Questions for your Medical Oncologist and Breast Surgeon:
- Would I benefit from chemotherapy?
- What factors suggest I will benefit from chemotherapy?
- What is the risk to my life if I do not undergo chemotherapy?
- What are the advantages of “Neoadjuvant Chemo” before surgery?
- Would a “Genomic Assay” help determine if I need chemotherapy?
What is chemotherapy?
Chemotherapy is the use of certain medications to treat cancer systemically, meaning throughout the whole body. If needed, chemotherapy is usually given after surgery for invasive breast cancer. It is a more intense cancer treatment than hormonal therapy (usually pills). Only a minority of breast cancer patients will ever need it. These complex decisions are ones you will make with your medical oncologist. Our goal is to quickly educate you about the basic indications for chemotherapy. Our list is far from complete. You will make better treatment choices when you are informed about chemotherapy and hormonal therapy before meeting with your medical oncologist.
General indications for chemotherapy
We outline below some of the more common indications for needing chemotherapy. The decision to undergo chemotherapy also involves being healthy enough to tolerate the treatment. Deciding who needs chemotherapy and what type of chemotherapy to administer is one of the most difficult decisions made in medicine. Your medical oncologist will guide you.
Do my “receptors” suggest I need chemotherapy?
Once a breast biopsy is found to be cancerous, the pathologists will automatically run more tests on the same tissue to determine what “receptors” are expressed. This information is critical in guiding what further therapies may be needed before or after surgery, such as chemotherapy or hormonal therapy. Learn more about “My Tumor Receptors“ with our video lesson (here) on the subject. You should be engaged with this aspect of your cancer care from the outset.
What “receptor patterns” suggest chemotherapy?
Your receptor pattern is a key piece of information that comes early in your breast cancer journey. 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. If your receptor results suggest you will benefit from chemotherapy, you should inquire about the possible benefits of “neoadjuvant chemotherapy,” meaning chemotherapy given before surgery, not afterwards. The key points regarding receptors are outlined below.
Estrogen Receptor Negative (ER -) tumors (20%) do not respond to anti-estrogen oral medications that are essential in 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 more favorably to chemotherapy than ER positive breast cancers.
Progesterone Receptors (PR) play a much smaller role than ER or HER2 receptors and are not addressed here.
HER2 Receptor Positive (HER2+) tumors (20%) are very responsive to chemotherapy when paired with new breakthrough drugs that target these tumors, such as Herceptin and Perjeta. The same holds true even if a HER2-positive tumor is also Estrogen Receptor positive (ER+). HER2+ tumors are more aggressive cancers, but we now can treat them more effectively with chemotherapy and new drugs that are “targeted” to destroy HER2-positive cancers. If you are “HER2-Positive“ take our video lesson (here) to learn everything you need to know.
“Triple Negative” (ER-)(PR-)(HER2-) tumors are fast growing tumors that are usually treated with a specific chemotherapy regimen. These tumors are not responsive to hormonal therapy at all, but may be sensitive to chemotherapy. View our video lesson (here) on “Triple Negative Breast Cancer“ to learn more.
What if cancer is detected in the lymph nodes?
If you have “lymph node positive” breast cancer, it is likely you will be offered chemotherapy. Premenopausal women and those with multiple “positive” lymph nodes generally benefit from chemotherapy. If your breast surgeon detects cancer in your lymph nodes before surgery, there may be specific advantages to undergoing “neoadjuvant chemotherapy.”
If you have “lymph node positive” cancer and are elderly (older than 80) or not healthy enough to tolerate the side effects of chemotherapy, you may conclude that the risks of chemotherapy outweigh its benefits. These situations vary greatly from person to person. A detailed discussion with your medical oncologist is essential to make the best decision for yourself or a loved one.
Some women who have an early stage, “lymph node positive” breast cancer may meet the criteria to consider “genomic” testing of a sample of their tumor to see if they might be able to avoid chemotherapy. This is a rapidly evolving field in breast cancer. Ask your medical oncologist if a “node positive genomic assay” is appropriate for your unique cancer situation.
“Inflammatory Breast Cancer” requires chemotherapy
If you have been diagnosed with inflammatory breast cancer, the first step is 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 treating this aggressive breast cancer. A mastectomy is performed after chemotherapy, followed by radiation to the area of the mastectomy to lessen the chance of cancer growing back in that area.
What are the advantages of “neoadjuvant chemotherapy”?
Neoadjuvant chemotherapy is when chemotherapy is given before surgery, not afterwards. There are specific advantages to neoadjuvant chemotherapy in appropriately selected patients. If your breast biopsy “receptor pattern” suggests that you will need chemotherapy, inquire about the possible benefits of neoadjuvant chemotherapy with your breast surgeon. Unfortunately, the benefits of neoadjuvant chemotherapy are often not offered to patients with early stage breast cancer. If cancer is detected in your lymph nodes with your breast surgeon before surgery you may also benefit from neoadjuvant chemotherapy. Our video lesson (here) on “Neoadjuvant Chemotherapy” covers this topic in more detail.
How can a genomic “Oncotype DX” test be helpful?
Patients who have a small, estrogen receptor positive, HER2 receptor negative tumor and no evidence of cancer in their lymph nodes may benefit from an Oncotype DX genomic assay. This cutting-edge test looks deeper into breast cancer cells to better identify people who may benefit from chemotherapy with ER+, HER2 – breast cancers. The results of this test can also confirm that only hormonal therapy will be needed. Our video lesson (here) on “Genomic Assays” provides much more detail about these advances in breast cancer care.
You will find well-organized guides on breast cancer treatment by stage. Follow the prompts to breast cancer and then “stage” in the dropdown menus. The NCCN is a consortium of organizations and governmental agencies to promote quality breast cancer care.
Their section on “Chemotherapy” is comprehensive and has great detail (here). The American Society of Clinical Oncologists is a leading organization of clinicians who care for people with cancer.
An outline of “Chemotherapy for Breast Cancer” is provided (here). The American Cancer Society is an organization that supports patients with cancer and funds research for cancer of all types.
More Detailed References:
If you want to get deep into the details, this free 200-page pdf document (here) has guidelines to help clinicians to make treatment recommendations about nearly all aspects of breast cancer. You can easily register (here) as a non-professional to get access and more information about breast cancer. The National Comprehensive Cancer Network is the leading organization in developing clinical guidelines.