Chemotherapy Before Breast Surgery is Valuable

Many Eligible Patients Are Unaware of Therapy Option

In 1998, Jeannie Frazier was diagnosed with breast cancer and then scheduled for surgery two days later.

But when friends convinced her to get a second opinion, she learned of another option: chemotherapy before surgery.

The treatment, known as neoadjuvant chemotherapy, has been used for 30 years, according to M. D. Anderson oncologists who pioneered the approach.

Still, many new patients are unaware of it, says Eva Singletary, M.D., a professor in M. D. Anderson's Department of Surgical Oncology.

Pre-surgery chemotherapy advantages are twofold

"We've been advocating neoadjuvant chemotherapy since the 1970s, starting with locally advanced breast cancer - tumors considered inoperable (too big or involving skin or many lymph nodes)," Singletary says. "Patients may not know about it because traditionally surgery was performed first.

"Also, patients might not be given the option of neoadjuvant therapy if they see a community surgeon or doctor, rather than cancer specialists on multidisciplinary teams who are more familiar with it."

The benefits of neoadjuvant therapy are:

• High likelihood of breast-conserving surgery
• Knowledge of whether chemotherapy can kill the cancer

Shrinking tumor makes breast conservation possible

Neoadjuvant chemotherapy shrinks large tumors enough to be removed with a lumpectomy (removal of part of the breast) instead of a mastectomy (removal of the entire breast), Singletary says.

Some patients arrive at M. D. Anderson for a second opinion after having a lumpectomy before chemotherapy. "If chemotherapy wasn't given before that surgery, the patient might be left with positive margins (microscopic cancer)," Singletary says. "In that case, when the patient comes here we may need to perform a second surgery, and often that may mean a mastectomy to ensure that we got all of the cancer.

"We might do a second surgery, and not chemotherapy, because chemotherapy is only given if there is a measurable tumor (usually larger than 2 centimeters). This is why we often recommend neoadjuvant chemotherapy - because the likelihood of breast-conserving surgery is much higher with neoadjuvant therapy than it is if surgery is done first."

Tumor response shows treatment is working

Chemotherapy allows doctors to see how the cancer responds to a particular drug. This is good information in the event of cancer recurrence and in charting current treatment progress.

"When my doctor explained this, it made a lot of sense," Frazier says. "I was told that during chemotherapy, ultrasounds would be done to make sure the tumor was shrinking, and if it wasn't shrinking or shrinking at the right rate, the dosage or the drug could be changed. Sometimes tumors go completely away."

That is exactly what happened to Frazier's tumor, which originally measured 3.7 centimeters in diameter.

Treatment works well with aggressive disease

Within the first three weeks of chemotherapy, the tumor shrank by at least 50%, says Frazier's surgeon Frederick Ames, M.D., a professor in M. D. Anderson's Department of Surgical Oncology. After nine weeks, an ultrasound showed the tumor had shrunk 75-80%. At the next ultrasound, the tumor was gone.

"Jeannie was diagnosed with a high-grade tumor that was more than three centimeters," Ames explains. "These more aggressive tumors, especially in younger patients, tend to have a higher degree of sensitivity to chemotherapy and more often achieve a complete response."

When she arrived at M. D. Anderson, Frazier was only 45, had not gone through menopause, and had a nuclear-grade 3 tumor (tumor with a high level of malignant cells), all of which suggests a more aggressive cancer, Ames says.

Treatment recommended for certain patients only

Because she responded well to chemotherapy and the cancer never spread to the lymph nodes, Frazier was eligible for a lumpectomy. This option wasn't available before she began treatment, because her tumor was too large.

Generally, neoadjuvant therapy at M. D. Anderson is recommended for patients with tumors measuring two centimeters or larger, Singletary says.

Patients like Jeannie are told upfront that the survival rate for having chemotherapy before surgery has not been proven to be better than if the patient underwent surgery first, Singletary says. "We can't say that neoadjuvant therapy is better for survival," she explains. "But we can say neoadjuvant therapy is not worse, and it has its advantages."

Survival is the same, but therapy has advantages

Educating new patients about the treatment is ongoing because at least half of the 2,400 new breast cancer patients seen at M. D. Anderson annually are candidates for neoadjuvant therapy, she says.

Frazier is doing her part by answering patients' questions as a Pink Ribbon volunteer in M. D. Anderson's Nellie B. Connally Breast Center.

"I constantly meet patients who don't understand why chemotherapy is recommended first," Frazier says. "I can relate to them because when I was diagnosed with cancer, I said, 'get it out,' I assumed the cancer would spread into my lymph nodes overnight.

"I was making a decision to have surgery first without having all the facts. Then I realized that I had time to get a second opinion. What I learned is that neoadjuvant chemotherapy gives patients who are eligible more options, so patients need to know about that."