In some cases, treatment with chemotherapy, targeted therapy or hormone therapy may be given before breast surgery. When treatment is given before surgery, it’s called neoadjuvant therapy or preoperative therapy.
Neoadjuvant chemotherapy and hormone therapy drugs are the same as those used after surgery (called adjuvant therapy).
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.
If your treatment plan includes chemotherapy, neoadjuvant chemotherapy may be an option as a first treatment.
Chemotherapy has the same effectiveness whether it’s 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 may be able to shrink a larger tumor enough so lumpectomy plus radiation therapy becomes an option to mastectomy .
Neoadjuvant chemotherapy may also be given to women who have enlarged lymph nodes in the underarm area (due to the spread of breast cancer to these lymph nodes) to make the surgery to remove these lymph nodes easier.
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.
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 about neoadjuvant trastuzumab and pertuzumab.
Learn more about chemotherapy drugs.
Learn more about HER2 status.
A meta-analysis that combined the results of 14 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 found that 10 years after treatment with neoadjuvant therapy, rates of breast cancer recurrence were :
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.
Neoadjuvant hormone therapy (usually with an aromatase inhibitor) may be able to shrink a tumor enough so 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 cancers.
It's an option for some postmenopausal women, including those who can't have chemotherapy due to health problems or advanced age.
Some women with low-grade tumors or invasive lobular breast cancer may be offered neoadjuvant hormonal therapy instead of chemotherapy.
For a summary of research studies on neoadjuvant hormone therapy, visit the Breast Cancer Research Studies section.
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 (Herceptin) and pertuzumab (Perjeta).
Trastuzumab is given by vein (through an IV) every 3 weeks for 1 year.Since trastuzumab is given over a long period of time, if you have neoadjuvant trastuzumab, you won’t get all the trastuzumab before surgery. You will likely get some trastuzumab before surgery and some after surgery.Trastuzumab is not usually given at the same time as anthracycline-based chemotherapy.
Pertuzumab may be used in combination with trastuzumab for neoadjuvant therapy and/or adjuvant therapy.
Other targeted therapy drugs are under study as neoadjuvant therapies for HER2-positive breast cancers.
Learn about HER2 status and prognosis.
After neoadjuvant therapy, a pathologist will check 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. And, many people who don't 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.
Learn more about hormone receptor status and HER2 status.
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.
Surgery is then 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).
A sentinel node biopsy checks for cancer in the lymph nodes in the underarm area (axillary lymph nodes).Most of the time, a sentinel node biopsy can be safely done after neoadjuvant chemotherapy. However, there are pros and cons to having it done before or after neoadjuvant therapy and the best timing is still under study [114-115].
Discuss the timing of the sentinel node biopsy with your surgeon before you start neoadjuvant therapy.
Although the exact treatment for breast cancer varies from person to person, guidelines help ensure high quality care. These guidelines are based on the latest research and agreement among experts.
The National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) are respected organizations that regularly review and update their guidelines.
In addition, the National Cancer Institute (NCI) has treatment overviews.
Talk with your health care providers about which treatment guidelines they use. Since there’s often a lag time between the latest research and guideline updates, most providers prefer to base their treatment on the latest research.
* 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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