PATH 1: Early Stage Breast Cancer

PATH 2: Neoadjuvant Therapy

PATH 3: Pregnancy During Breast Cancer

PATH 4: DCIS

PATH 5: Metastatic Stage 4

Neoadjuvant (Pre-surgery) Chemotherapy

Neoadjuvant chemotherapy refers to chemotherapy that is given prior to cancer-related surgeries. It is often given to women who have:

"Locally advanced" breast cancer
A large tumour in their breast (usually over 5 cm in size)
Enlarged lymph nodes under their arms (this may mean the cancer has spread into the lymph nodes)
Inflammatory breast cancer
Triple negative or Her-2 positive breast cancer

If you receive neoadjuvant chemotherapy, you will still have to have surgery, even if you have what is called a complete pathological response where the tumor appears to have disappeared on imaging you will have at the end of the neoadjuvant chemotherapy.

WHAT YOU NEED TO KNOW NOW
WHAT YOU NEED TO DO NOW
HOW YOU MIGHT BE FEELING
WHO THE TEAM IS AT THIS POINT

WHAT YOU NEED TO KNOW NOW

Neoadjuvant chemotherapy (NAC) refers to the delivery of chemotherapy before your cancer surgery. We have seen that the outcomes (like survival and recurrence rates) are the same between similar patients who get chemotherapy before surgery compared to those who have chemotherapy after surgery.

Traditionally, NAC was recommended for a group of patients with “locally advanced breast cancer.” In more recent years, even patients without locally advanced breast cancer, but who we know will receive chemotherapy as part of their treatment plan, may still be referred for NAC. Many young patients start their breast cancer treatments with neoadjuvant chemotherapy.

Why NAC?

Your care team may recommend NAC for a number of reasons. The most common reasons include a large tumour size (more than five centimetres) and any evidence that many lymph nodes are already affected. Conditions such as inflammatory breast cancer or advanced disease that cannot be treated surgically first (e.g. tumours stuck to the skin or muscles) are other situations where you would need NAC.

More recently, we have found that triple negative (ER-, PR-, and Her2-) or Her-2 positive cancer (ER-PR-Her2- and ER-PR-Her2+) typically have very good responses to NAC, and therefore are more commonly referred for chemotherapy first compared to estrogen positive tumours.

Finally, in some cases NAC may be given in order to help shrink the tumour and allow you to have a lumpectomy rather than needing a mastectomy if this is your preference.

Although in some cases NAC can lead to complete disappearance of the tumour on imaging (like MRI), surgery is still required to make sure all of the cancer cells are truly gone.

NAC with other treatments

Imaging is often done at the end of NAC in order to determine how the disease has responded to the treatment and to plan for your surgery. Surgery usually occurs round four to six weeks after your last chemotherapy cycle. Radiation will happen about four to six weeks after surgery.

Side effects

The chemotherapy treatments may affect your fertility; this is something you should discuss with your health care team. There are some options to try and preserve fertility (such as egg and embryo preservation) that can be addressed before starting your treatment.

WHAT YOU NEED TO DO NOW

Your health care team will discuss the side effects of this treatment with you. In some cases, you may need to have a procedure to put in a Port-a-cath. This device is embedded in the skin of the upper chest in order to use for the intravenous chemotherapy drug injections. Your doctors will order a variety of other tests (such as CT and bone scans) for staging the disease. You will also have blood work to monitor your liver/kidney functions and check your blood counts.

If you are working, there is no need to stop working if you feel up to it, but this is the time to take care of yourself.

You may also decide that participating in clinical trials is the right choice for you. Again, this is a personal decision, but many options are available.

HOW YOU MIGHT BE FEELING

At this stage you will start to process the information and begin the process of coping with the diagnosis emotionally and physically.

You may have a variety of feelings—from being scared to angry, sad, bewildered, and out of control. Many cancer patients begin to experience general anxiety or scanxiety; this is normal and expected. Your personal and medical support team can help you work through these feelings. Our resource directory may also help guide you through common experiences of breast cancer patients.

You may feel particularly apprehensive about starting with chemotherapy as part of your cancer journey; however, today’s medications are much better tolerated, and the side effects can be minimized significantly. Most importantly, this is a finite treatment and you will get through it!

For young women, fertility may be a concern. Be sure to share these concerns with your doctor prior to treatment and ask for a referral to a fertilty specialist who can discuss options, such as embryo freezing or ovarian suppression, that are available to you. This decision aid will help you find more information.

Many women have heard stories from friends and loved ones about common and rare things. Remember you are not alone! There are several support systems in place both locally through your hospital as well as online to help you though this time in your journey.

WHO THE TEAM IS AT THIS POINT

Your main team during NAC will be your medical oncologist and nurses. You will meet with your surgeon at the beginning and at various points during the chemotherapy treatment (e.g. sometimes in the middle). You will have a meeting with your surgeon at the end of chemotherapy to finalize a plan about surgery. You will also meet with a radiation oncologist to discuss the radiation therapy which (in the vast majority of cases) will follow your surgery. There are other specialists in psychology/psychiatry, genetics and fertility that you may also meet at this stage.

Ideally, you should prepare for your appointment and bring along someone who knows you well and can be a second set of ears during the consultation. You might consider recording your appointments on your smart phone as well.

Be sure to ask plenty of questions to help yourself gain the best undertanding of your situation.