In select cases, chemotherapy or hormone therapy may be an option prior to breast surgery. When treatment is given before surgery, it is called neoadjuvant therapy. Neoadjuvant therapy can improve a woman’s surgical options.
If you are a candidate for neoadjuvant therapy, a core biopsy will be done. 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 the breast cancer diagnosis and identify tumor characteristics, such as hormone receptor and HER2/neu status [57]. These factors determine the type(s) of neoadjuvant therapy that will offer the most benefit.
Neoadjuvant chemotherapy
For those who are candidates for chemotherapy, neoadjuvant chemotherapy can be an option as a first treatment [57]. There are advantages to starting treatment with neoadjuvant chemotherapy compared to waiting until after surgery. For larger tumors, neoadjuvant chemotherapy may shrink a tumor enough that lumpectomy (instead of a mastectomy) becomes an option [57]. If a tumor does not respond well to one neoadjuvant chemotherapy regimen, then the regimen can be changed, or it may be best to proceed with surgery.
Response rates to neoadjuvant chemotherapy are highest among women with:
- Hormone receptor-negative breast cancer (ER- and/or PR- tumors)
- High grade tumors
- HER2-positive tumors (when regimen includes trastuzumab)
However, neoadjuvant chemotherapy can be effective in treating tumors of any grade and hormone receptor status.
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 and are mostly anthracycline- and taxane-based therapies. For more on these therapies, visit the Chemotherapy Drugs section.
Recurrence and survival with neoadjuvant chemotherapy
A meta-analysis of eight studies found no difference in rates of recurrence of breast cancer in the same breast among women who had neoadjuvant chemotherapy versus those who did not [58]. Although still under study, women who are able to have lumpectomy instead of mastectomy after neoadjuvant treatment may have a higher rate of breast cancer recurrence in the same breast compared to those who choose mastectomy [57,58]. However, even if the risk of breast recurrence is slightly higher among those who have lumpectomy instead of mastectomy, it does not mean that survival rates are lower [57].
Neoadjuvant hormone therapy
Neoadjuvant hormone therapy with aromatase inhibitors is an option for postmenopausal women with hormone receptor-positive tumors (estrogen and/or progesterone receptor-positive cancers) [57]. Like neoadjuvant chemotherapy, neoadjuvant hormone therapy can make lumpectomy an option for some women who are at first only candidates for mastectomy [59].
Neoadjuvant hormone therapy is mostly given to women who are not candidates for chemotherapy due to other health problems or advanced age. It may also be an option for women with:
Most young women with large tumors are treated with chemotherapy.
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
Women with HER2 positive breast cancer benefit from trastuzumab (Herceptin) treatment. For those with HER2/neu-positive breast tumors, neoadjuvant trastuzumab may be added to the neoadjuvant therapy regimen [57]. Trastuzumab is not generally given at the same time as anthracycline-based chemotherapy. Women who have neoadjuvant trastuzumab often receive adjuvant trastuzumab after their surgery.
Find more on HER2/neu status and prognosis.
Find more on trastuzumab.
After neoadjuvant therapy is completed
To evaluate the response to neoadjuvant therapy, you may have several diagnostic tests, including a clinical breast exam, a mammogram, MRI and/or an ultrasound. Once you complete neoadjuvant therapy, surgery is planned much in the same way as for a person 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, to check if there is 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 [60]. This issue should be discussed with your surgeon before starting neoadjuvant therapy.
Updated 08/25/09
