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Which patients are given adjuvant chemotherapy?

Adjuvant chemotherapy is given with an intent to achieve a complete cure, and to prevent the disease from coming back. Adjuvant chemotherapy is given to patients who have undergone a 'curative' surgery for breast cancer (irrespective of whether it is a breast conserving surgery or a mastectomy). The rationale of giving adjuvant CT is that, even though the primary tumour in the breast has been operated upon, there may still be some cancer cells which may be in circulation, and chemotherapy is targeted to destroy such cells, so the chances of disease coming back becomes less. According to present guidelines, chemotherapy is given to paitents who have undergone surgery for early or locally advanced breat cancer, who meet any of the following criteria:

  • Any tumour size of 1 cm (centimeter) and above

  • Any node positive breast cancer (even if only one node positive)

  • If patient has received a neoadjuvant CT, adjuvant chemotherapy is given to complete the total no. of cycles, even if there was a complete response after neoadjuvant CT and all the nodes are negative and there is no residual tumour

Which patients are given neoadjuvant chemotherapy? (NACT)

Patients who present with a locally advanced breast cancer (stage 3A, 3B), or patients who have a large (but not locally advanced) operable breast cancer and who desire a breast conserving surgery, chemotherapy is given prior to surgery with an aim to achieve a reduction in the size of the tumour and make it operable. Of course, some patients who have only a small area of skin involvement and s smaller tumour, may demand for an upfront mastectomy, and it is feasible. But studies have shown that giving a prior CT in such cases will have a survival advantage.
NACT is usually given for 4 cycles. Response is charted at every cycle by a local examination, so non responders can be identified by the 2nd cycle. Most women will be able to see some response by around 10 or 15 days after 1st chemo, and by the end of 2nd CT, the response is usually very obvious. So to sum up, the indications of neo adjuvant CT are as follows:

  • Locally Advanced Breast Cancer (LABC)LABC's, in most cases, are not amenable to direct surgery either due to skin involvement over a large area or satellite nodules or matted lymph nodes in the axilla. NACT is given to cause a reduction in size of tumour, skin involvement, nodal shrinkage etc. Usually 4 cycles are given, with documentation of response at every cycle. In more than 70% of cases, the result is very favourable, with almost complete disappearance of skin involvement, reduction in size of tumour. A fair number of paitents who have LABC and undergo NACT become amenable to breast conserving surgery. After surgery the remaining cycles of CT are to be given as adjuvant CT.
    In some patients, there is no response even after second cycle of chemo, and in fact, there might even be disease progression. These patients are non responders, and have to undergo change in regimen to chemotherapy to second line drugs. If they respond, surgery can be considered. If they dont respond, there is nothing much we can really do, and have to treat patient with a palliative intent. Fortunately, the numebr of non responders are very few, majority of patients respond favourably.

  • Large Operable breast Cancer (LOBC) In there patients, the tumour is large (more than 5 cm), but is yet operable, there are no signs of skin involvement, nipple changes, etc. But if the tumour is large and breast is relatively small, breast conservation surgery may be difficult. So here also, an NACT is given with an intent to reduce the size of the tumour, and once a good shrinkage is achieved (usually 4 cycles), we can proceed with breast conservation surgery

Which patients are given palliative chemotherapy?

The term 'palliative' CT implies chemotherapy which is given with an aim to achieve some prolongation of life, in those conditions, where we cannot achieve a 'cure'. The following are the conditions where a patient will be advised a palliative chemotherapy:

  • A lady diagnosed with breast cancer and having spread to distant organs at the first presentation

  • A lady who was treated successfully for breast cancer, had a disease free interval, and now has recurrence of disease.