Neoadjuvant therapy

Neoadjuvant treatment refers to the treatment that a doctor may prescribe for a patient to be administered before they undergo surgery for breast cancer.

Neoadjuvant systemic therapy, also referred to as primary or preoperative systemic therapy, is a common treatment strategy for patients with breast cancer.

Neoadjuvant systemic therapy is the accepted approach for women with locally advanced breast cancer for whom immediate surgery is inappropriate or impossible. It is an option for women with operable breast cancer, particularly when there is an attempt to perform breast conserving surgery.

Neoadjuvant treatment can take the form of either chemotherapy, biological therapy, hormonal therapy or a combination of these treatments.

When is it prescribed?

Once a person has been diagnosed with breast cancer they will be seen by either their surgeon or oncologist who will determine if they are a suitable candidate to undergo surgery to remove the breast tumour. It is important to remember that surgery is the only way to cure breast cancer.

A biopsy of the tumour will be perfomed, either by making a small incision into the tumour or by inserting a needle into the tumour to remove a small sample. The doctor will also want to determine whether the cancer has spread into the lymph glands under the arm. This can also be done with a needle biopsy, or in some cases, a sentinel node biopsy will be performed.

Once the biopsy has been performed certain tests will be done on the specimen to determine the best form of treatment, be it chemotherapy, biological treatment or hormonal suppression.

Why is it prescribed?

Sometimes the doctor may decide that the tumour is too large to be safely removed or, in consultation with the patient, may offer the option of breast conserving surgery to avoid a mastectomy. In these instances the oncologist will start the patient on neoadjuvant treatment in order to shrink the cancer as well as to kill any possible cancer cells that may be floating in the blood stream.

The most common form of neoadjuvant treatment involves chemotherapy which is administered intravenously to rapidly shrink down the tumour. Occasionally this will be combined with a new form of treatment called a biological treatment if the cancer is Her2 positive.

Occasionally a patient may be too sickly, or elderly, and may not be suitable for aggressive chemotherapy. In these cases a tablet will be used to block the hormones which may be causing the cancer to grow. This form of treatment has a much slower response so the tumour shrinks very slowly but this method can avoid some of the side effects of aggressive chemotherapy. These tablets can only be used however if the cancer is positive for the oestrogen receptor.

On the very rare occasion that the tumour is extremely large and does not shrink enough with chemotherapy, the doctor may advise undergoing neoadjuvant radiation therapy before considering surgery.

Surgery

An important point to bear in mind is that neoadjuvant therapy should always be followed by surgery, no matter how small the tumour is and even if it seems to have disappeared. The reason for this is that there is always a significant chance of some cancer cells remaining behind which may not be visible on mammograms or other xrays.

In conclusion, neoadjuvant chemotherapy can often alter the prognosis of breast cancer from being incurable to potentially curable and, just as importantly, it can often mean the difference between keeping your breast or needing to have a mastectomy. A very important role indeed!

Written by Dr Owen Nosworthy

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