Should You Have Chemotherapy Before Surgery for Breast Cancer?

Treatment shrinks tumors first in some cases

Woman meeting with doctor

Thanks to improvements in chemotherapy — and new thinking about the order of treatment — surgeons can save more women’s breasts than ever before.

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“Traditionally, we’ve done surgery first, then treatments such as chemotherapy,” says Stephen Grobmyer, MD, Director of Breast Services at Cleveland Clinic. “But for certain patients, it makes sense to reverse the order and do chemotherapy first.”

Neoadjuvant therapy starts with a basic idea: Shrink a tumor first, then surgery becomes easier and more likely to succeed.

The approach doesn’t work for everyone, Dr. Grobmyer notes. But it’s worth discussing with your doctor to find out if you are a candidate.

Saving the breast

“Often, we can do chemotherapy first to shrink the tumor. Then a surgeon can do a smaller surgery that preserves the breast.”

The most common reason to use neoadjuvant therapy is breast conservation. 

Only certain tumors qualify. Doctors typically won’t consider it unless a tumor is larger than 2 centimeters and has affected the lymph nodes. But when conditions are right, it can offer an alternative to mastectomy.

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“When a patient has a large tumor, surgeons often have to perform a mastectomy rather than a breast-conserving surgery,” says Cleveland Clinic oncologist Alberto Montero, MD. “But often, we can do chemotherapy first to shrink the tumor. Then a surgeon can do a smaller surgery that preserves the breast.”

Success for certain cancer types

The size of a tumor matters when considering neoadjuvant therapy. So does the type of breast cancer.

Neoadjuvant therapy tends to work best in triple-negative breast cancer and HER2-positive breast cancer. These types are more likely to respond to neoadjuvant chemotherapy, Dr. Montero notes.

In the best cases, such therapy produces a highly positive response. “When neoadjuvant chemotherapy is very effective, it results in what is called pathologic complete response,” he says. “That means a pathologist finds no trace of the invasive tumor in the breast or lymph nodes after treatment.”

That’s good news, not only in the short term but also over a patient’s lifetime. “With a pathologic complete response, there’s usually a less than 10 percent chance of recurrence of cancer,” Dr. Montero adds.

Neoadjuvant therapy also takes forms other than chemotherapy. For example, the FDA approved the anti-HER2 medication pertuzumab last year. For some patients, this drug increases the chances of eliminating a tumor altogether.

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For women with estrogen receptor-positive breast cancer — the most common type — neoadjuvant chemotherapy may not always be the best option. But anti-estrogen therapy can help shrink a tumor before surgery in select patients, Dr. Montero says.

Hope for inoperable cases

Sometimes, shrinking a tumor before surgery isn’t about breast conservation. It’s about providing a treatment option.

“There are times when neoadjuvant therapy converts an inoperable tumor into an operable one,” Dr. Grobmyer says. “The therapy basically shrinks a tumor enough to make surgery possible.”

Dr. Montero adds that such cases are less frequent these days. Breast cancer detection has improved enough that inoperable cases are much less common than in the past. But when they do occur, neoadjuvant therapy offers hope.

“It’s not perfect,” Dr. Montero says, “but then again, no treatment is without shortcomings.”

He adds that one of the main disadvantages is possible overtreatment. “The best way for us to understand a patient’s stage and risk of cancer recurrence is after surgery,” he says. “Imaging can help us estimate it, but it may not be completely accurate, and not all breast cancer patients need chemotherapy. But we discuss these pros and cons with all patients who are considering neoadjuvant therapy.”

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