What is better adjuvant chemo/neoadjuvant chemo for TNBC

The786

Someone I know has been diagnosed with TNBC. The lump is approximately 5-6cm and their doctor recommended neoadjuvant chemotherapy mastectomy then radiation afterwards. However the person I know said she wanted surgery first. She made that decision based on a few friends (who didnt have TNBC but different a BC) who said to her remove it first because it will be within her breast for the next 3-4months and that it is bad.

I on the other hand told her maybe what her doctor recommends may be better because neoadjuvant chemo can show whether it is effective towards the 5-6cm tumor and any stray abnormal cells. But if she does surgery first then she will need to wait a few weeks to a month for recovery and then receive chemo followed by radiation. How will the doctors know if the chemo they give her will be effective for TNBC after surgery. What is better in terms of NOT ever having a recurrence which step helps destroy these abnormal cells from the root. Is waiting with  a lump bad even when the person is receiving neodjuvant chemo or is it still ok to have surgery first then chemo and not knowing if the chemo is really destroying any stray abnormal cells. Needle biopsy for lymph nodes were clear (Thanks to the grace of God) still some will be removed anyway. Just want the best procedure for this person to have the best outcomes. Knowing that TNBC is aggresive and the tool for it is chemo then which way is better and what is the difference. The person I know will get mastectomy neoadjuvant or adjuvant, so breast conserving is not an option (made by her) doc thinks neoadjuvant may show good results because of the type of tumor it is though is large. Doc also said if neoadjuvant chemo isn't effective they will jump to surgery. Dont want this thing to no where near get worse so how to battle it quick. We need second third fourth fifth whatever opinions. There is fear and hope both mixed with a ton of confusion.

Anyways any help on this matter will be appreciated. Sorry if I had made it confusing in any way all of this is still new and I am learning about it as I do more research. 

Worrywart9390

I had surgery first, but I'm hearing doctors are moving towards chemo first, because chemo is our only defense (plus rads) and they get to see how effective it is.  If you have surgery first, you just dont know.  I wish her the best.

Worrywart9390

and thats with triple negative of course that they are moving towards chemo first.

jenjenl

I had surgery 1st and wish I didn't, now I will never know if the chemo was effective.  BUT on the other hand I was happy to have it removed from my body.

KSteve

I had chemo first, then BMX, then radiation.  Because of the aggressive growth rate of TNBC, my oncologist wanted to make sure the chemo regimine was reducing the size of the tumor.  If it didn't, then it gave him the chance to try a different chemo.  As opposed to removing the tumor first and then hoping that the chemo is killing the remaining cells in your body.  As my ONC said, it kills the cells before they have a chance to set up shop elsewhere in your body.  In my case, I had a complete response, meaning there was no evidence of disease in my breast tissue or lymph nodes at the time of my BMX.  Good luck to your friend.  Don't hesitate to ask any further questions.  I'll be glad to answer anything about my journey.

Kathy

Luah

The786: When I was diagnosed, nearly everyone was getting surgery first, then chemo. However, in the years since, there is quite a lot of momentum towards doing chemo first for TN, then surgery, for all the reasons stated above... as well as to shrink a large tumour for a good Lx result, though that doesn't apply in your friend's case if she is doing Mx.  

If I were doing it over, I'd go with chemo first, but all of us have to make choices that we are most at peace with... and perhaps for your friend that is surgery first. I can understand that too. It would be helpful to get one or two more doc opinions, and then she can make a truly informed decision. At the end of the day, though, it is her choice to make... 

GoWithTheFlow

I had chemo first, then bmx, and will start rads in a week.

As Kathy said above, it will allow them to track and see how effective the chemo is for your friend.  I had a complete response also and there was NOTHING in my pathology after my BMX.

I have a friend who did surgery first and now going through chemo, wonders if the chemo is working.

I also had pulling under my arm from my tumor growing so quickly.  Literally, the day after chemo, the pain subsided substantially.  After one AC treatment, my tumor shrunk 50%, after the 2nd treatment, it shrunk another 50%.

InspiredbyDolce

The786:

First, this is so nice of you to be so proactive of your friend's care.  You are a great support and advocate for her!

I would suggest in this case, your friend consider strongly what the doctor is recommending.  That doctor could have additional information about her case that could also influence why he is suggesting this.  For instance, perhaps the tumor is in a very specific location where it might be riskier to remove with the size that it is, so conducting chemo first could be a way to shrink it, in order to remove it while minimizing risk of cancer cells escaping. Her doctor is an expert in his field, and so she should ask him why is he recommending this, what will this regimen bring, and find out more about why he is suggesting this. Sometimes things make more sense to us, if the doctor can explain why they are recommending a particular option.  I would drill down deeper to the doctor, ask more questions about his action plan and have more facts before exploring a different direction.  Outcomes and options are dependant on so many influences and factors that I would really want to lean towards what information my doctor is providing, as only the doctor has the entire complete picture of what is going on with her pathology.  So he likely has formulated a plan that has taken everything on her pathology report into account.

Hope this helps a little! 

The786

The oncologist surgen wanted to do neoadjuvant chemo to shrink down the tumor for conservation but she said she was happy to also do surgery first and feels she can completely remove everything without a problem. She said either one was a fine choice and didn't effect outcomes. She said whether it was neoadjuvant or adjuvant the chemo type would be same and it is usually effective on patients. 

BikerLee

The medical team on my case strongly felt neoadjuvant was better for triple negative. PLUS - I got to see results as my tumor was completely converted to scar tissue with chemotherapy. What a huge mental bonus! I KNEW that the chemo was effective against the cancer I had. In addition, a complete pathological response means a much much lowered risk of recurrence, so I get to know that as well.  Finally, the med experts were telling me there is a slight improvement for long term recurrence-free survival with neoadjuvant - probably because the chemo is treating the whole body, which one hopes includes any pesky, wandering cells.  If those wandering cancer cells are present, they have a few more weeks of wandering when surgery comes first.

A couple of other benefits.

One - seems like it's faster/easier to get started on chemo than schedule surgery.  Two - gives you time to truly consider your surgical options. Reconstruction or go for flat? If reconstruction, what approach? One mastectomy or two? Lumpectomy? Rads (if optional)... etc....  Having the TIME to come to a decision about the surgery step is really a huge bonus.  

GOOD LUCK!  I hope she is able to come to a decision and feel peace around that decision... Personally, I feel like chemo first, if available as an option, is the best way to go.

KSteve

Wow, BikerLee!  It's like you went into my mind and wrote down my thoughts exactly!  I, too, have no regrets from neoadjuvent.  I just wanted to say that was very well written, and will hopefully help The786's friend to make the right decision for her.  I know I had a lot of piece of mind know that the chemo went to work right away so these cancer cells couldn't spread any further.

Good job,

Kathy

konandkaismom

I had chemotherapy first. My tumor shrunk by 90%. I then had a lumpectomy and a few lymph nodes removed and everything came back clean. I then had 6 weeks of radiation. I am one year out of treatment. So far it was successful for me.

encyclias

I started out with two 2+cm solid tumors.  My MO put me on chemo first; A/C x 4.  By the third cycle, you could no longer feel the lumps nor the lymph node or two which were also involved.  By the end of the chemo, neither a mammo nor an US could find them -- only the biopsy markers were visible.  A few months later, the surgeon went in for a lumpectomy and only found a 3mm residual carcinoma where the larger of the two lumps had been, he took it out.  Margins clear, nodes clear.  I am now into my 3rd week of rads.

I hope when the rads are done that I can rest for a while and get my stress levels down.  I would also be delighted never to hear the word 'cancer' again, God willing.

(I am actually HER2 Equivocal -- they don't have a place to check that off)

Carol

joannnc

I was diagnosed in 2003 and my oncologist strongly recommended chemo first.  If the chemo is going into your body the cancer cannot spread so there is no harm or risk in waiting for surgery.  With chemo first the cancer is being attacked immediately.  If you have surgery first you have to wait at least 4 weeks for recovery before chemo can start.  Originally, I was scheduled for four chemo treatments - surgery - then four more chemo treatments.  However, after four treatments the tumor had shrunk by 50% so the Dr. said to do all eight treatments before surgery.  It worked for me. 

anamerty

Tn scares the pee out of me.I had bmx first then followed by chemo I was to have 4 but it was cut to 3 because of getting pnumonia right after 3rd chemo and almost dying which was caused by the taxatore.mo said if he gave me the last one it would have killed me.so who knows weather the chemo has been affective.of course ct for lungs revealed a spot on my rib subsequent ct showed it had shrunk this is why they are convinced its bone mets as there would be no reason it would shrink within 2 weeks unless it was mets as there was still chemo in me 3 months later it was srtill there hut not progressed so now im being watched nothing they can do until it grows enough for a biopsy.they think it was there pre surgery but I didnt have ct scan pre surgery so they dont know 100% problem is with tn it can bypass lymph nodes and still be metastising so I think with tn its not going to matter chemo before or after surgery because as soon as chemo is over it can begin to spread I assume that I also had a complete response as that spot on rib shrunk but theres nothing that is stopping it now. knowing that the type of chemo worked on the initial tumor is not any gaurentee (sp?) So dont beat yourself up if you didnt have chemo first

Teddi

I was just diagnosed with TN IDC last month and my MO recommended chemo first for the same reasons as previously given - to know that it is working and to shrink the tumor prior to surgery.  I was very uncomfortable with leaving the tumor inside me for another 6 or 7 months but was assured it will be watched to make sure the chemo is keeping it from growing and spreading.  I've done some research and have found that this is the usual treatment and I am much more comfortable with my decision to follow the MO's recommendation.  For me personally, I feel much better knowing the chemo is working before having the surgery instead of wondering afterward.  

Peachygirl

I'm scheduled for surgery on aug 19... I have been diagnosed with dcis 2.5 cm on my right breast and had an MRI that showed another lump that was 1.5 cm and a line in the middle of my breast and also 4 lymph nodes lit up on the same side... the left side showed nothing abnormal...I haven't had a biopsy on the other lump or lymph nodes but my bs (after talking with the oncologist she works with)is reccommending me to have a mastectomy and then if we need to chemo afterwords...(I should include that I'm 34 and my family has questionable background for breast cancer... My mom may have had it but dosnt like to call it cancer and my grandma may have had ovarian cancer at a young age... No one likes to be open about it and give it to me straight which leads to frustration and confusion... I had genetic testing but will not get results for two weeks) My mom told me I'm making a huge mistake by doing a double mastectomy based on reccommendation of a dr which adds to my already high stress level... I looked up chemo treatments on bc.org and surgery first seems to be common... Am I making a mistake?

ProfTNBC

Some things to consider for TNBC - how fast growing is the tumor?  Ask your doctor about the % of TNBC patients that respond to chemo therapy.  Posters here seem to have been compete responders - they make up about 1/3 of TNBC patients and the results for them are fantastic.  Ask your doctor what will happen if you don't respond to chemo?  How long will the doc try chemo before sending you to surgery?  Will the onc try a different chemo regimen with you if you don't respond?  How long will all of this take?

In my situation, my tumor was extraordinarily fast growing (as are most TNBC tumors, from what I understand) and it did not yet seem to be in the lymph nodes.  My onc would do nothing different in terms of my treatment whether applied neoadjuvant or adjuvant.  I would receive ACT - AC every other week for 8 weeks and weekly Taxol for 12 weeks.  With a lumpectomy I would get 7 to 8 weeks of radiation.  With a mastectomy, I wouldn't need the radiation.  Staging is done at the time of the surgery.  It's great if you choose chemo first and your tumor responds.  I decided not to take that risk b/c my tumor was already 4 cm and invasive, but didn't seem to be in my lymph nodes.  I didn't want to take the change that it would spread to my lymph nodes while on chemotherapy (which it would do if I was a nonresponder to the chemo treatment).  I did not want to take that risk for me.  It's true that I won't know whether I am responding to the chemo treatment, however, since my doctor was not going to give me any other regimen than ACT, then it doesn't matter.  In my case, surgery first was the better option.  It took a month from discovery of the tumor to get to the surgery, and I was lucky - the cancer had not spread to my lymph nodes.  I am okay not knowing whether the chemo is working.  I felt immediately better once the tumor was out (I looked better, and felt better.)  It was a good choice for me.  Everyone is different, and everyone's situation is different.  It's a tough time deciding what to do.  Once you do, I'd encourage you to not second guess yourself.  You'll make the right decision for you.

mlm445

I struggled with this same issue and decided neoadjuvant

My tumor was 4.7. I too just wanted this thing out of me. First chemo shrunk it in half. I also had a complete pathological response and feel blessed. If you trust your team...I would go with their recommendations. Big decisions.. for a stressful time.

mlm445

I struggled with this same issue and decided neoadjuvant

My tumor was 4.7. I too just wanted this thing out of me. First chemo shrunk it in half. I also had a complete pathological response and feel blessed. If you trust your team...I would go with their recommendations. Big decisions.. for a stressful time.