Confused as why everyone seems to have surgery first

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eva9310
eva9310 Member Posts: 2
edited December 2014 in Stage II Breast Cancer

I'm newly diagnosed but have already started my chemo treatment.  I'm in Houston, TX so we have excellent care here fortunately and I'm with MD Anderson which has some of the best cancer docs and research so I feel confident in my care.  I noticed so many people have surgery first.  That was my initial reaction too but then after hearing my doc explain why chemo first I couldn't see it any other way.  Just curious.  I know everyone has a different story but in the few posts I've read, I hardly see anyone doing chemo first.

Stage 2B, 2 tumors 1-4.5 CM left side only, the other was less than 2cm, 2+ lymph nodes

ER/PR - Negative, HER2 - Positive

6 months of chemo (3 months of Adriamycin & Cytoxan then 3 months of Perjeta, Taxol, Herceptin), then surgery then 9 months of Herceptin)

We won't know about radiation till after surgery and I will weigh that with the overall odds of recurrence at that point.

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  • Lily55
    Lily55 Member Posts: 3,534
    edited June 2014

    It really does vary a lot between doctors, cancer centres, and types of cancer, whether any spread is suspected etc etc too

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  • Moderators
    Moderators Member Posts: 25,912
    edited June 2014

    Hello eva, and welcome to Breastcancer.org. As well as the replies you'll have from other members' own experiences, the main Breastcancer.org site includes a section on Planning Your Treatment that explains the sequence of treatments, and why there are so many types of treatments. 

    We're sorry that you had to find this great community, but glad you're here for support as you work through treatment!

    • The Mods

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  • rozem
    rozem Member Posts: 1,375
    edited June 2014

    chemo first is very common with your diagnosis   Aggressive cancers respond well to chemo. Being er/pr neg the docs want to make sure the are using the right cocktail as i dont have adjuvant hormone therapy

    You are getting the lastest and greatest protocol!!

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  • ben50
    ben50 Member Posts: 46
    edited June 2014

    For your case, it pretty much all has to do with your Her2+ status in conjunction with your stage. Results have been very positive with neoadjuvant chemotherapy for aggressive cancers, so it has become standardized for most stage II-IIIers with high grade cancers (mostly Her2+ and Triple Negative). With neoadjuvant chemotherapy, one of the primary hopes or endpoints is to achieve a pathological complete response (pCR) which is the absence of any residual tumor cells at the time of surgery. Achieving a pCR  has big implications as you probably already know based on your waiting to decide about radiation until after surgery. So yeah, you're getting cutting-edge treatment. Perjeta was only approved last September.

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  • MsPharoah
    MsPharoah Member Posts: 1,034
    edited June 2014

    Hi Eva9310,  Others have offered good information.  I wanted to add that for some ER/PR + cancers, chemo may not be an option and the surgical staging process is what provides the best tissue for Oncotype testing...or so that is the thought.  

    I ended up having chemo and I would have liked doing chemo first so that we could really see that it was killing cancer.   You are with a great team of doctors and I wish you well in your treatment.

    MsP

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  • eva9310
    eva9310 Member Posts: 2
    edited June 2014

    Wow!!  Thanks for the responses.  I really only found out about my cancer and within one month my team at MD Anderson had me started on my chemo.  I tried to do as much research as possible but it was all so confusing and I was so busy trying to line up my life, kids, summer etc before chemo.  I really assumed this was the "standard of care" for my type of chemo, I did have the option of surgery first but my medical and surgical oncologist strongly suggested I go this route with the hope of having complete ratification or as close to it as possible.  I didn't know Prejeta was new but I believe I do remember them saying that between that and taking the perception for another 9months after chemo they have had great success.  

    You all don't know this but my hair just started falling out yesterday (sad but true statement, my hair and my boobs were my two better assets :-) - so I was feeling down and  your responses made me feel good about my treatment and put a smile on my face (especially since I'm new to post).  This website is one of 3 my medical oncologist suggested I visit to avoid a bunch of wrong information.  I'm glad I came here!  Thank you all again!

    Eva

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  • momwriter
    momwriter Member Posts: 310
    edited June 2014

    Whether or not to do surgery first perhaps is center-dependent. At the time of my DX (sept, 2012) the MO, Hal Burstein, whom I consulted at Dana Farber said that there had been no difference in outcome between chemo before and after surgery-- he said they had hoped they would learn something or had different outcomes from chemo first but hadn't. Not sure if he was talking about all BC or just her2+. Right now Perjeta is only approved for pre-surgery so there was no other choice for you anyway. BTW, recent studies said that the Perjeta- Herceptin combo was especially effective with ER-, Pr-, HER2+, so seems like you're going to do great!

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  • jbdayton
    jbdayton Member Posts: 700
    edited June 2014

    I am going to jump in here with another angle.  Sometimes chemo first allows you to do lumpectomy and rads instead of mastectomy.  

    I had a rather large 2.5cm ER &PR+ HER2- grade 3.  My oncologist used MDAnderson's standard of care to do neo-adjuvant chemo actually a 2nd generation of TAC*6 3 week intervals.  The goal was to shrink the tumor and do a lumpectomy instead of mastectomy.  

    I did have a complete response to the chemo but ended up with DCIS so ended up having to do mastectomy instead.

    I trust MDA; my doctors are previous MDA doctors with great reputations and I have been more than pleased.

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited June 2014

    The reason for neoadjuvent chemo for you is two-fold. You are ER-, PR- so there is no hormonal therapy available for you adjuvently. It is important to determine whether the selected chemo regime is effective and the only way to know that is to measure shrinkage of your tumor(s). Secondly, to maximize effectiveness of agents for the Her2+ aspect they are combining Perjeta and Herceptin which is only approved  neoadjuvently for early stage breast cancer. 

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  • K51
    K51 Member Posts: 20
    edited July 2014

    Hi Ava,

    I am also in Houston- will get my biopsy soon. The Doctor that was interpreting my Ultrasound results says that the Tumor below my nipple- about 2.4cm - will have to come out- so she says right now I am classified as stage 2. I am with Herman -Cypress right now- but I am thinking about M.D. Anderson as well. I have lots of pain  & indentation concerning my breast, and right now I am having back pain- do not know if its the possible cancer or because I have a tipped uterus- everything seems to hurt since I have the Diagnostic Mammogram with Ultrasound on yesterday....

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  • justamy
    justamy Member Posts: 532
    edited August 2014

    My doc does it both ways. If you are having a lumpectomy, they tend to do chemo first to shrink the tumor prior to surgery. With aggressive stage 2 chemo may be done first to stop the tumor spreading. My doc is doing it first because you have to recover 6-8 weeks after a bilateral mastectomy before chemo and any tiny tumors could spread while you were waiting. I don't care which way its done as long as it improves my chances of survival and I trust my oncologist.

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  • shewolfpg
    shewolfpg Member Posts: 142
    edited August 2014

    All my docs gave me a choice. Honestly I am triple negative grade 3 tumor and at least 2 lymph nodes already affected. I am only 35 and the stress of finding this one was too much to handle. I decided I want to fight this as quick and as mean as possible. I wanted a double Masectomy even if only the one side was involved.  My chemo doc told me 4 weeks after surgery I will start chemo and I will still have radiation. My tumor also grew since ultrasound biopsy to the MRI a week later. I swear I feel it growing as well. I have pain with my cancer as well as lymphnode pain. My surgeon did try to talk me into a lumpectomy at first but once my receptors came back realized that this can be a huge bitch. I also don't think I could just do the lumpectomy and worry every time I found any bump. I know that's how I would be. I don't think there is a right or wrong. It is all up to you. 

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  • Sassy_Seven
    Sassy_Seven Member Posts: 47
    edited August 2014

    Hi All,

    I have been doing neoadjuvent hormonal therapy (Letrozole) for HER2-/ER+ for 6 months. The goal was to shrink the tumor from 3.5 cm in order to do a lumpectomy. It has worked. The tumor is 2.5 cm. However I have been wondering why I my MO didn't do chemo first. Originally I thought there was not a chemo package for HER2-/ER+, but reading on this blog sounds like there is. I am waiting for a call back from my MO but thought I would ask. My lumpectomy is next week, so at this point it is moot. Just curious though.

    Any thoughts?

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  • msphil
    msphil Member Posts: 1,536
    edited September 2014

    hey sweetie, I did 3 months of chemo and then surgery(L mast) then 3 more months of chemo and then 7 wks of rads, and 5 yrs tamoxifen, msphil(idc,stage2,0/3 nodes,chemo:cytoxin, adriamycin, 5 fu)

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  • Gretta
    Gretta Member Posts: 70
    edited September 2014


    Hi Eva9310,  I'm an Australian girl who has been doing a lot of research.  MD Anderson comes up a lot, & read an article by a leading oncologist who basically said this treatment gives Her2 pos girls a 97% survival rate.

    I'm so pleased you girls can get this tx.  Unfortunately, here we can not get this state of the art treatment.  I would have given anything for my docs to do this for me.  We do get Herceptin here but they don't do chemo first which is what I wished for, also BMX begged for that too.

    I wish you every success with your treatment, from what I've been reading you are in great hands. 

     

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  • april25
    april25 Member Posts: 772
    edited December 2014

    I'm thinking of doing chemo first. At first it was because I was thinking lumpectomy and if I had to do chemo anyway, why not first to conserve breast tissue?

    But I may go with a MX... still deciding!

    Now, I'm still thinking of chemo first because I'm HER2+ and can take advantage of Herceptin attacking right away instead of waiting until after surgery.

    I'm still deciding on everything, though. Getting 2nd opinions like crazy because first BS didn't have my HER2 result when I saw here, and first MO is thinking of TCH, but no Perjeta... So lots of stuff to iron out! And so many decisions!

    BUT I'm definitely leaning to neoadjuvent.

    I've been told to go with the longer-studied "gold standard" of surgery first many times, though. Doing Chemo first is still a bit too new for many. And for many, surgery first and chemo second is better for their particular cases.

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  • agness
    agness Member Posts: 576
    edited December 2014

    Having systemic treatment first makes a lot of sense for HER2 disease. You will be able to gauge the cancer's response to treatment and limit its spread at the same time without delay of healing from surgery.

    Surgery first offers more precise staging but it isnt more valuable than knowing if the chemo and targetted therapies worked. I was able to avoid mastectomy and ALND because my surgeon was willing to do less surgery pending pathology results -- and they found no cancer cells post chemo.

    In my case I also had affected internal mammary node behind my breastbone that they couldn't remove so we argued that if rads was enough to treat that area then why not also my axilla -- to try to lessen the amount of surgical damage done to my body. I pushed her beyond standard of care but i also understood the risks.

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  • april25
    april25 Member Posts: 772
    edited December 2014

    Thank you agness and kayb for your posts. I'm feeling more and more like Neoadjuvent chemo is for me! I only need to iron out the type of chemo and whether it comes with Perjeta, now...

    I still need to make the lx vs mx decision, too.

    And the SNB and port before chemo or after during surgery decision.

    And find the doctors who will do all that! I can't wait to get the ball rolling, even if all my hair falls out and I get horribly nauseous! I just want to get some treatment that will make me happy and healthy in the long run... but I'm seeing that this isn't easy!


    -------

    agness -- got your PM. Stupid daily PM limit prevents me from replying, but thank you!

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  • Hopeful82014
    Hopeful82014 Member Posts: 3,480
    edited December 2014

    I'm chiming in late here - I'm ER/PR+ and HER2- doing neoadjuvant endorcrine therapy rather than chemo. In my case the goals are pCR, which would have the advantage of probably allowing just SNB rather than ALND, and trying to lower the proliferation rate. So far we're seeing very good results - the rate dropped in 5.5 weeks from 43% to 4%, which is a very strong response. I'll have 4 more mo. on Femara before surgery. If any cancer's left in the node at that point we'll have a conversation about chemo, but BS is pretty optimistic that won't be the case, based on my early results.

    What is particularly great about this approach is that we KNOW how my body and this cancer are responding to Femara - there's no guesswork or crossing our fingers and hoping it helps. Even if I weren't responding strongly to it, this would be useful info to have.

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  • april25
    april25 Member Posts: 772
    edited December 2014

    My 2nd opinion oncologist just recommended neoadjuvent TCHP chemo. That sounds good to me. Now if I can only get the doctors I have to go along!!

    I am thinking of switching from KP to a PPO so I can go with 2nd Opinion Doc or someone he recommends, since he sound like he knows what he's doing and my first MO sounded like I knew more than he did, which is SCARY. My MO didn't want Perjeta with TCH. He didn't think Port or SNB was important before chemo... (and my veins aren't so great!).

    Anyone switch insurance during treatment??? KP is sort of a fancy HMO where you have to do everything in-house. But so far I'm not been encouraged by what their MO had to say...!

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