Some patients with a large tumor may be offered chemotherapy before surgery to remove the cancer. Neoadjuvant chemotherapy can often reduce the size of a tumor and therefore reduce the amount of tissue that is removed during surgery. Women who are candidates for a simple mastectomy may be able to have a skin sparing mastectomy or lumpectomy as a result of neoadjuvant chemotherapy.

This option is highly dependent on your hormone receptor status. Her-2 positive or TNBC patients are most likely to be converted from mastectomy to lumpectomy with neoadjuvant chemotherapy. This option is less successful for ER/PR positive patients. However, if an ER/PR positive cancer is so large that even a mastectomy is not possible, neoadjuvant chemotherapy may help shrink the tumour to allow for a successful mastectomy surgery.

Reconstruction options are often improved if you have chemotherapy before surgery. By shrinking the tumor before surgery, your surgeon will potentially have more skin and tissue available to work with when reconstructing the breast.

If your treatment plan includes radiation after surgery, having neoadjuvant chemotherapy will reduce the time allowing for adequate tissue expansion before radiation. Your medical team can provide more details on the evidence based research that doctors use for the timing of required treatments.

Chemotherapy drugs are typically given in combination, two or three different drugs at the same time. These combinations are called regimens. When you discuss chemotherapy with your physician, you may want to ask if you are eligible for more than one combination and, if so, what are the pluses and minuses associated with each one (e.g., clinical outcomes, side effects). Again, your eligibility for different therapies will depend on your hormonal receptor status and other tumor factors.

In some cases, ONCOTYPE DX can be ordered for your tumor. This test evaluates the genes in your tumour and provides a recurrence score. This score indicates whether or not you would benefit from chemotherapy and greatly helps in your decision making as to whether or not you want to proceed with chemotherapy when you have an ER/PR + tumor that is node negative.

The most commonly used chemotherapy drug combinations are:

• CMF: cyclophosphamide (Cytoxan®), methotrexate, and 5-fluorouracil (fluorouracil, 5-FU)
• CAF (or FAC): cyclophosphamide, doxorubicin (Adriamycin®), and 5-fluorouracil
• AC: doxorubicin (Adriamycin) and cyclophosphamide12
• EC: epirubicin (Ellence®) and cyclophosphamide
• TAC: docetaxel (Taxotere®), doxorubicin (Adriamycin), and cyclophosphamide
• AC → T: doxorubicin (Adriamycin) and cyclophosphamide followed by paclitaxel
• (Taxol®) or docetaxel (Taxotere). Trastuzumab (Herceptin) may be given with the paclitaxel or docetaxel for HER2/neu positive tumors.
• A → CMF: doxorubicin (Adriamycin), followed by CMF
• CEF (FEC): cyclophosphamide, epirubicin, and 5-fluorouracil (this may be followed by docetaxel)
• TC: docetaxel (Taxotere) and cyclophosphamide
• TCH: docetaxel, carboplatin, and trastuzumab (Herceptin) for HER-2 positive tumors