Neoadjuvant therapy

Sometimes drug treatments for early breast cancer are given before breast cancer surgery. This is called neoadjuvant therapy or pre-operative therapy.

If you have neoadjuvant therapy, your treatment may start with:

• chemotherapy
• targeted therapy
• hormone-blocking therapy
• immunotherapy.

Usually, you will have this treatment for several months before surgery. Some therapies may continue after surgery.

There are benefits to neoadjuvant therapy, but it is not for everyone. We encourage you to talk to your treating team about the pros and cons of neoadjuvant therapy. The Neoadjuvant Patient Decision Aid from Breast Cancer Trials can also help you discuss the options. 

When neoadjuvant therapy may be recommended

There are pros and cons for whichever order you have your treatment. You and your doctor will decide what is best for your personal situation.

They may recommend neoadjuvant therapy before surgery to:

• reduce the size of the tumour so the operation can be smaller, such as lumpectomy instead of mastectomy
• reduce the tumour so less tissue needs to be removed – this may give you a better cosmetic result
• reduce the number of lymph nodes that need to be removed from the armpit (‘axilla’). You may be able to have a smaller sample removed, rather than all of them, if you have cancer in your lymph nodes at diagnosis
• give you time to have genetic testing if you have a strong family history of breast or ovarian cancer. If you have an inherited breast cancer gene mutation, you may decide to have a different type of surgery
• see how your cancer responds to chemotherapy, targeted therapy, or immunotherapy ('in vivo response')
• provide more information about the risk of the cancer coming back (‘recurrence’)
• make you eligible for a neoadjuvant clinical trial
• personalise treatment for you after surgery, to reduce the risk of the cancer coming back ('recurrence').

If your doctor recommends this treatment, it does not mean your cancer is worse than a patient who has surgery first. Studies have shown that these treatments before surgery can sometimes be more effective in terms of overall survival.

When you may not want neoadjuvant therapy

Some people do not feel comfortable having breast cancer in their body once it has been detected. They want to have it removed with surgery as soon as possible. They may feel uncertain and anxious about whether the neoadjuvant therapy will work.

If you have any of these concerns, talk to your doctor. You can also use the Neoadjuvant Patient Decision Aid to understand more of the pros and cons.

Types of neoadjuvant therapies

Chemotherapy, targeted therapies, hormone-blocking therapy or immunotherapy may all be given before surgery.

By shrinking the size of the cancer, you may have the option of a lumpectomy followed by radiotherapy, instead of a mastectomy.

You’re more likely to have treatment such as chemotherapy before surgery if you have:

• HER2 positive breast cancer
• triple negative breast cancer
• inflammatory breast cancer.

Chemotherapy treatments for early breast cancer usually include anthracycline drugs such as doxorubicin, and taxanes such as paclitaxel or docetaxel. 

For HER2-positive breast cancers

Neoadjuvant treatment is usually a combination of:

• chemotherapy
• HER2-targeted therapies trastuzumab and pertuzumab (Perjeta).

Note: Perjeta is not available through the Pharmaceutical Benefits Scheme for early breast cancer, so you need to pay for it yourself. Read about Ways to access new drugs for breast cancer treatment. Ask your medical oncologist if you'd like information about Perjeta.

For triple negative early breast cancer

Neoadjuvant treatment may involve:

• chemotherapy
• immunotherapy such as pembrolizumab (Keytruda).

For hormone receptor positive (ER+ and/or PR+) breast cancer

If your breast cancer is HR+ (ER+ and/or PR+), you may be offered neoadjuvant hormone-blocking therapy. This is most common in older patients. Find out About hormone-blocking therapy.

For women after menopause

Neoadjuvant therapy may be an option for people who can’t have other treatments due to underlying health problems or advancing age.

Steps to prepare for neoadjuvant therapy

Imaging

This is usually the first test you will have done. This may be a mammogram, ultrasound and/or MRI. This tells the treating team where and how big the cancer is, and if any lymph nodes are enlarged and may contain cancer. 

Biopsy

If the imaging shows something suspicious, you will have a biopsy done to take some tissue from the cancer (tumour).

A pathologist looks at the tissue sample under a microscope and prepares a report. This pathology report contains the type and subtype of breast cancer, which helps doctors decide which neoadjuvant therapy is best for you.

A marker to locate the tumour

In some cases, you will have a ‘marker’ inserted into the tumour. The surgeon uses this later, during surgery, to see where the cancer was before treatment. This can be important if the cancer responds well to the treatment and shrinks to a size that is difficult to see on imaging.

The marker is inserted into the tumour under a local anaesthetic. Usually, an ultrasound or mammogram is used as a guide. Different types of markers may be used, including:

• titanium and stainless steel markers – these are inserted in a procedure similar to a biopsy
• carbon, which looks like ink – this is injected into the tumour. 

Checking progress during treatment

While you have neoadjuvant therapy, your doctor will regularly assess how the breast cancer is responding to treatment. They will examine you to feel if the lump is getting smaller. They may send you for tests such as mammograms, ultrasound or sometimes MRI.

In rare cases, the tumour may grow while you are having treatment. If this happens, your doctor will discuss the options, which may be:

• continuing neoadjuvant therapy but changing the treatment drug
• stopping neoadjuvant therapy and having surgery or neoadjuvant radiotherapy.

After you finish neoadjuvant treatment

After neoadjuvant treatment, surgery removes any breast cancer that remains in the breast and/or lymph nodes.

This may be a lumpectomy (‘breast conserving surgery’) or a mastectomy.

The pathologist checks the tissue removed during surgery to see how much of the tumour is left. This is called the ‘pathological response’.

 The amount of cancer found in the tissue the surgeon took out helps provide information about prognosis – how likely the cancer is to come back.

In some cases, the cancer can disappear entirely (‘pathological complete response’).

If the cancer does not disappear after neoadjuvant therapy, this guides further treatment after surgery.

Clinical trials and neoadjuvant therapy

In some cases, neoadjuvant therapy is given as part of a clinical trial. This is usually to:

• test how effective a new treatment or 
• help find drugs that improve the rate of 'complete response'.
• Your doctor will discuss with you if there is a trial suitable for you. 

Many clinical trials have shown that:

• neoadjuvant chemotherapy is safe
• the outcome of the treatment is the same as having chemotherapy after surgery.

For more information about clinical trials visit Breast Cancer Trials. 

Important trials have shown recently that if cancer survives neoadjuvant therapy, changing the drug treatments after surgery can reduce the risk of it coming back. This leads to better cancer survival.

These findings have transformed what medical professionals think about neoadjuvant therapy. Now, it is the ‘standard of care’ for people with HER2 positive and triple negative breast cancer that is over 2cm in size and/or involving the lymph nodes.