Neoadjuvant Chemotherapy (NACT) and the effort to provide Breast-Conserving Surgery
- Chemotherapy is most commonly used after breast cancer surgery to kill any cancer cells that may be left in the breast or lymph nodes or in other parts of your body. When it is used before surgery it is referred to as Neoadjuvant Chemotherapy. When given after surgery is called Adjuvant Chemotherapy.
- Neoadjuvant chemotherapy for breast cancer is a new strategy that was introduced towards the end of the 20th century with the aim of reducing tumor size. It has four main rationales. Firstly, it should render an otherwise inoperable tumor operable or, secondly, allow more conservative surgery. Thirdly, starting systemic treatment preoperatively was hoped to lead to improved overall survival in patients with locally advanced cancers, who are at high risk of having distant disease.
- The main aims of neoadjuvant therapy are to treat occult metastases, decrease the bulk of the tumor and allow breast-conserving surgery.
- Oncoplastic Breast-conserving surgery (OBCS) is an attractive option for many patients with early-stage breast cancer because it provides a better cosmetic outcome than modified radical mastectomy while reducing surgical morbidity. In patients with large, operable breast tumors who are ineligible for BCS, neoadjuvant therapy is a useful option for reducing the tumor size and for increasing the proportion of candidates for BCS.
Breast cancer is the most common cancer in women worldwide. Breast cancer is the most common form of cancers in women and is second only to lung cancer as the leading cause of cancer deaths among women in the United States. It is estimated that 1 in every 8 U.S. women (12.4%) will develop breast cancer at some point in her life. Breast cancer occurs more frequently in the older woman, but 1 in 4 breast cancers is diagnosed in woman under the age of 50. Less than 5% of all breast cancer diagnosed in women younger than 35.
There are a number of reasons why neoadjuvant chemotherapy may be offered to you.
Neoadjuvant chemotherapy for breast cancer is a new strategy that was introduced towards the end of the 20th century with the aim of reducing tumor size. It has four main rationales. Firstly, it should render an otherwise inoperable tumor operable or, secondly, allow more conservative surgery. Thirdly, starting systemic treatment preoperatively was hoped to lead to improved overall survival in patients with locally advanced cancers, who are at high risk of having distant disease. Finally, unlike adjuvant chemotherapy is given in the absence of any measurable disease, neoadjuvant chemotherapy gives us the opportunity to observe the tumor shrink both palpably and on imaging, enabling a rapid assessment of clinical response. This could help test responses in vivo to new drug regimens, which could then be used as adjuvant therapies, in the so-called window of opportunity studies.
Breast cancer is now considered to be a systemic disease from the outset, with no correlation seen between the intensity of local treatment and survival or recurrence. Adjuvant therapy has clearly demonstrated a reduction in local and distant relapse; neoadjuvant therapy is similarly being assessed. It aims to treat occult metastases and decrease tumor bulk. Its use has demonstrated down-staging of the tumor with increased rates of breast-conserving surgery.
Breast-conserving surgery (BCS) is an attractive option for many patients with early-stage breast cancer because it provides a better cosmetic outcome than modified radical mastectomy while reducing surgical morbidity. In patients with large, operable breast tumors who are ineligible for BCS, neoadjuvant therapy is a useful option for reducing the tumor size and for increasing the proportion of candidates for BCS. Additionally, newer oncoplastic breast conservation techniques now allow very large partial mastectomies followed by the use of mastopexy or breast reduction techniques to rearrange the breast to maintain and possibly improve post-operative breast form.
Among the most innovative techniques are implemented in breast cancer oncoplastic surgery, breast cancer preventative surgery, and reconstructive breast. Oncoplastic breast conservation surgery adds an essential element into the aesthetic approach to lumpectomy by reshaping, remodeling or rebuilding the breast to maintain a natural look and feel along with a reasonable cosmetic appearance This type of surgery not only removes the cancer, but is also designed to prevent excessive scarring following surgery and radiation. This multidisciplinary approach allows the clinical oncologist, the surgical oncologist, radiation oncologist and reconstructive surgeon work as a team, collaborating on a strategy to remove cancer in a way that takes into account incision placement and the long-term aesthetic appearance of the breast. Aesthetic and reliable Plastic surgery techniques such as breast lift, breast reduction or local flaps are commonly used in these types of operations. Surgery on the other breast may also be performed to create or improve symmetry.
In addition to preserving a healthy physical appearance, oncoplastic breast conservation surgery may also help women heal emotionally after cancer surgery—restoring feelings of confidence, self-esteem, and femininity.
The management of breast cancer has gone through a significant change in the last few decades, with the super-radical mastectomy no longer a common entity. Breast cancer is now considered to be a systemic disease from the outset, with most patients with early breast cancer developing metastases whatever the treatment undertaken. Moreover, the intensity of local treatment does not correlate with survival and the risk of metastatic recurrence. A possible explanation for this may be the blood-borne micrometastases that are present at initial diagnosis. These observations have lead to a more conservative approach to surgical intervention in breast cancer and the concurrent use of medical therapy. A clear survival benefit has already been shown with adjuvant therapy, presumably by eradicating occult metastases. Neoadjuvant therapy is now being evaluated in this setting and has shown encouraging results.
The main aims of neoadjuvant therapy are to treat occult metastases, decrease the bulk of the tumor and allow breast-conserving surgery. It seems to have the potential of improving the results in more advanced cancers, for instance, in cancers with local fixity. Neoadjuvant therapy trials also offer a means for evaluating the effectiveness of the systemic agents compared to the adjuvant setting. The biological rationale for neoadjuvant therapy in breast cancer has been provided by Fisher and his colleagues. In a mice cancer model, they demonstrated that tumor excision was associated with an increase in metastases and that preoperative chemotherapy prevented these changes.
Originally neoadjuvant therapy was a means to downstage patients with inoperable locally advanced breast cancer and neoadjuvant therapy is now integral to the treatment of patients with early-stage disease. Large clinical trials such as EORTC 10902 and NSABP B-18 have shown no differences between the same systemic therapy given pre- or post-surgery on disease-free (DFS) and overall survival Other benefits (i.e. the conversion of patients requiring mastectomy to breast-conserving surgery [BCS]) and some potential concerns have been investigated and are well
What is the purpose of administering Neoadjuvant Chemotherapy?
While all systemic therapy given for nonmetastatic invasive breast cancer is intended to reduce the risk of distant recurrence, the purpose of administering it prior to surgery includes:
- Downstage the tumor, which may allow less extensive surgery.
- Avoiding the risks associated with breast reconstruction in patients able to undergo breast-conserving surgery in place of mastectomy.
- Avoiding mastectomy and being able to perform breast conservation surgery provides the benefit of less surgery, quicker recovery, and fewer post-operative complications
- Shrink a larger tumor enough so that lumpectomy plus radiation therapy becomes an option to mastectomy
- Render an otherwise inoperable tumor operable
- improved cosmetic outcomes.
- Reduced postoperative complications such as lymphedema.
- Permits an early evaluation of the effectiveness of systemic therapy.
- Gives us the opportunity to observe the tumor shrink both palpably and on imaging, enabling a rapid assessment of clinical response.
- Giving clinicians some new options in the struggle to cure patients diagnosed with breast cancer while improving the quality of survivorship
What to expect before neoadjuvant therapy
Before neoadjuvant therapy begins, you will have a needle biopsy to remove a small amount of tumor tissue. A radio-opaque clip is often placed in the tumor bed so the tumor can be found later when you have surgery. (This clip will be removed during surgery.) Tests on the biopsy tissue confirm your diagnosis and identify tumor characteristics, such as hormone receptor status, HER2 status, size on imaging studies, and pet scan results.
Increasingly, molecular tools such as Oncotype Dx™, MammaPrint™, and others inform decisions on choice of therapy. However, these tools have been most commonly used in combination with rather than in substitution for other clinical parameters. For example, Oncotype Dx™ which quantifies expression of 21 different genes is most rigorously validated to date in node-negative, ER+ patients, and its readout (risk of distant recurrence at a time point, or prediction of chemotherapy’s effectiveness in reducing the likelihood of distant recurrence) is influenced by the number of involved lymph nodes found at the time of surgery. It is important to remember that all of the variables necessary to determine whether chemotherapy will be of value are not always known from an initial core biopsy, and therefore many women may not be ideal candidates for neoadjuvant therapy. All these factors determine the type(s) of neoadjuvant therapy that will offer the most benefit.
A reasonable, clear indication for neoadjuvant chemotherapy is the need to reduce tumor size in an effort to provide breast conservation as an option. A typical patient for this would be a woman with small to medium breast size with a relatively large cancer who would prefer breast conservation as an option. This downstaging of tumor size to avoid a mastectomy has been well documented with long-term loco-regional recurrence and survival rates being similar to traditional adjuvant chemotherapy treatment. Avoiding mastectomy and being able to perform breast conservation surgery provides the benefit of less surgery, quicker recovery, and fewer post-operative complications.
While the benefit of downstaging tumor size using neoadjuvant chemotherapy is clear, there may be special considerations in particular circumstances. In the case where breast size is larger and the tumor is large (e.g., T2–T3 invasive cancer) breast cancer, neoadjuvant chemotherapy should certainly be in the discussion to reduce tumor size and facilitate breast conservation. However, newer oncoplastic breast conservation techniques now allow very large partial mastectomies followed by the use of mastopexy or breast reduction techniques to rearrange the breast to maintain and possibly improve post-operative breast form.
The need to reduce tumor size pre-operatively in this circumstance may not be as critical as oncoplastic surgical techniques can remove these large tumors while maintaining breast aesthetics. In patients with node-negative, ER positive, PR positive, Her2-neu negative invasive breast cancer, this presents an interesting dilemma in that these patients may not need chemotherapy especially if found to have favorable molecular profiling. Neoadjuvant chemotherapy in this population is less likely to achieve a pathologic complete response, and neoadjuvant chemotherapy might be overtreatment particularly if oncoplastic surgical options can provide breast conservation even in the setting of larger invasive breast cancers. This underscores the critical need to assess the necessity of (neo)-adjuvant chemotherapy on a case by case basis.
The second benefit of neoadjuvant chemotherapy from a surgical perspective is its ability to facilitate complete surgical resection especially when the breast cancer presents in a large, bulky fashion. Breast tumors close to or involving the axilla can be particularly challenging if they are large and abutting critical neurovascular structures such as the thoracodorsal vessels and nerve. Fisher and associated reported in the National Surgical Adjuvant Breast and Bowel Project that after neoadjuvant chemotherapy that involved doxorubicin and cyclophosphamide, breast tumor size was reduced in 80% of patients and completely resolved clinically in 36% of patients. Additionally, clinical nodal response occurred in 89% of node-positive patients of whom 73% had a complete clinical response. The ability for neoadjuvant chemotherapy to decrease tumor burden can aid the surgeon’s ability to safely remove cancer from the breast and axilla region which provides a clear advantage in potential post-operative surgical complications. Pre-operative imaging modalities such as ultrasound and MRI in addition to the clinical exam can help evaluate the presence of bulky tumor burden and discussion involving the oncology team and the patient should determine the appropriateness of neoadjuvant chemotherapy in these situations.
Another advantage of using neoadjuvant chemotherapy for invasive breast cancer is the ability to safely delay surgery in certain circumstances. Patients at times are not optimal candidates for surgery based on poor compliance with modifiable behaviors. Common modifiable behaviors include smoking and blood glycemic control for diabetes. Abundant surgical literature exists noting the association of smoking to poor wound healing and postoperative complications. In particular, smoking significantly increases post-operative infections in both mastectomy and breast conservation surgery patients. Therefore, patients who are willing to stop smoking close to the time of their breast cancer diagnosis should be considered for neoadjuvant chemotherapy given that a surgical treatment delay while they stop smoking minimizes their post-operative complication rate. Association between poor glycemic control and post-operative wound complications also exist in breast surgery. Thus, neoadjuvant chemotherapy can allow for a purposeful delay in surgery during which time better glycemic control is achieved so that optimal post-operative results can be obtained. Of note, pre-operative chemotherapy is not associated with increased post-operative complications in major breast surgery.
Why might neoadjuvant chemotherapy be recommended?
Neoadjuvant chemotherapy may be recommended:
- To reduce the size of your breast cancer (tumor) if it is too big to be removed in an operation
- If you have inflammatory breast cancer
- To reduce the size of the tumor so that you can have breast-conserving surgery (lumpectomy) instead of mastectomy
- To reduce the size of the tumor so that a smaller amount of tissue can be removed – this may give you a better cosmetic outcome
- To give you time to have genetic testing if you have a strong family history of breast cancer – you may decide to have a different type of surgery if you are found to have an inherited breast cancer gene mutation
- To delay surgery if you are pregnant so that you can deliver your baby as near to full term as possible (certain breast cancer chemotherapy drugs have been found to be safe in pregnancy)
- To give you time to consider your surgical options, including breast reconstruction
Neoadjuvant therapy can include combinations of cytotoxic chemotherapy, hormonal therapy and increasingly targeted molecular agents such as trastuzumab and pertuzumab depending upon the breast cancer subtype.
If your breast cancer is hormone receptor positive (ER+), you may be offered hormone therapy before your surgery (also known as neoadjuvant hormone therapy). The aim of neoadjuvant hormone therapy is also to shrink your breast cancer prior to surgery and control any cancer in lymph nodes or elsewhere in the body. Hormone therapy is given as an oral medication (tablet). The most common hormone therapy medications are tamoxifen, letrozole, anastrozole a, d exemestane. If you are premenopausal, you may also be offered an injection (goserelin) to stop the ovaries from making estrogen. This may be given alone or in combination with tablet hormone therapy. You may be offered Herceptin if your cancer is HER2-positive.
Breast-conserving Surgery (BCS)
Breast-conserving surgery (BCS) is an attractive option for many patients with early-stage breast cancer because it provides a better cosmetic outcome than modified radical mastectomy while reducing surgical morbidity. In patients with large, operable breast tumors who are ineligible for BCS, neoadjuvant therapy is a useful option for reducing the tumor size and for increasing the proportion of candidates for BCS.
One of the world’s most glamorous women had an operation that once was terribly disfiguring — removal of both breasts. But new approaches are dramatically changing breast surgeries, whether to treat cancer or to prevent it as Angelina Jolie just chose to do. As Jolie said, “the results can be beautiful.” Jolie revealed, that she had a double mastectomy and reconstruction with implants because she carries a gene mutation that puts her at high risk of developing breast cancer.
For women who already have the disease, the choice used to be whether to have the lump or the whole breast removed. Now there are more options that allow faster treatment, smaller scars, fewer long-term side effects and better cosmetic results. It has led to a new specialty — “oncoplastic” surgery — combining oncology, which focuses on cancer treatment, and plastic surgery to restore appearance.
“Cosmetics is very important” and can help a woman recover psychologically as well as physically, said Dr. Deanna Attai, a Burbank, Calif., surgeon who is on the board of directors of the American Society of Breast Surgeons.
More women are getting Neoadjuvant Chemotherapy before surgery to shrink large tumors enough to let them have a breast-conserving operation instead of a mastectomy. Fewer lymph nodes are being removed to check for cancer’s spread, sparing women painful arm swelling for years afterward.
Newer ways to rebuild breasts have made mastectomy a more appealing option for some women. More of them are getting immediate reconstruction with an implant at the same time the cancer is removed rather than several operations that have been standard for many years. Skin and nipples increasingly are being preserved for more natural results. Jolie, for example, was able to keep her nipples and presumably her skin. Some doctors are experimenting with operating on breast tumors through incisions in the armpit to avoid breast scars. There’s even a “Goldilocks” mastectomy for large-breasted women — not too much or too little removed, and using the excess skin to create a “just right” natural implant.
Neoadjuvant therapy improves patient outcomes substantially by increasing the rate of breast-conserving surgery. Following primary surgery, women with hormone-sensitive early breast cancer remain at risk for loco-regional and systemic recurrence. The most common relapse event, distant metastases, is associated with the poorest outcomes. As a neoadjuvant therapy, anastrozole, letrozole, and exemestane have been investigated and have shown efficacy in this setting. All three aromatase inhibitors (AIs) significantly improved the rate of breast-conserving surgery. As initial adjuvant therapy, the third-generation AIs anastrozole and letrozole are more effectively reduce recurrence risk compared with tamoxifen following surgery, especially in the first 2 years, when the risk is greatest.
In patients with endocrine-responsive tumors, neoadjuvant endocrine therapy with either tamoxifen or an aromatase inhibitor (AI; anastrozole, letrozole, or exemestane) provides an alternative to neoadjuvant chemotherapy. Clinical trials have demonstrated the superiority of neoadjuvant AIs over tamoxifen in achieving a clinical response and increasing the frequency of BCS. In addition, adjuvant endocrine therapy with AIs, whether used as initial therapy instead of tamoxifen, in a switching strategy after 2-3 years of tamoxifen, or as extended adjuvant therapy after 5 years of adjuvant tamoxifen, has been shown in several randomized clinical trials to improve disease-free survival, reduce distant metastases and, in some cases, improve overall survival. The availability of the AIs for effective and well-tolerated neoadjuvant and/or adjuvant endocrine therapy represents an important advance in breast cancer treatment.
Oncoplastic breast conservation surgery adds an essential element into the aesthetic approach to lumpectomy by reshaping, remodeling or rebuilding the breast to maintain a natural look and feel along with a reasonable cosmetic appearance This type of surgery not only removes the cancer, but is also designed to prevent excessive scarring following surgery and radiation. This multidisciplinary approach allows the clinical oncologist, the surgical oncologist, radiation oncologist and reconstructive surgeon work as a team, collaborating on a strategy to remove cancer in a way that takes into account incision placement and the long-term aesthetic appearance of the breast. Aesthetic and reliable Plastic surgery techniques such as breast lift, breast reduction or local flaps are commonly used in these types of operations. Surgery on the other breast may also be performed to create or improve symmetry.
In addition to preserving a healthy physical appearance, oncoplastic breast conservation surgery may also help women heal emotionally after cancer surgery—restoring feelings of confidence, self-esteem, and femininity.
Neoadjuvant therapy for HER2-positive breast cancers
HER-2, the human epidermal factor receptor, is over-expressed in 15%–25% of breast cancers.2 Several studies have shown a survival benefit of trastuzumab, a HER-2 receptor antibody, in metastatic breast cancer in combination with chemotherapy. There are several small trials that have shown a benefit of using trastuzumab in the neoadjuvant setting. One of the trials with trastuzumab had to be closed early due to its significant superiority in the group in which this was used. In this randomized study by Buzdar et al., . In the M.D. Anderson Cancer Centre (MDACC. The study showed a marked superiority in the trastuzumab plus chemotherapy arm with a pCR of 65% compared to a pCR of 26% in the other arm. Cardiac toxicity remains one of the main drawbacks of its use. Its optimal duration of administration and its impact on long-term outcome await further details, with several trials in progress. For HER2-positive breast cancers, neoadjuvant therapy usually includes trastuzumab and pertuzumab.
If you have neoadjuvant trastuzumab, you will likely also have trastuzumab after surgery (adjuvant trastuzumab). Trastuzumab is not usually given at the same time as anthracycline-based chemotherapy in either setting.
Pertuzumab. Pertuzumab is only used in neoadjuvant therapy and is not usually given after surgery
Pathological response after Neoadjuvant chemotherapy
When you have when you have been subjected to neoadjuvant therapy, normally, a pathologist checks the breast tissue removed during surgery for a pathologic response.
The Pathologic response describes how much of the tumor is left in the breast and lymph nodes after neoadjuvant therapy.
Pathologic complete response
In some cases, when the neoadjuvant therapy has been an effective function, shrinking the tumor so much that the pathologist can’t find any remaining cancer. This is called a pathologic complete response (pCR). A pCR can give some information about prognosis, but it doesn’t change your treatment plan. Although a pCR is encouraging, it doesn’t mean the cancer will never return. And, many people who do not have a pCR will still do very well.
The pCR rates to neoadjuvant chemotherapy are highest among women with:
- High-grade tumors
- Hormone receptor negative (estrogen receptor-negative and/or progesterone receptor-negative) tumors
- HER2-positive tumors (when the neoadjuvant treatment plan includes trastuzumab and pertuzumab)
However, neoadjuvant chemotherapy can be effective in treating tumors of any grade and hormone receptor status.
What is next after neoadjuvant therapy ends?
To check the response to neoadjuvant therapy, you may have several tests, including a physical examination, including a breast exam; a mammogram; breast MRI and/or a breast ultrasound, and a PET CT scan. MRI has been shown to be better than physical examination, mammography, and USG for assessing residual disease after neoadjuvant chemotherapy
Surgery is then planned much in the same way as if you did not have neoadjuvant therapy.
Sentinel Node Biopsy and Neoadjuvant Chemotherapy
Axillary lymph node status is regarded as a prognostic indicator of invasive breast cancer. Sentinel lymph node biopsy (SLNB) is being used increasingly in patients with early breast cancer in predicting node status. The remainder of the axilla can be considered to be tumor-free when the sentinel lymph node is negative. SLNB has an identification rate of 86–93% and a false negative rate of 7–13%.
A sentinel node biopsy will be done either before neoadjuvant therapy begins or after neoadjuvant therapy (at the time of your breast surgery). A sentinel node biopsy checks for cancer in the lymph nodes in the underarm area (axillary nodes).
SLNB assessment becomes difficult in the neoadjuvant setting due to the histological changes which may alter the accuracy of SLNB and lead to an increase in false negative results. Several small studies have examined the efficacy of SLNB in this setting. One of the largest of these, the NSABP B-27, involved 428 patients from several centers that underwent SLNB and axillary lymph node dissection following neoadjuvant therapy. The sentinel lymph nodes were successfully identified and removed in 85% of the patients. The false negative rate was 11%, not far from the false negative rate of SLNB in the normal clinical setting. Charfare and collegues have combined the results of 14 studies and describe an overall detection rate of SLNB in 89% of the patients with a false negative rate of 11%. These figures are almost comparable to those obtained prior to neoadjuvant therapy and suggest that sentinel lymph node biopsy may be applicable in the neoadjuvant setting.
The timing of SLNB in the neoadjuvant setting is also controversial, with advocates for both pre- and post-neoadjuvant SLNB. Performing the SLNB in the pre-neoadjuvant scenario may provide a more definite node status at presentation and provide the therapists with an opportunity to tailor the treatment based on the node status. However, it exposes the patients to a further surgical procedure. The number of positive lymph nodes may be altered by the neoadjuvant therapy and may alter further treatment plans in the axilla. In the NSABP B-18 trial, axillary down-staging has been described following neoadjuvant chemotherapy (41% node positive in the neoadjuvant group compared to 57% in the adjuvant group). In patients where there has been a significant reduction in lymph node disease, a pre-neoadjuvant SLNB may subject them to an unnecessary axillary lymph node dissection later on. The other alternative may be to perform the SLNB after neoadjuvant therapy. This has also been met with several controversies. Though this may mean a reduction in the surgical procedure for the patient as this can be combined with the surgical procedure on the breast, the identification rates may not be as good compared to when done before neoadjuvant therapy. Moreover, performing the SLNB after adjuvant therapy may be technically more demanding and involve a significant learning curve.
It’s unclear whether it’s better to have a sentinel node biopsy before or after neoadjuvant therapy. There are pros and cons to each and the best timing is still under study. Discuss the timing of the sentinel node biopsy with your surgeon before you start neoadjuvant therapy.
What is the role of radiotherapy after neoadjuvant chemotherapy?
In patients treated with neoadjuvant chemotherapy and mastectomy, post-mastectomy radiation has been shown to lower the rate of loco-regional recurrence. Huang, performed a retrospective analysis of 542 patients who were treated in six prospective trials within the same institution and compared the data with 134 patients with similar treatment but without radiation. They demonstrated a reduced loco-regional recurrence rate in irradiated patients (10-year recurrence rate of 11% vs. 22%.). The benefit was more in patients with clinical T3 & T4 stage, a tumor size of >5.1 cm and in those with more than four positive nodes. This led to their recommendation that patients with locally advanced disease at presentation or with four or more positive lymph nodes should be considered for radiation after neoadjuvant chemotherapy and mastectomy. Based on their review, it remains unclear whether patients with stage II breast cancer with less than three positive lymph nodes would benefit from radiation therapy in a similar setting.
Neoadjuvant chemotherapy for breast cancer is a new strategy that was introduced towards the end of the 20th century with the aim of reducing tumor size. It has four main rationales. Firstly, it should render an otherwise inoperable tumor operable or, secondly, allow more conservative surgery. Thirdly, starting systemic treatment preoperatively was hoped to lead to improved overall survival in patients with locally advanced cancers, who are at high risk of having distant disease. Currently, guidelines for neoadjuvant therapy include giving all planned therapy prior to surgery to standardize comparison of responses, improve the uniformity of practice and reduce complications or inconvenience for the patient. Increasingly it will be desirable for the oncologist’s team to refine the composition of neoadjuvant treatment as well as the post-treatment surgical and radiation variables such as timing, dose, and extent. It is reassuring to know that optimal planning of surgery can be done safely within a reasonable time interval (≤8 weeks from completion of chemotherapy) without compromising outcomes. Thus it appears that the neoadjuvant approach will continue to represent both a way forward and a convenient option for many women diagnosed with early-stage breast cancer.
The information in this document does not replace a medical consultation. It is for personal guidance use only. We recommend that patients ask their doctors about what tests or types of treatments are needed for their type and stage of the disease.
- American Cancer Society
- The National Cancer Institute
- National Comprehensive Cancer Network
- American Academy of Gastroenterology
- National Institute of Health
- MD Anderson Cancer Center
- Memorial Sloan Kettering Cancer Center
- American Cancer Society