What to Expect During Neoadjuvant Chemotherapy for Breast Cancer

Neoadjuvant therapy (NAT) refers to any systemic treatment of breast cancer, such as chemotherapy, prior to surgical removal of a breast tumor. The goal of NAT is to shrink a breast cancer tumor so that local resection is possible. This is in contrast to adjuvant chemotherapy, which is administered after surgery to kill any remaining cancer cells.

Studies show that neoadjuvant chemotherapy increases the likelihood of getting breast conservation therapy (such as lumpectomy), reduces morbidity (medical problems), and results in a better self-image.

Examples of neoadjuvant therapy include chemotherapy, radiation therapy, and hormone therapy.

This article will discuss what you need to know about preoperative chemotherapy cancer treatment and why it may be a good option for you.

Purpose of Neoadjuvant Chemotherapy

All systemic therapy given for non-metastatic, invasive breast cancer is intended to reduce the risk of your cancer returning. But the purpose of administering it prior to surgery is to shrink your tumor or stop the spread of cancer to make surgery less invasive and more effective.

This process, called downstaging, may make it possible for you to have less extensive surgery on the breast and/or axilla (armpit), especially for those with large tumors. By having the size of the tumor reduced, you may become a candidate for surgical resection or breast-conserving surgery rather than mastectomy.

Neoadjuvant chemotherapy has also been shown to improve cosmetic outcomes and reduce postoperative complications such as lymphedema, particularly in those who undergo breast reconstruction surgery.

Up to half of the patients undergoing neoadjuvant treatment may become suitable candidates for breast conservation rather than mastectomy.

One systematic review of neoadjuvant chemotherapy for operable breast cancer found that those who received chemotherapy before surgery had a lower mastectomy rate than those undergoing some surgical procedure before being given chemotherapy.

Risks and Contraindications

In general, if you are a candidate for adjuvant systemic therapy, you are a candidate for neoadjuvant chemotherapy. Patients with tumors that are small (less than 2 centimeters), low grade, or ER-positive/Her2-negative may not require systemic chemotherapy and therefore should undergo surgery first.

The people who benefit the most from NAT are:

• Patients with locally advanced breast cancer, including triple-negative and inflammatory breast cancer
• Patients with early stage breast cancer who present with larger breast tumors (greater than or equal to 2 centimeters) and chemo-responsive tumor markers (i.e., triple-negative, Her2-postive), who will benefit from downsizing for breast-conserving surgery
• Patients who are not surgical candidates: If you have absolute or relative contraindications to surgery, such as advanced age, obesity, or multiple medical comorbidities, in the setting of hormone receptor-positive tumors (PR+/ER+), you should be considered for neoadjuvant endocrine therapy.

Before Therapy

A healthcare professional will perform a needle biopsy of your breast cancer tumor before NAT. Once your tumor's size, type, and extent are identified, you and your oncologist will determine the best course of action.

Most neoadjuvant chemotherapies are anthracycline- or taxane-based therapies. For HER2-positive tumors, neoadjuvant therapy usually includes a combination of chemotherapy and the HER2-targeted therapy drugs Herceptin (trastuzumab) and Perjeta (pertuzumab).

Chemotherapy and radiation may cause side effects like nausea, headache, vomiting, or fatigue. Fasting for a few days beforehand has been shown to limit these side effects. 

Timing

If you are a candidate for NAT, you will likely start chemotherapy, radiation, or hormone therapy soon after your diagnosis. The average length of treatment is six to eight weeks, but it may be longer if you have more extensive disease.

The type of therapy that you use depends on the type of breast cancer you have. Doctors often use neoadjuvant chemotherapy as a way to see if your cancer will respond to a particular medication. If the cancer does not respond to that drug, your doctor will use other drugs for treatment, which may prolong your treatment course. 

Location

NAT is usually administered in outpatient oncological centers or at the hospital. You will likely receive all your treatment at the same location.

What to Wear

You should dress comfortably for your NAT sessions. Loose clothing and comfortable shoes are suggested. 

Food and Drink

You may eat and drink as you normally would before NAT, although some studies have shown that fasting for up to five days prior to therapy may protect you against the harmful side effects of chemotherapy or radiation therapy.

Cost and Health Insurance

The price of neoadjuvant therapy varies depending on the length of treatment needed and whether you have access to health insurance. For those with health insurance, the average cost is about $5,000.

Although NAT may cost thousands of dollars, most insurance companies cover these treatments. Also, successful neoadjuvant therapy will likely save you money in the long run by making more cost-effective treatment, like local removal of your breast cancer tumor, possible. 

What to Bring

Bring a list of the medications you are taking, identification, and your insurance card. Ask whether you will be able to use electronic devices such as your cell phone or an electronic book in the therapy room. Also, ask whether a support person can keep you company during the treatment.

Chemotherapy side effects can affect your judgment, motor skills, and vision in subtle ways, even in those who feel completely fine afterward. Fatigue and drowsiness are additional side effects that you may have to contend with.

Your doctor will likely suggest that you get a ride home after your chemotherapy appointments, whether from a family member, friend, or rideshare service like Uber or Lyft. Some clinics even offer transportation to and from appointments. Use your best judgment, especially if you are not feeling well.

During Therapy

Neoadjuvant chemotherapy is performed in cycles. The number of cycles varies from patient to patient. Sometimes you are administered medication beforehand that can make you tired. You will be administered a round of chemotherapy treatments followed by a resting cycle. Chemotherapy can be given via an intravenous (IV) tube or orally.

During your appointment, you can expect the following:

• A blood sample will be taken.
• You will meet with your oncologist and, likely, the healthcare staff so that they can check your health and blood test results.
• You will meet the nurse or other health professionals who will give your treatment.
• They will check your blood pressure, pulse, breathing, and temperature before starting treatment.
• Your height and weight will be measured to find the right dose of chemotherapy.
• A nurse may have an IV tube, also called a catheter, put in your arm.

The time it takes to administer neoadjuvant chemotherapy varies by patient and may take up to an hour. Sometimes chemotherapy can make you feel ill. Having a supportive friend or family member who can help you afterward by driving you home and helping you to remember important information may be helpful.

After Therapy

Some people experience no side effects from chemotherapy while others experience side effects in the first few weeks afterward. Most chemotherapy symptoms usually last two to four weeks before resolving on their own.

More bothersome symptoms like nausea and vomiting can be treated with prescription or over-the-counter medications.

Neoadjuvant chemotherapy has some notable side effects, including:

• Hair loss
• Extreme fatigue
• Weight loss or loss of appetite
• Vomiting and nausea
• Sores in the mouth
• Neuropathy (nerve damage)
• Increased risk of infection
• Decreased cognitive function
• Constipation or diarrhea
• Oral mucositis (inflammation of the lining of the mouth)

Most chemotherapy side effects are temporary and disappear once your treatment is over. But some might take months or even years to go away completely, a phenomenon called late effects.

In rare cases, neoadjuvant chemotherapy can cause long-term damage to the heart, lungs, kidneys, or reproductive organs. But this is usually not the case because NAT is typically administered for a short period of time.

Interpreting the Results

If you respond positively to the chemotherapy treatments, as evidenced by a decrease in tumor size and the presence of tumor cells, you may be able to have surgery within weeks after the last cycle of your neoadjuvant chemotherapy.

Neoadjuvant therapy may shrink the tumor so much that a pathologist can’t find any remaining cancer, called a pathologic complete response (pCR). This does not mean that your cancer will never return, but it does mean that you may be eligible for less invasive and more cost-effective treatment options like lumpectomy versus mastectomy. 

The rates of pCR after neoadjuvant chemotherapy are highest among people with tumors that are:

• High-grade
• Hormone receptor-negative (estrogen receptor-negative and/or progesterone receptor-negative)
• HER2-positive, when the neoadjuvant treatment plan includes trastuzumab and pertuzumab

Summary

A person with breast cancer may receive neoadjuvant chemotherapy before surgery to remove the tumor. The goal is to shrink the tumor and reduce or prevent its spread. However, it is not appropriate for all people with breast cancer.

Neoadjuvant chemotherapy may result in being able to have a lumpectomy or other breast-conservation therapy rather than a mastectomy. It may also reduce other complications. As it is chemotherapy, it comes with a range of side effects.

A Word From Verywell

Neoadjuvant chemotherapy designed to be used before surgical removal of a tumor has received significant attention as an entry point for personalized medicine.

Not only does neoadjuvant chemotherapy offer the advantage of downstaging breast cancer, and therefore potentially reducing the extent of surgery, but, in an era of individualization of therapy, it also allows doctors to test the efficacy of new therapies.

The preoperative setting is a great time to study the activity of novel agents or therapy because they work better in cancers in their early or intermediate stages and it avoids the issue of adaptive resistance.

Frequently Asked Questions 

What is the goal of neoadjuvant therapy for breast cancer?

The goal of administering neoadjuvant chemotherapy is to shrink the tumor or stop the spread of cancer, making surgery less invasive and more effective. This process, called downstaging, reduces the size of your breast tumor, making surgical resection possible or making you a candidate for breast-conserving surgery rather than mastectomy.

There are several other advantages of neoadjuvant chemotherapy, including:

• Allows your doctor to immediately assess your tumor's response to medication
• Allows for evaluation of new and novel agents
• Allows for evaluation of change in biomarkers with treatment
• May allow for earlier control of micrometastases (small groups of cancer cells spreading to other parts of the body)

How effective is neoadjuvant chemotherapy for breast cancer?

Up to half of the patients undergoing neoadjuvant treatment may become suitable for breast conservation rather than mastectomy. Still, studies have shown little or no evidence of increased life expectancy with neoadjuvant chemotherapy versus adjuvant chemotherapy.

Which neoadjuvant therapy is right for me?

Neoadjuvant hormone therapy is mainly used to treat hormone receptor-positive (ER-positive and/or PR-positive) breast cancers, but the breadth of NAT use has expanded in recent years. If you are newly diagnosed with breast cancer, discuss the pros and cons of NAT with your doctor.