Surgery First? Chemo First?

Breast Cancer Treatment Planning

Which will come first?
Surgery or Chemotherapy?

In very broad terms, we can divide the types of breast cancer treatment into three - Surgery, Chemotherapy and Radiation Therapy. The term 'Chemotherapy' includes the standard chemotherapy, Targeted Therapy (Trastuzumab and others) and Hormonal Therapy. And each treatment has its own specialized doctor - Surgery is performed by a Surgical Oncologist, Chemotherapy is administered by a Medical Oncologist and Radiation is given by a Radiation Oncologist.

It is very crucial that all the three - Surgical, Medical and the Radiation Oncologists are involved in the decision making for the patient. And it is also crucial that they have a good co ordination amongst them for the treatment. This is termed as a 'Multi Disciplinary Team'

Does the choice and sequence of treatment affect outcome?

Let us consider the three broad treatments - surgery, chemo and radiation. Some patients may need only one of them, while others may need two of them, most will need all three. Usually, patients are known to get operated first, then take chemo and finally radiation. But do all patient have to undergo the treatment in same sequence? No!

The sequence is decided by the tumour burden. The main principle of a cancer surgery is, we should be able to remove all visible cancer, with a good margin of normal tissue. For smaller tumours with a few nodes, surgery is possible and removing tumour and nodes is not a problem. But as the tumour increases in stage, the area it involves widens, sometimes the skin over breast becomes very thick and nodes can be large and stuck to blood vessels. In such situation, surgery is not feasible. Here, we try to give chemotherapy first (it is called Neo Adjuvant Chemotherapy ) to reduce the cancer burden and then operate. And in cases, where cancer has already spread to some other organ, there is no role of surgery.

So, in short, to make it simple for you to understand, we have divided the staging of breast cancer into three broad categories (Local Cancer, Locally Advanced Cancer and Metastatic Cancer) and standard sequences in those categories. And the category is decided by the following three points:

1. Tumour in Breast - Judged during Breast Examination
2. Nodes in arm pit - Judged during Breast Examination
3. Spread to organs - Judged from Staging Tests

Localized Breast Cancer

Features in this category:

1. Tumour in Breast: Small (few centimetres) or maybe even a little larger, but no skin / nipple involvement.
2. Nodes in arm pit: No nodes, or just a few small nodes
3. Spread to organs: No spread to any organ

This would be early stages of cancer, and the treatment here is Surgery First followed by Chemotherapy and Radiation (if needed). The accompanying figure shows an early breast cancer. This is of a 56 years old lady, with an early breast cancer. On examination:

1. The lump was small (about 2 to 3 centimetre) and marked by 'X' in the picture. The skin overlying the tumour was 'pinchable' which means, it was free of cancer and the nipple was also normal.
2. On feeling the armpit nodes, I could barely feel them, indicating they were not enlarged in size.
3. PET CT was done and did not show any spread to anyother organ like the liver, lung, bone etc.

Mammography for breast lumps
Mammography for breast lumps

Locally Advanced Breast Cancer

Features in this category:

1. Tumour in Breast: Usually on larger side, with skin / nipple involvement. The skin looks like a 'peel of orange', is not 'pinchable' and in medical terms is called as PDO (Peau D'Orange) and indicates a bulky underlying cancer.
2. Nodes in arm pit: Either there could be no nodes or there could be definite large nodes stuck to each other
3. Spread to organs: No spread to any organ

In this stage, usually the cancerous lump has gone un noticed, and got time to grow by the time the patient realized. This stage is called as 'Locally Advanced'. It means, the tumour is still in the 'local' area (breast and armpit) and has not spread to other organs, but, the volume of that tumour 'locally' is too much. A locally advanced breast cancer is a marker of a 'rapidly spreading cancer' and by no means should we touch it by surgery. It is important to reduce it by chemotherapy first, re assess later and then consider surgery if feasible. So the treatment here is Chemotherapy First followed by Surgery (if a good response is achieved) and Radiation (always needed). The accompanying figure shows a locally advanced right sided breast cancer, in a 49 years old lady. On examination:

1. The skin of the left breast (which is normal) is pinchable, while the skin of the right breast is somewhat 'red', thick, and just cannot be 'pinched'. The tumour was occupying almost whole of the right breast.
2. On feeling the armpit nodes, I could clearly feel two enlarged, hard nodes.
3. PET CT was done and did not show any spread to anyother organ like the liver, lung, bone etc.

Metastatic (Spread) Breast Cancer

Features in this category:

1. Tumour in Breast: Any size
2. Nodes in arm pit: Any number of Nodes
3. Spread to organs: Spread to other organs on staging tests

In this stage, called as Stage 4 Breast Cancer, the cancer from the breast has gone out and spread to other organs like liver, lung, bone, brain or elsewhere. This spread happens because the cancer cells have entered the blood stream and have reached the other organ and started multiplying there. Surgery has no role in Stage 4 Breast Cancer (It is done in very very selected settings). The main treatment here is by chemotherapy. If there is spread to spinal bones, or brain, radiation may be given to those areas to reduce the pain.

The detection of spread is by one of the staging scans - either PET CT or CT Scan and Bone scan, whichever was done.

Our Approach at this Step

From the three categories mentioned above, I decide the category for the patient, depending on my findings during clinical breast examination and the staging tests. The treatment planning and sequence decision is a very important, probably the most crucial step in this journey of breast cancer treatment, which is going to determine the outcome. I explain the patient in detail about how I have narrowed down to a particular category for them. If I feel, the patient is in localized cancer stage, I offer the option of surgery to them and counsel in detail about it (covered in the next section).

If it is Locally Advanced, I immediately get in touch with my Medical Oncology colleagues and jointly plan the treatment. For patients with Locally Advanced Breast Cancer, they start chemotherapy (called as Neo Adjuvant Chemo Therapy - NACT) with my Medical Oncology colleagues. I review them after two cycles, and do a clinical breast examination to assess if the tumour is shrinking or not. In most, it does, and we continue further two more cycles (a total of four) and then take a call for doing a review PET CT, to objectively assess the response of chemotherapy. Depending on the PET findings, we take a call whether to go ahead with surgery now and do rest of chemo later OR finish all the chemo first and operate later.

These decisions are challenging, and are not same for all patients with same stage. Decision will vary from patient to patient (depending on stage and many other factors) and are individualized. Hence, a close co ordiantion between the Medical and the Surgical Oncologist is very essential.

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Journey of BC: Diagnosis

1. I feel a lump! - The first visit to doctor
2. Is it really cancer? - Confirmatory tests
3. What is the stage? - Staging and fitness tests
4. Will it be surgery first? or chemo first? - Treatment planning and sequence - You are presently on this page

Journey of BC: Surgery

5. Should I conserve or remove breast? - Choice of Surgeries for breast cancer
6. How long will be the surgery? - Admission and Surgery
7. Care after surgery - Precautions and guidelines
8. What next? - The Pathology Report

Journey of BC: Further Treatment

9. How many chemo cycles? - Chemotherapy Consultation
10. Is a PORT necessary? - ChemoPORT insertion
11. Will I be normal during chemo? - The Chemotherapy time
12. Is Radiation painful? - Radiation Therapy
13. Yes!! I did it! - Treatment is over
14. How frequently do I meet doc? - Follow up guidelines

Other Topics

Risk Factors - The Risk Factors for Breast Cancer
Symptoms of Breast Cancer - Know the Symptoms of Breast Cancer
Early Detection of Breast Cancer - The Guidelines

Neo Adjuvant Chemotherapy (NACT) - For LABC
Sentinel Node Biopsy - How is it done?
Targeted Therapy - Trastuzumab
Hormone Therapy - Who gets it?