Winter 2016 Ask the Expert: Neoadjuvant Therapy
Breast cancer treatment given before breast surgery
, to shrink tumors or slow cancer spread, is called neoadjuvant therapy. Not everyone gets neoadjuvant therapy, but for many people, it is a good treatment option. Neoadjuvant therapy may be used to shrink a tumor to allow you to have lumpectomy instead of mastectomy. New studies are also looking at how a cancer’s response to treatment before surgery might impact treatment after surgery.
This Winter, Living Beyond Breast Cancer expert Rena Callahan, MD, answered your questions about neoadjuvant therapy, including what treatments may be used, who may get it, why it may be offered and how it could affect the rest of your treatment and your risk of recurrence.
Remember: we cannot provide diagnoses, medical consultations or specific treatment recommendations. This service is designed for educational and informational purposes only. The information is general in nature. For specific healthcare questions or concerns, consult your healthcare provider because treatment varies with individual circumstances. The content is not intended in any way to substitute for professional counseling or medical advice.
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What factors cause a doctor to recommend neoadjuvant therapy to a patient?
There are several situations in which a doctor may recommend neoadjuvant therapy. Sometimes, the tumor is too large to be surgically removed and neoadjuvant therapy is used to shrink it down to a size at which surgery with clear margins can be performed.
There are times at which a mastectomy would be needed to remove the tumor because of its size. But neoadjuvant therapy may shrink it down to a size at which a lumpectomy, also known as "breast conserving surgery" is possible.
For some breast cancer subtypes, such as those that are HER2-positive, neoadjuvant treatment with both chemotherapy and HER2-directed therapy are very successful in shrinking and even completely getting rid of a tumor.
For triple-negative tumors, giving treatment prior to surgery may also shrink or completely get rid of the tumor. Seeing this disappearance of the tumor lets us know if our treatments are working. After surgery, we are not able to make this assessment since there is no tumor left to see with the eye or on scans. But there may still be microscopic disease left behind that could lead to future recurrence.
Are the treatments given after surgery the same as the treatments given before? Or are there medicines that I can only get if I have neoadjuvant therapy?
In the case of HER2-positive breast cancer, pertuzumab (Perjeta) is a HER2-directed treatment that is only currently FDA approved for use before surgery. This medicine has been shown to be very effective when combined with trastuzumab (Herceptin) and chemotherapy. So, I typically recommend pre-surgical treatment of HER2-positive breast cancer partly to ensure that my patient receives this important therapy.
Will neoadjuvent treatment reduce the risk of recurrence? What is a pathologic complete response (pCR) and how does that affect my risk?
Neoadjuvant treatment is not known to lower the risk of recurrence. But if the tumor completely disappears from the breast and lymph nodes after neoadjuvant treatment (called a pathologic complete response, or pCR), it is less likely to recur or spread.
If a pathologic complete response (pCR) is achieved, is more chemotherapy necessary after a mastectomy? If so, why?
After pathologic complete response (pCR) is achieved, I would not recommend further chemotherapy since pathologic complete response is a marker of improved overall survival versus those tumors that do not achieve a pCR. Additional chemotherapy for someone who has achieved pCR may only increase side effects, rather than increasing survival. But for a HER2-positive tumor, maintenance trastuzumab (Herceptin) would be continued after surgery.
Do certain breast cancer subtypes (like hormone-positive, HER2-positive, triple-negative or inflammatory) benefit more from neoadjuvant therapy? What about people with BRCA mutations?
HER2-positive and triple-negative breast tumors are more likely to achieve pathologic complete response (pCR) with chemotherapy than hormone receptor-positive tumors. The HER2 and triple-negative tumor subtypes are more sensitive to chemotherapy than their hormone receptor-positive counterparts. This may indicate that hormone receptor-positive tumors would benefit more from treatments that reduce hormones, rather than chemotherapy. Ongoing studies are looking at the response of hormone receptor-positive tumors to these types of treatments that are not chemotherapy.
Tumors with BRCA mutations, especially those that are triple-negative, are especially sensitive to neoadjuvant chemotherapy. In some studies, the use of platinum chemotherapy is particularly effective in this group.
Should you have surgery right away after neoadjuvant therapy? Could the tumor start growing again between the time I stop neoadjuvant therapy and the time I have surgery?
For those with rapidly growing tumors, we recommend having surgery within about a month of completing neoadjuvant therapy. This allows a short amount of time for the body to recover after the last chemotherapy treatment without waiting so long that the tumor starts to grow rapidly.
I have breast cancer that has spread to my lymph nodes. The idea of leaving all of those cancer cells in my body while I receive neoadjuvant therapy, instead of removing them right away, seems crazy to me. Shouldn't they get the cancer out of the lymph nodes at least, before it spreads, and then take out the breast tumor after neoadjuvant chemotherapy is done?
When there are tumors in the lymph nodes, we are especially concerned that there may be microscopic disease elsewhere in the body. Surgery only removes disease from the breast and regional lymph nodes, whereas neoadjuvant therapy attacks cancer wherever it is in the body. For this reason, starting treatment of the whole body with neoadjuvant therapy may be especially useful when we know cancer has spread to the lymph nodes.
I’ve been hearing a lot about immunotherapy lately. Is immunotherapy used in neoadjuvant treatment at all?
There are currently no FDA-approved immunotherapies for breast cancer. But there are ongoing breast cancer research studies of immunotherapies that have been used in diseases such as melanoma and lung and kidney cancer. Right now, these studies are usually looking at metastatic disease, though.
