Neo Adjuvant Chemo Therapy

First Chemotherapy Then Surgery

What is Neo Adjuvant Chemo Therapy (NACT)
for Breast Cancer?

Breast Cancer, broadly, has three different treatments - surgery, chemotherapy and radiation therapy. All patients do not need all of them, but most of them do. Some patients undergo surgery first and then chemotherapy, while some receive chemo first and then surgery. This 'sequence' of chemo and surgery is decided by the stage of breast cancer. If you have not already read about Breast Cancer treatment planning, I request you to read that section first by clicking here - Breast Cancer Treatment Planning. Please read about what is 'Locally Advanced breast Cancer' and then you can close that page and come back here to read further.

So what is 'Neo Adjuvant Chemo Therapy?

When we treat any cancer, we make our treatment decisions based on 'how much bulk' or 'how much burden' or 'how much volume' of the cancer seems to be there in the patient's body. Basically, we try to assess - is it an 'early' cancer or is it 'advanced'. There are certain 'indicators', which, an Oncologist 'notices' and 'assesses' during the breast examination, which tell him that the cancer looks advanced - the Oncologist then confirms his assessment, with findings on a mammography, PET CT, core biopsy and other tests.

In simple terms, for breast cancer, the Oncologist tries to see whether is it just a 'small lump' with maybe a few 'tiny' nodes in the armpit (indicators of an early cancer); or is it a 'larger tumour', with skin thickening and lots of nodes in the arm pit (indicators of an advanced cancer). This second description - 'larger tumour' with 'skin thickening', 'enlarged nodes or lots of nodes in the arm pit' definitely tell us that this cancer looks a 'bit advanced'. And in such advanced cancers, the 'chances' that cancer cells are moving around in the blood, all over the body, is very high (even though PET CT may show no 'distant' spread). Such 'advanced' cancers (they are 'advanced' where they are - in and around the breast- but they have not spread to other organs like liver, lungs, bones) are called 'Locally Advanced breast Cancer' (LABC). If a cancer has spread to any organ, like liver, lung, brain, bone etc., it is called 'Metastatic breast Cancer' (MBC). Our discussion below, is limited to Locally Advanced Breast Cancer (LABC). In such advanced cancers, it is not advisable to operate because of the following two reasons:

  • Apart from the tumour and skin involvement, there will be lots of cancer cells in a wide area around the tumour and the breast; if we try to operate, easily we will 'leave behind' many cells which will grow within no time and cancer will come back at the same site.

  • If we operate, we are tackling the cancer in and around the breast. What about the of cancer cells in the blood, moving around? We want to control those cells first, as they are the ones which are going to cause a 'recurrence' of cancer

In LABC, surgery is not feasible or advisable. We first want to 'reduce the burden' of cancer cells in the body and then consider to operate later. And how do we do it? We have to kill the cancer cells. That is done by chemotherapy. A Chemotherapy, which is given before surgery, with an aim to reduce the cancer burden in the body, and to make the cancer operable, is called 'Neo Adjuvant Chemo Therapy' (NACT).

Please note, NACT is not given only for LABC (Locally Advanced breast Cancer). Sometimes, the tumour is a little larger (especially in a smaller breast), but the skin is normal, there are no nodes or barely a few nodes- this situatuion is not advanced. But if we operate directly, we may not be able to preserve (conserve) the breast. We want to 'reduce' the size of the tumour, so we can do a breast conserving surgery later. Here also, an NACT is given.

So to sum up, Neo Adjuvant Chemo Therapy (NACT) is given in two situations:

  • Locally Advanced breast Cancer

  • Non Advanced but 'larger' breast tumour


This has been written in a 'flow chart' form, to make it easy to understand. And the best way to underdstand is by a real example. Read on below.

Detection and Staging
A 44 years old lady is feeling a 'lump in her breast', since three months. She visits a Surgical Oncologist. Her Surgical Oncologist (SurgOnc) examines her - the lump feels about 4 cm in size, the skin over central area of the breast is 'thickened' like a 'peel of orange', and there are a few enlarged, hard lymph nodes in the armpit, measuring about 2 cm each. He labels this as 'Locally Advanced Breast Cancer'. Core Biopsy has confirmed breast cancer. PET CT shows 'uptake' in the breast tumour, the thickened skin also shows some uptake, and there is 'uptake' in the nodes. Rest all organs - liver, lungs, bones etc. - seem fine.

Treatment Planning
The SurgOnc reviews all reports and feels this is advanced. Presently, it is not feasible for surgery. She must get chemo therapy first and then assess. He explains the patient in detail, and refers them to a Medical Oncologist (MedOnc)

MedOnc Assessment
The MedOnc assess the lady in detail. He notes the SurgOnc's assessment. He notes her age, weight, height, general condition, health status, family history. He assesses her PET CT, and most importantly, the 'type' of breast cancer in the Core Biopsy Histopathology Report. He examines her; he also sees her veins on hand. He then decides which chemo to be given, calls up the SurgOnc and they both discuss it. He counsels her and her husband in detail, solves their queries. He plans a date for the first chemo, and refers back to the SurgOnc for Chemoport insertion.

Chemoport Insertion
The SurgOnc counsels the lady about Chemoport in detail, he shows her one - how it looks, what it is, and how will chemo be given to her. Most importantly, he shows her, why will it be beneficial to put in a Chemoport. Two days prior to starting of chemo, the SurgOnc performs the Chemoport surgery.

First few cycles of Chemo
The lady is back with the MedOnc at the Chemo centre on the day of first chemo. She undergoes the first chemo through the chemoport. The nurses at the centre counsel her, a dietician may be called to guide her on diet during this period. On discharge, she is given a detailed guidance on side effects and what to do, if they arise, as also the emergency contact numbers.

Interim Assessment by SurgOnc
15 days after the second cycle (if it's a 21 day or 15 day chemo cycle) OR 7 days after the sixth cycle (if it's a weekly chemo), usually, the SurgOnc will wish to examine the lady once, to assess effects of chemo or not. In most women, there is a 'definite' visible 'reduction' in the 'bulk' of the tumour. This visit is only to confirm the chemo is working or not. Once the SurgOnc confirms, chemo seems to be working, the patient goes on for further chemo.

Another Few Cycles of Chemo
4 cycles of chemo are done now, and we have reached half way, of chemo cycles (Most patients will need 8 cycles of chemo). So after 4 cycles (if it's a 21 day or 15 day chemo cycle), or after 12 cycles (if it's a weekly chemo), the team of docs (SurgOnc and medOnc) will decide if a PET CT is needed or not. In cases, where there is a clearcut and significant reduction in the 'bulk' of tumour, a PET CT may not be needed; whereas in cases, where the 'reduction' is mild, a PET CT may be advised.

Midway Assessment and Planning
So now again, after assessing the patient in detail, the SurgOnc has to take a call, whether it looks feasible to operate now and give remaining chemo later? Or is it better to complete all the chemo cycles first and then operate? This is a very indivudualized decision and is influenced by many factors, which the team of doctors will consdier and then decide.

Further Treatment
So in this present example, the SurgOnc assesses the 44 year old lady, 15 days after the 4th cycle of chemo. On breast examination, he barely feels any tumour now, all the skin thickening has gone, and even the nodes in the arm pit have disappeared. He is happy with the response, and plans for surgery. After surgery, the patient will undergo the remaining cycles of chemo and then radiation.


What could be the possible further treatment after 'Midway Asssessment' after NACT (Neo Adjuvant Chemo Therapy)

  • Good Response: Most patients have a definite reduction in the size of the tumour and skin thickening. In fact, in some of them, the tumour entirely disappears and no lump is found, even of mammography! In a majority of these patients, where the response is good, and the SurgOnc feels surgery is now feasible, may go in for surgery. But there are some, especially, Triple Negative Breast Cancers, and a few others, where, in spite of good response, we still continue with the remaining chemo and the operate.

  • Not So Good Response: Some patients witness only a 'mild' reduction in tumour size or the 'skin thickening'. In such, we prefer to continue with the remaining chemo, while also keeping a close watch on what is happening to the lump, every few cycles. Most of them do respond, and may be suitable for surgery later.

  • Poor Response or disease progression: In a few patients, the tumour doesn't shrink at all. While in some, it even grows further, telling us that the particular chemotherapy drugs are not working. This is not a good sign, and there are very high chances that tumour will spread or has already spread to other organs. There is no role of surgery here. The MedOnc will have to try some other drugs depending on the 'type' of breast cancer.

The importance of sequencing of surgery and chemotherapy

The sequencing of chemotherapy and surgery plays a very crucial role in the outcome of breast cancer. It goes without saying that, for planning the same, it is essential for the Surgical Oncologist to have a good clinical skill in picking up subtle signs and properly stage the patients. If you have read the flow chart above, it is evident that a good co ordination between the Surgical Oncologist and the Medical Oncologist, in the treatment of a patient is so important. Such a co ordination not only gives the best possible outcome for a patient, but also reinforces the patient's faith in the treating team.


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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

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 - You are presently on this page
Sentinel Node Biopsy - How is it done?
Targeted Therapy - Trastuzumab
Hormone Therapy - Who gets it?