:
- Estrogen receptor- and progesterone receptor-positive tumors
- Low grade tumors
- Invasive lobular breast cancer
Most young women with large tumors are treated with chemotherapy rather than hormone therapy, even if their tumors are hormone receptor-positive.
Find more on chemotherapy.
Find more on hormone receptor status.
Find more on tumor grades.
Find more on lobular and ductal invasive breast cancer.
Find more on subtypes of breast cancer.
Neoadjuvant therapy for HER2/neu-positive breast cancers
If you have HER2/neu-positive breast cancer, neoadjuvant trastuzumab (Herceptin) may be added to your neoadjuvant chemotherapy [66]. Trastuzumab is not usually given at the same time as anthracycline-based chemotherapy.
If you have neoadjuvant trastuzumab, you will likely also have adjuvant trastuzumab after surgery.
Find more on HER2/neu status and prognosis.
Find more on trastuzumab.
After neoadjuvant therapy ends
To check the response to neoadjuvant therapy, you may have several tests, including a clinical breast exam, a mammogram, an MRI and/or an ultrasound. Then, surgery is planned much in the same way as for a woman who did not have neoadjuvant therapy.
Sentinel node biopsy and 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 armpit.
It is unclear, whether it is better to have sentinel node biopsy before or after neoadjuvant therapy. There are pros and cons to each and the best timing is still under study [74-75]. You should discuss this issue with your surgeon before you start neoadjuvant therapy.
Treatment guidelines
Although the exact treatment for breast cancer varies from person to person, some organizations have guidelines to help ensure quality care. These guidelines are based on the latest research and the consensus of experts. The American Society of Clinical Oncology (ASCO) and National Comprehensive Care Network (NCCN) are two respected organizations that regularly update and post their guidelines online. The National Cancer Institute (NCI) also has overviews of treatment options.
Updated 01/24/12
