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Forward Look

Treatment Before Surgery

Neoadjuvant therapy may be an option. By Dara Chadwick

Many people assume surgery is the first step in cancer treatment. But for some patients, neoadjuvant therapy—chemotherapy, radiation therapy or hormone therapy given before surgery—can be part of their cancer care.

Study Raises Questions
Does neoadjuvant therapy create an avenue for metastasis?
Neoadjuvant treatment is routinely used for certain breast, esophageal, lung, stomach and rectal cancers, as well as for some sarcomas. Nikesh Jasani, an oncologist at the University of Texas M.D. Anderson Cancer Center in Houston, says it is typically used to shrink the tumor, allowing the surgeon to preserve all or parts of an organ (for example, the oropharynx in those with head and neck cancer), spare a limb (such as in certain sarcomas), or do a smaller surgery. In addition, in some patients with highly aggressive tumors, Jasani says, “you may have better control of the tumor” if you give chemotherapy before surgery.

When Nancy Touhill of Atlanta was diagnosed in 2015 at age 33 with stage II triple-negative breast cancer, she hadn’t heard of neoadjuvant chemotherapy. But her doctors wanted to see if they could shrink her large tumor, she says.

Touhill had eight rounds of chemotherapy. The treatment worked, contributing to her decision to have a lumpectomy instead of a mastectomy. Although she had post-surgery radiation, Touhill did not need additional chemotherapy because there was no cancer seen during the surgery. Her oncologist told her this “complete pathological response” was an indicator of a good prognosis, she says.

Chemotherapy drugs were the first treatments used in the neoadjuvant setting. Today researchers are studying other options. Cynthia Ma, a medical oncologist at the Washington University School of Medicine in St. Louis, for example, is leading a phase III trial of nearly 1,500 postmenopausal women with stage II-III breast cancer to determine whether neoadjuvant Faslodex (fulvestrant), an anti-estrogen drug approved to treat metastatic breast cancer, or the combination of Faslodex and Arimidex (anastrozole), an anti-estrogen drug used to treat early-stage breast cancer, is better than Arimidex alone for shrinking breast tumors. The findings could lead to new treatment options.

Treatment before surgery isn’t right for every patient, Jasani says. He advises patients to ask their doctors whether neoadjuvant treatment is an option and if so, why it might be beneficial. “Every cancer is different, and clear communication about treatment is the most important thing,” Jasani says.


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