Looking for C.U.R.E.

  • Increase font size
  • Default font size
  • Decrease font size
Home Treatment Options Chemotherapy Neoadjuvant Therapy

Neoadjuvant Therapy

E-mail Print
Attachments:
File
Download this file (NEOADJUVANT THERAPY.pdf)PDF

 

Type of chemotherapy given before the surgery is called neoadjuvant chemotherapy. It is commonly used in locally advanced inoperable disease in order to achieve surgical resection and facilitate breast conserving surgery.

Story behind neoadjuvant therapy

In the budding years of breast tumor treatment, the tumor affected breast tissue was completely removed along with the draining lymph nodes in the axilla of the affected breast either unilaterally or bilaterally. This surgical removal of the complete breast was termed as mastectomy. It was considered to potentially remove the disease from the body. But unfortunately, the tumor returned after few years and had similar and even worse complications. Therefore, the doctors and researchers developed chemotherapeutic therapies to cure patients after surgery. These therapies included

  • Hormonal chemotherapy
  • Radiation chemotherapy

This new practice of treatment of cancer after surgery was termed as adjuvant chemotherapy. This way of treatment turned out to be very effective in curing the patients and helping them live a disease free life.

As medicine entered in the era of molecules and newer drugs, researchers and doctors carried out clinical trials and research at all levels to limit the spread of cancer. With the advent of modern technology and newer diagnostic tecniques, early detection of cancer is possible. This has led to great outcomes in terms of cure rates of breast cancer. The current treatment consists of shrinking the large inoperable tumors to operable limits and the small tumors to disappear completely without resection if possible.

This can be done by the above three therapies. Administration of chemotherapy before the surgery in order to reduce the tumor size is termed as neoadjuvant therapy.

 Neoadjuvant therapy has marked the beginning of new era in the treatment of breast cancer. The major advantage of neoadjuvant therapy apart from decreased recurrence of the disease is; possibly having a breast conservation surgery, after radiation and chemotherapy. This breast conservation surgery is termed as lumpectomy. But all tumors cannot be shrunken before surgery.

When is mastectomy performed?

Mastectomy is performed only when breast conservation surgery is contraindicated.

The specific conditions include:-

  • When the disease has spread extensively and multiple excisions are not possible.
  • If two or more tumors are present in separate areas of the breast.
  • If there is a genetic predilection of the disease i.e. there is past history of breast cancer in blood relations, then as a precautionary measure mastectomy is performed if suspected.
  • If there is history of prior irradiation to the breast-therapeutic or non-therapeutic

What do experts and scientists have to say on mastectomy versus lumpectomy?

“The failure to observe a survival advantage of mastectomy after 20 years should convince even the most determined skeptics that mastectomy is not superior to breast conservation for treatment of breast cancer.” –says Monica Morrow M.D. Northwestern university Feinberg school of medicine in an editorial accompanying two groups of researchers in separate studies published in Oct 17, 2002.,New England journal of medicine.

They inferred that women with relatively small breast cancers who were treated with breast conserving surgery plus radiation therapy were likely to be alive and disease free 20 years later as women treated with mastectomy.

What are the criteria to decide preoperative chemotherapy?

Doctors can estimate the prognosis of the disease, by evaluating the underlying factors and predict the recurrence of the tumor. This helps in the multi-disciplinary approach to treat the cancer.

  • Menopausal status
  • Women’s age
  • Stage of cancer
  • Grade of the tumor
  • Proliferative capacity of the tumor
  • Hormone receptor status
  • Her-2 status

After evaluating these factors the disease is treated effectively.

 

What are the advantages of preoperative chemotherapy?

Its preferred before the surgery in order to reduce the number of cancer cells that spread to the other parts of the body, reducing the likelihood that cancer will return and potentially prolonging life. It helps shrink large tumors making less invasive surgery possible.

How does the doctor go about it?

The therapy consists of four to six cycles lasting for four to six months. If the doctor chooses to start hormonal therapy the drugs are usually administered orally.

Neoadjuvant chemotherapy shrinks the tumor enough to be able to have breast conservation surgery followed by radiation therapy. The type of treatment used depends upon the character of the tumor cells. Neoadjuvant therapy is the same therapy as adjuvant except that, it is administered before surgery.

How does the doctor decide whether to continue neoadjuvant chemotherapy?

It majorly depends on three conditions including the outcomes of the therapy

Firstly, if the tumor shrinks, chemotherapy is the logical conclusion to ensure the decreased size of tumor followed by a lumpectomy or a breast conserving surgery.

Secondly, if the size of the tumor does not change then the minimum necessary cycles are administered followed by surgery.

Thirdly, it the tumor grows during the neoadjuvant therapy then the therapy is stopped and the patient may be offered a different neoadjuvant chemotherapy or surgery.

How does radiation help in the treatment?

Radiation therapy can be administered either before or after surgery depending upon the size and extent of the disease.

After surgery that is either lumpectomy or mastectomy, radiation therapy is given to limit the spread of the disease by killing the cancerous and the normal cells.

When is radiation therapy contraindicated?

In cases of pregnancy with breast cancer, radiation therapy is absolutely contraindicated as it has lethal effects to the growing fetus.

If the patient is suffering from active collagen disease particularly scleroderma or systemic lupus erythematous may cause complications hence radiation is not preferred in such patients.

Why are hormones administered in breast cancer treatment?

Breast cells respond to hormones. The tumor cells show receptors for the female hormones. The basis of hormone therapy lies in blocking of these hormones. The specific receptors include (ER) and (PR).

Another type of protein responsible for the aggressive nature of the breast cancer is commonly known as HER-2 also known as ErB-2. Over-expression of this receptor in breast cancer is associated with increase in disease recurrence and worse prognosis.

References:

1)      This document is FCS8827, one of a series of the Department of Family, Youth and Community Sciences, Florida Cooperative Extension Service, Institute of Food and Agricultural Sciences, University of Florida. Publication date: February 2007. Reviewed August 2010.

2)      Azria D, Jacot W, Gligorov J, Belkacémi Y, Zaman K, Romieu G, Ozsahin M.SourceDépartement d'oncologie-radiothérapie, Inserm U896, CRLC Val-d'Aurelle-Paul-Lamarque, Montpellier, France. David.Azria@valdorel.fnclcc.fr Abstractedis.ifas.ufl.edu.ttp://edis.ifas.ufl.edu/fy89

3)      http://onlinelibrary.wiley.com/doi/10.1111/j.1524-4741.2008.0full 

4)       http://en.wikipedia.org/wiki/Neoadjuvant_therapy0575.x

5)       www.breastcancer.org/dictionary/n/neoadjuvanttherapy_t.jsp - CachedMar 31, 2011

6)      breastcancer.org/treatment/targeted_therapies/new_research/20090123.jsp?gclid=CN6zs7CynaoCFUvCKgod_SmNxg#mastheadwrap.

7)       http://www.ncbi.nlm.nih.gov/pubmed/21823890 

8)      http://www.breastcancer.org/treatment/surgery/mast_vs_lump.jsp?gclid=CLGK_YzaxaoS.E. Singletary, C. Allred, P. Ashley, L.W. Bassett, D. Berry and K.I. Bland et al., Taging system for breast cancer: revisions for the 6th edition of the AJCC cancer staging manual, SuCFYfCKgodCyHZ2Q 

9)      M.A. Bollet, B. Sigal-Zafrani, L. Gambotti, J.M. Extra, M. Meunier and C. Nos et al., Pathological response to preoperative concurrent chemo-radiotherapy for breast cancer : results of a phase II study.

10)  M. Kuerer, L.A. Newman, T.L. Smith, F.C. Ames, K.K. Hunt and K. Dhingra et al., Clinical course of breast cancer patients with complete pathologic primary tumor and axillary lymph node response to doxorubicin-based neo-adjuvant chemotherapy, J Clin Oncol 17 (1999).

11)  William C.Wood, Hyman b muss,Lawrence solin,Olufunmilayo.I.olopade, Vincent de vita,Samuel hellman,Steven A Roenberg, Principles of practice of oncology-7th edition

 

 

Swati Pendharkar, Visiting medical student at UIC, Sri Aurobindo Institute Of Medical Sciences,Indore

Edited by: Dr. Divyesh G. Mehta, Dr. Jigisha P Thakkar