Rethinking breast cancer treatment options: Should chemotherapy or surgery come first?

Anees Chagpar, MD, illustrates a breast tumor with a chocolate chip cookie. Chemotherapy can either cause cancers to shrink concentrically or to break apart, leaving cookie crumbs. That’s why surgery, and often radiation, is recommended as a follow-up to chemotherapy, and why it’s important to make sure patients have clear margins (or no crumbs at the edge of the tissue that is taken out). Speaking at Upstate last fall, Chagpar explained the difficulty in predicting which patients will have tumors that will completely disappear with chemotherapy, which will fragment or shrink and which may not respond at all.


Many people with a breast cancer diagnosis will face surgery and chemotherapy as part of their treatment. A question more doctors and patients must answer is: In which order?

Chemotherapy is increasingly prescribed to help shrink breast tumors before surgery, similar to how it is used to treat some pancreatic, ovarian and bladder cancers. When it is used as a first step in treatment, chemotherapy is what doctors refer to as neoadjuvant therapy.

“The concept of neoadjuvant chemotherapy has really taken hold because it holds so much promise,” Anees Chagpar, MD, told caregivers and researchers at Upstate in her delivery of an annual lecture paid for by the Carol M. Baldwin Breast Cancer Research Fund. Chagpar is director of The Breast Center at the Smilow Cancer Hospital at Yale-New Haven.

Chagpar says survival rates are the same, regardless of whether patients receive chemotherapy or surgery first. The National Comprehensive Cancer Network recommends considering chemotherapy before surgery in certain patients with breast cancer, and Chagpar said she favors chemotherapy before surgery for several reasons:

* An inoperable tumor may shrink enough after chemotherapy for a surgeon to consider removing it.

* Women facing mastectomy, or complete removal of a breast, may instead be able to have a breast-conserving operation if chemotherapy adequately reduces the size of the tumor. “For patients who want breast-conserving surgery, this is a way to get that,” she says.

* Chemotherapy may wipe out cancer cells completely, providing what doctors call a “pathological complete response.” Chagpar describes operations in which she removes tissue believed to contain the tumor, only to have a pathologist report there are no viable cancer cells.

* Options are growing for clinical trials that involve neoadjuvant therapy, giving patients access to cutting-edge treatment that would otherwise not be available.

Support group meets monthly

UpstatePinkChampionsFINALUpstate Pink Champions is a breast-care support group that holds monthly meetings on the second Wednesday of the month from 5:30 to 7 p.m. in a conference room of the Upstate Cancer Center. The meetings focus on networking, support, education, advocacy and awareness. To learn more, email

                                                                                                                                                                                Layout 1This article appears in the winter 2017 issue of Cancer Care magazine.

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