Manuel A. Torres-Salichs MD,FACS Surgical Oncology, Breast Surgeon

Edileidis Tarrio, ARNP-BC, OCN





Neoadjuvant (Primary) Chemotherapy and Breast Cancer

The goal of surgery as the primary treatment for breast cancer is the complete removal of the primary tumor together with the removal of the surrounding normal breast tissue.

Operable or Early Stage Breast Cancer:
Operable or early-stage invasive breast cancer refers to tumors that can be removed completely with surgery. Stage I and II breast cancers are included in this category as well as some early stage IIIA tumors greater than 5 cm in size, but with negative lymph nodes. Primary surgery is the standard of care in early-stage breast cancer. Studies have shown that preoperative chemotherapy (chemotherapy given prior to surgery) and postoperative chemotherapy (chemotherapy given after surgery) result in the same survival rate. The most recent data suggests that younger women may have a benefit in terms of survival. Preoperative chemotherapy is a treatment alternative for those women who are believed, based on tumor size, not to be an optimal candidate to preserve their breast, but want to avoid a mastectomy. Chemotherapy may shrink the tumor and increase the possibility for breast conservation.


Chemotherapy is considered a systemic treatment. It will treat the cancer in the breast as well as possible deposits of cancer in other parts of the body. Neoadjuvant chemotherapy is given to downstage the breast tumor in cases of locally advanced breast cancer. The goal is to make an unresectable breast cancer into one that can be removed surgically. It also treats the possibility of metastatic disease at the early stage of treatment.


Most people undergoing chemotherapy turn first to family members and friends for support. You may also want to consider breast cancer support groups. Most women attending group sessions report lower levels of stress and anxiety in dealing with breast cancer.


Locally Advanced Breast Cancer:
Neoadjuvant chemotherapy is also given to patients with locally advanced breast cancer. It has been used in the setting of locally advanced disease, both in patients who might not otherwise be appropriate candidates for preservation of the breast and in patients whose breast cancer is significantly advanced and when successful complete removal is not possible.
Locally advanced breast cancer, also known as stage IIIB breast cancer, encompasses a variety of clinical presentations, which include:

  Large tumors (>5 cm)
  Extensive involvement of lymph nodes
  Direct involvement of the skin or underlying chest wall
  Inflammatory breast cancer

Locally advanced breast cancer refers to tumors that are inoperable. Complete surgical removal is not possible without prior systemic therapy. The goal of primary chemotherapy is to make these tumors operable and to treat the possibility of metastatic disease at the earliest stage of treatment (chemotherapy is given through the bloodstream and goes to all parts of the body). Neoadjuvant or primary chemotherapy has the theoretical advantage of allowing us to see the tumor response to the therapy (shrinkage, complete disappearance, or no response). The response itself may be prognostic. It gives us objective feedback on the effectiveness of the therapy. You can actually see and measure the response of the tumor to chemotherapy. If the therapy is not effective the patient can be switched to another type of treatment. The disadvantage of adjuvant chemotherapy (chemotherapy given after the removal of the tumor) is that you have no idea whether the chemotherapy is working or not because the only evidence of disease (the tumor) has been taken out.

Neoadjuvant chemotherapy can also be given when surgery must or might be delayed due to medical issues or indecision about surgical treatment. The patient can start treatment while these issues are considered and a decision is made.


Most chemotherapy drugs to treat breast cancer are administered intravenously. The chemotherapy is given using a peripheral vein in the upper extremity or by placing a portacath under the skin in the upper chest area.


Adjuvant Therapy and Breast Cancer

Adjuvant therapy refers to additional treatment after surgery. The role of adjuvant therapy is to treat breast cancer cells that may have spread outside the breast but have not yet established identifiable tumors (micrometastasis). The goal is to reduce the risk of recurrence and as a result may reduce mortality. The improvement in breast cancer mortality is partly due to better medications and adjuvant treatment.
There are several factors that determine whether a patient needs adjuvant therapy. These are:

  Size of tumor
  Cancer cells in the lymph nodes
  Presence of hormone receptors
  Presence of tumor biomarkers such as HER2/neu


A portacath is an implantable venous access device use for patients who need continuous and frequent administration of chemotherapy. It is also used in patients with poor venous access. Some chemotherapeutic agents can often be toxic and cause damage to the skin and small veins in the extremities. The portacath is placed in a large central vein where the medications are diluted and delivered throughout the body.


Chemotherapy treatment uses drugs to destroy cancer cells by interfering with their growth and reproduction. It works against cells in the original tumor as well as cancer cells that may have spread to other parts of the body.
Chemotherapy is recommended when the cancer has a high possibility of recurrence or spreading to other parts of the body. It is also recommended when the tumor has metastasized to other organs. Different combinations of chemotherapeutic agents are recommended in this setting.


Chemotherapy consists of cancer-fighting drugs that travel in the bloodstream to kill cancer cells that may have spread to other parts of the body. Oncology nurses work as part of the cancer team. They provide and supervise the care for cancer patients. They administer chemotherapeutic drugs and manage their side effects. The chemotherapy is given in an outpatient setting under professional supervision.


AC followed by T:






AC followed by T plus H :

  Trastuzumab (monoclonal antibody)















  Trastuzumab (monoclonal antibody)


Hormonal Therapy:
Hormonal therapy plays an important role in the adjuvant treatment of breast cancer. It can be used alone or in combination with chemotherapy. Hormone therapy is used to treat cancers that are sensitive to hormones. These cancers contain estrogen and /or progesterone receptors and depend on estrogen for their growth. Hormonal therapy works by either blocking hormones from attaching to cancer cells or by stopping the body from making hormones. This therapy will prevent hormones from fueling the growth of breast cancer. It is important to understand that this is not the only mechanism by which breast cancer cells grow. There are other pathways independent of hormones that can feed a breast cancer cell.

SERMs (selective estrogen receptor modulator):
SERMs act by blocking any estrogen present in the body from attaching to the estrogen receptor on the cancer cell. This action slows the growth of the tumor or kills the tumor cells.
Tamoxifen is the best known SERM which inhibits the estrogen receptor in the breast. It is effective in both premenopausal and postmenopausal women. Tamoxifen does have estrogen receptor stimulating effects in the bones and uterus. It helps to preserve bone density and its stimulating effect in the endometrium increases the risk of uterine cancer 2 to 4 fold. Tamoxifen has been shown to decrease the recurrence and mortality associated with breast cancer. It has also been used for chemoprevention (to decrease the risk of developing breast cancer) in high-risk patients.

AIs (aromatase inhibitors):
The enzyme aromatase is the only source of estrogen in postmenopausal women.
This enzyme is present in the body fat, breast tissue, breast cancer cells and the adrenal glands. It converts androgens in the body into estrogen. Aromatase inhibitors block the function of this enzyme and shut down the production of estrogen in postmenopausal women. AIs have no effect on ovarian estrogen production. The three best known aromatase inhibitors are:

  Anastrozole (Arimidex)
  Letrozole (Femara0)
  Exemestane (Aromasin)

ERDs (estrogen receptors down regulators):
These medications block and destroy the estrogen receptors in breast cancer cells.
Fulvestrant (Faslodex)
Oophorectomy or chemical shutdown of the ovaries
Estrogen levels in premenopausal women can be lowered by removing the ovaries surgically or by shutting down their function with medication.
Bilateral salpingo-oophorectomy
Zoladex (goselerin acetate)

Targeted Therapy:
Targeted drugs work by attacking specific proteins receptors that may be present in some, but not all breast cancers. HER2-neu is one of the best known protein receptors that help in the growth of cancer cells. Over expression of HER2neu is seen in approximately 20% of breast cancers. HER2-neu positive tumors were known to be more aggressive and to have a worse prognosis, prior to the development of targeted therapies against this protein.

Herceptin is an immune targeted therapy. It is considered an antibody. Herceptin targets breast cancer cells that over express the HER2-neu protein. The HER2-neu protein tells the cancer cell to grow and divide into more cancer cells. Herceptin attaches to the protein and marks the cancer cell. It tells the body's defense system to target the HER2+ cancer cell. The immune system recognizes the antibody in the cancer cell and destroys it.

Bevacizumab (Avastin):
Avastin blocks a growth factor necessary to produce blood vessels. This drug is designed to stop the signals cancer cells used to attract blood vessels. Tumor cells can not grow and will die without new blood vessels.

Lapatinib (Tykerb):
Lapatinib is in a class of medications called kinase inhibitors. It works by blocking the action of the abnormal protein that signals cancer cells to multiply. It blocks the function of the epidermal growth factor (EGFR), ErbB2, and the Erk-1 and -2 and AKT kinases.