Chemo before or after surgery?

pp729

My mom:  Diagnosed January 2011

Hi all.  I am new to this board and wanted your opinions.  My mom has been diagnosed with Invasive Ductal Carcinoma.  She underwent an excisional biopsy, removing a 1.7cm mass on 1/21/11.  The entire mass was removed because they originally thought she had an infected cyst.  Not until we got back the path report (see details below) did she learn that she has cancer.  Her margins are not clear, so we are now getting ready to begin treatment.

Mammo/ultrasound/MRI - found no additional masses in either breast.

From Excisional Biopsy pathology report - 1/26/2011:
Right breast mass.  Skin/associated soft tissue involved by Moderately Differentiated Infiltrating Ductal Carcinoma measuring up to approx. 1.7 X 1.5 X 1.4 cm.  Tumor focally involves labeled edges of specimen.  Focal dermal lymphatic involvement noted.

ER positive 99%; PR positive 98%; HER-2/NEU Negative 1+; Ki67 = High 80%

Bloom-Richardson scale grade = 9/9 = Grade III.

In-situ component:  Focal, cribriform and/or solid type, high grade.

Surgical margin:  Positive

The treatment options offered so far include lumpectomy or mastectomy with chemotherapy, and perhaps (but not certain about) radiation.  Sentinel node testing will be done during surgery, and the cancer will also be staged then. She seems to be favoring a mastectomy. 

The question for you all is:  which is better, chemo before or after surgery?  The 3 oncs that mom has seen have differing opinions -- one says before so as to reduce the size of the tumor, but 2 say it can be done after if she selects a mastectomy instead of a lumpectomy (since the tumor has already be removed so the remaining issue is with the margins and the involvement of the dermal lymphatics).  She desires chemo after surgery, so I am wondering your opinion on this?

Thanks so much for your help. 

RangerMom

I can't wait to see the replys to this too. I have been given a treatment plan of chemo first to reduce the lump size, then lumpectomy with lymph removal, then radiation. I was hoping to save my breast. However, I'm waiting on results of biopsy of the left breast with possible DCIS. Wondering how that will change my treatment plan?

mrsnjband

Sorry to hear about you mom having to join our club, the one that no one wants to join. 

I am not an expert my any means, but it seems like they usually do chemo after surgery.  I had chemo first because I had inflammatory breast cancer.  It is rare & more aggressive type of breast cancer. 

I don't understand all the lingo from your report since I didn't ask for any reports when I went through treatment.  I didn't know about this site & sure I had know about it back then.  This is a wonderful place for support & knowledge.  I'm sure others will be along soon and give you better info than I can.

Sending love & support your way. NJ

SATEX12

Hi There,

So sorry about your Mom! I had neoadjuvant chemo in order to shrink the breast tumor ( according to mammogram and ultrasound was approx, 3.5 cm) and one lymph node that we knew for sure was positive for IDC ( biopsy was done on this lymph node at the same time as the breast mass). I did 4 dose dense treatments of AC followed by 12 weekly treatments of Taxol and had progress mammograms and ultrasounds after the first 4 treatments and again after the last weekly Taxol in order to determine if the chemo treatments had done their job. According to the radiology reports, the tumor had decreased to 1.8 cm and the positive lymph node had a complete clinical response to chemo. It sounded pretty good to me and I was happy that we did the chemo before surgery, however, I noticed another very small mass in the same breast and although the mammograms and ultra sound did not identify the mass as cancerous or suspicious for cancer, I just had an uneasy feeling so I opted for bilateral mastectomy. Good thing I did...the breast tumor was still over 6.5 cm and I had multiple lymph nodes that had cancer bursting through them, and adipose IDC tumor in the tissue surrounding the lymph nodes under my arm and that new little mass I felt during chemo was actually another IDC tumor. I ended up with more chemo, carboplatin and 5FU plus 33 treatments of radiation. Based on the surgical pathology and the shrinkage of the tissue surrounding the breast tumor, my Oncologist and Breast Surgeon now believe that it was at least 10 cm at the time of diagnosis.

So, point of sharing all this information is that while chemo before surgery is usually not a bad idea ( dependent on individual circumstances), sometimes, as in my case, even after surgery, more chemo might be necessary. My Oncologist said that it's good to do chemo before surgery because it gives us a chance to monitor how the cancer is responding to the chemo treatments and adjustments to treatment plans can be made sooner rather than later if necessary. In my case, not all of the breast tumor was visualized on the breast imaging tests at the time of diagnosis or on the interval tests and to complicate matters, radiology made a mistake on the reporting so we were not working off of accurate reports at either the end of the dose dense treatments or the end of Taxol. If we had received accurate information sooner rather than later, we would have known that the dose dense AC treatments were not working for me, in fact the tumor grew slightly during the AC regimen, so as long as the radiology reports are accurate at interval testing, then neoadjuvant chemo is a great tool for your Mom's Oncologist to make the proper decisons regarding her treatment plan.

Good luck and continue to be supportive of your Mom. It's great that you are so involved!

pp729

Thanks all for your comments.  It does help to see what others are doing.  My mom is likely to select chemo after mastectomy as she has some other health issues to consider as well.  She has had opinions from three oncs -- 2 who have said that chemo before or after will be acceptable and 1 who recommended chemo before, but conceded that after would be effective as well. 

The benefits that we have been given for chemo before surgery by the oncs are:  1)  the chemo may help to shrink the tumor (not really that applicable to my mom as she has already had an excisional biopsy in which the entire 1.7cm tumor was removed; so all that is left as best we can tell now is the margins and there is no indication of other masses in either breast); 2)  she would have about a 4 week period after chemo and before surgery to recover and gain her strength again; and 3)  chemo before surgery would mean that the chemo would not impact the tissue healing process, whereas chemo after surgery could prolong healing.  I am not sure that I understand point #3 -- it would seem to me that tissue would heal better after a mastectomy without the implications of a compromised immune system that chemo gives you, so I would think the tissue would heal more naturally and at it's proper pace without chemo than with.  Can anyone share some light on this for me?

The benefits that we have been given for chemo after surgery are:  1) they would have more information on her cancer -- her lymph node status, her cancer staging, and more info from the pathology report after surgery; and 2)  they would be able to better select a chemo regimen with this additional info.

Regardless, we understand that things can change along the way as they learn more from the tests.  So we have to be flexible in all this.  And, I keep reminding my mom that she's the patient and she is the one who makes the final decision on what she wants to do.

Are there any other things that we should consider?  Thanks so much.

RangerMom

Just wanted to pop in and say that halfway through my chemo my lumps have reduced in size! So its working. I will soon have a surgical date to remove both breasts sometime in Sept. I feel really good that I know the cancer is going away. So for me, I like the idea of chemo first. will make the surgery easier and cleaner to not have to work or cut around those large lumps I started with.