Questions for your Breast Surgeon and Medical Oncologist:
- Do you know now, before surgery, if I will need chemotherapy?
- If “yes,” should we consider “Neoadjuvant Chemo” before surgery?
- What are the benefits of Neoadjuvant Chemotherapy?
- Isn’t Neoadjuvant Chemo recommended more now?
- Do my receptors suggest I will need chemotherapy?
- Do I have cancer in my axillary nodes?
- Will you ultrasound my axillary lymph nodes today?
What is Neoadjuvant Chemotherapy?
Neoadjuvant chemotherapy is when chemotherapy is given before surgery, not afterwards. Most never require chemotherapy. But if chemotherapy is needed, there can be specific advantages to neoadjuvant chemotherapy. This approach is a “cutting edge” trend in sophisticated breast cancer care.
If your breast biopsy “receptor pattern” suggests you need chemotherapy, it is important for you to inquire about the possible benefits of neoadjuvant chemotherapy with your breast surgeon. If cancer is detected in your lymph nodes before surgery, you may also benefit from neoadjuvant chemotherapy. Learn more about receptors and chemotherapy with our video lesson “My Tumor Receptors” (here).
When is chemotherapy generally needed?
If needed, chemotherapy is most commonly given after surgery (“adjuvant” chemo) for invasive breast cancer. It is a more intense cancer treatment than hormonal therapy. Only a minority of breast cancer patients will ever need chemotherapy. These complex decisions are ones you will make with your medical oncologist and breast surgeon. You will make better treatment choices when you are well informed about chemotherapy before you meet your breast surgeon and medical oncologist. To learn more about chemotherapy, view our short video lesson entitled “Will I need chemotherapy?.”
Would I benefit from “Neoadjuvant Chemo?”
What is often overlooked are the benefits of offering neoadjuvant chemotherapy for appropriate “Early-Stage” breast cancer. The decision to consider neoadjuvant chemotherapy always begins with your breast surgeon. You and your breast surgeon will choose the initial direction of your entire breast cancer treatment plan. You must address this treatment option before surgery to benefit from neoadjuvant chemotherapy. Some breast surgeons do not yet embrace neoadjuvant chemotherapy for early stage cancers. Do not be afraid to ask. This is a very important question.
The Potential Benefits of Neoadjuvant Chemo:
- Begin life-saving chemotherapy earlier
- Reduce the need for a mastectomy
- Improve cosmetic outcomes with a lumpectomy
- Reduce the need for an “Axillary Dissection”
- Allow more time for BRCA genetic testing
- More time to think about “lumpectomy vs. mastectomy”
- Shows your cancer team if the chemo is working
- Can eliminate all cancer cells before surgery in some
- Reduce the need for radiation after a mastectomy
Who may benefit from Neoadjuvant Chemo:
We list below a few of the criteria important in deciding if neoadjuvant chemotherapy is an option for someone who has yet to undergo breast cancer surgery.
Your Breast biopsy “Tumor receptors” reveal
- “HER2-positive” receptors
- “Triple Negative” receptors
- Estrogen receptor negative
- Cancer is found in the Axillary Nodes before surgery
- A tumor larger than 5 centimeters
- Diagnosis is inflammatory breast cancer
What “Receptor Patterns” suggest Neoadjuvant Chemo?
Your “receptor pattern” is a key piece of information in your breast biopsy pathology report. The receptor results will be detailed a few days after the initial diagnosis of cancer is determined. Receptors are small proteins on the surface of cancer cells that act like home “light switches” to turn cancer cell growth “on or off.” In about 30% of patients with an invasive breast cancer, the receptor pattern alone can strongly suggest that chemotherapy will be needed, regardless of what is found at surgery. Make sure to ask your breast surgeon about your “receptor pattern” and ask for a copy of your biopsy pathology report for your records. Make sure to review our lesson “My Tumor Receptors“ for more detail. We list the most common receptor patterns below that likely will benefit from chemotherapy.
HER2-Positive Receptor (HER2+) tumors are incredibly responsive to chemotherapy when paired with new breakthrough drugs that target these cancers, such as Herceptin and Perjeta. The same holds true if a HER2-positive tumor is also ER positive. HER2-positive tumors are more aggressive cancers, but we now can treat them more effectively with chemotherapy and “targeted immunotherapy” drugs that are designed to destroy HER2-positive cancers. Review our “Her2-Positive“ video lesson (here) to learn more.
“Triple Negative” (ER-)(PR-)(HER2-) tumors are also fast growing tumors that are usually treated with a specific chemotherapy regimen. These tumors are not responsive to hormonal therapy, but can be very sensitive to chemotherapy. Visit our “Triple Negative Breast Cancer“ video lesson (here).
Estrogen Receptor Negative (ER-) tumors do not respond to anti-estrogen oral medications that are essential for treating estrogen receptor positive (ER+) tumors. Quite simply, patients with ER negative tumors will benefit from chemotherapy if they are healthy enough to tolerate it. ER negative tumors are more aggressive cancers, but respond to chemotherapy. This includes “triple negative” breast cancers.
Do I already have cancer in my axillary nodes?
If you are found to have “lymph node positive” breast cancer before surgery, it is likely you will benefit from neoadjuvant chemotherapy. Your breast surgeon’s exam is not always successful at identifying breast cancer in the “axillary” lymph nodes under the arm. Request an axillary ultrasound from your breast surgeon while you are in the examination room. You want to know early on whether cancer is suspected to have spread to your lymph nodes. Take our video lesson on “Axillary Ultrasound“ (here). You can have a minimally invasive needle biopsy to see if the abnormal node has cancer within it. If so, it opens the door for more sophisticated treatment options including neoadjuvant chemotherapy.
What is an axillary ultrasound?
This simple look at your axillary lymph nodes under your arm with ultrasound can often show if you will benefit from neoadjuvant or adjuvant chemotherapy. The goal is to identify any enlarged or suspicious appearing lymph nodes that may harbor breast cancer. Ask your breast surgeon to do this as a part of your examination. You can also ask for an order for an “axillary ultrasound” to be performed by a radiologist. This advance in breast cancer is rapidly being adopted by experienced breast surgeons and breast centers across the country. Review our short video lesson on “Axillary Ultrasound” to learn more about this “cutting edge” look into your breast cancer.
Ultrasound of an Axillary Node involved with breast cancer
Why does “Inflammatory Breast Cancer” mean Neoadjuvant Chemo?
If you have been diagnosed with inflammatory breast cancer, the first step is always neoadjuvant chemotherapy before surgery. This type of cancer has a high likelihood of spreading to the lymph nodes and other parts of the body. Starting chemotherapy as soon as possible is essential to curing this aggressive breast cancer. A mastectomy is performed after chemotherapy, followed by radiation to the area of the mastectomy to lessen the chance of the cancer growing back.
Their website page (here), “Neoadjuvant Chemotherapy” is a good overview of the topic. This site is created for patients by the American Society of Breast Surgeons.
This interactive web page, “Treatment Navigation: Neoadjuvant Chemotherapy” is excellent at outlining neoadjuvant chemotherapy. This page (here) covers “HER2-positive” tumors. This page (here) covers HER2-negative tumors. The Susan G. Komen organization is a leading advocacy group dedicated to assisting patients, funding research, and ensuring quality breast cancer care.
- 4HER HER2+ Breast Cancer App
This iphone app (here) is a resource specifically designed to help women who have been diagnosed with HER2-positive breast cancer. This link (here) is the online version. It is created by Genentech, Inc., the maker of anti-HER2 treatments in conjunction with www.breastcancer.org.
More Detailed References:
This interactive website about neoadjuvant therapy for breast cancer is an incredible resource for patients and physicians. Merck (here) is an innovative, global healthcare leader that is committed to improving health and well-being around the world.
Their journal article (here), “Performance and Practice Guidelines for the Use of Neoadjuvant Systemic Therapy in the Management of Breast Cancer” is an overview for physicians about the benefits of neoadjuvant chemotherapy. The document was written by the American Society of Breast Surgeons and published in the Annals of Surgical Oncology.
If you want to get deep into the details, this free 200-page pdf document by the National Comprehensive Cancer Network has guidelines to help clinicians make treatment recommendations about nearly all aspects of breast cancer. You can easily register (here) as a non-professional to gain access.