Most commonly in Australia, the decision on whether or not to recommend chemotherapy for a patient with breast cancer has been made after all the cancer has been removed. In this setting the pathologist has reviewed the entire cancer specimen from the breast as well as looked at any of the lymph nodes that the surgeon has removed.
There are various parameters that the MDT members will look at, for example whether or not the lymph nodes are already involved with cancer, and if so how many, the size of the tumour in the breast specimen, the grade (how “aggressive” the tumour looks down the microscope) and levels of expression (staining) of various receptors e.g. oestrogen and HER 2 (a growth factor). When all these factors have been assessed recommendations for chemotherapy are made. More recently however, decisions about the need for chemotherapy can be made on the basis of clinical and imaging assessments combined with the results from a core needle biopsy (the sample taken from the cancer to confirm a diagnosis). This means that increasingly our team is recommending the use of chemotherapy “up front”, or before surgery. Ultimately all the same treatments are given (surgery, chemotherapy, + /- radiotherapy) but the sequence is reordered. Delaying surgery by giving chemotherapy up front does not negatively impact on outcomes, but in some cases has some significant advantages. Perhaps the most common reason for considering using a NACT approach is to try to “downsize” a cancer. Sometimes even with modern oncoplastic techniques, attempting to preserve the breast and retain a pleasing aesthetic result is not possible if the tumour is very large compared with size of the remaining breast tissue. One way of trying to overcome this is to shrink the tumour using chemotherapy first. This is not always successful but for approximately 80% of women this will result in sufficient reduction in the tumour size to allow successful breast conserving surgery. In some cases (15-50%) the tumour will melt away completely with NACT. It is important that you have a marking clip placed before cycle 2 of chemotherapy to mark where the cancer is / was so that after the NACT, any residual cancer can be removed at operation. Placing the marker clip is a very similar process to that of having a biopsy. In some cases there is not of a lot of response to chemotherapy which can be disappointing and may mean that your surgeon still may end up recommending a mastectomy +/- a reconstruction. The decision to have NACT can be complex and difficult but you will have opportunities to speak with both your surgeon and the medical oncologist about what your options are.