Should Surgery Be Done Before Other Breast Cancer Treatments?

One of the first questions asked by patients with breast cancer is whether they will need surgery before or after other treatments. The answer is different for each person. That’s why it’s a good idea to schedule a consultation with either a breast surgical oncologist or a breast medical oncologist before selecting your next steps on the treatment journey. This team of physicians will work together to create a plan they feel will be most effective.

Let’s look at how doctors determine the timing of cancer treatments and surgery, as well as the factors that impact the selection for each patient.

Adjuvant vs. Neoadjuvant Breast Cancer Treatments

Neoadjuvant therapy is the term used when treatments are given before surgery to shrink the tumor. The most common types of neoadjuvant treatments are:

• Neoadjuvant chemotherapy: The most commonly used treatment before surgery. Chemotherapy drugs before surgery shrink the tumor and potentially change the type of breast cancer removal surgery needed.
• Neoadjuvant radiation therapy: Directly targeting the tumor with radiation therapy before surgery often shrinks it to a size that reduces the amount of tissue that needs to be taken from the breast during a breast-conserving surgery.
• Neoadjuvant targeted therapy: If the cancer is fueled by the HER2 protein, a drug that targets the overgrowth of that protein can be given to slow the growth and even shrink the tumor before surgery.
• Neoadjuvant hormone therapy: Some patients will be given drugs that lower hormone levels, which can slow the growth of the breast cancer tumors.

Treatment after surgery is called adjuvant therapy. The goal is to reduce the likelihood of the cancer returning and ensure that any remaining microscopic cancer cells are killed. A patient might receive the same treatments both before and after surgery, or some may be given before surgery, and different treatments administered after surgery.

Factors that Affect Breast Cancer Treatment Plans

When it comes to deciding what’s best for each patient with breast cancer, there are several considerations. A cancer care team is going to consider the following:

• The patient's age, health, and menopausal status
• Stage of breast cancer, which includes the tumor size.
• Grade of the tumor (how fast it’s likely to grow)
• Location of the tumor(s) in the breast
• The tumor’s hormone status, including estrogen and progesterone receptor status
• HER2 status - is there an overgrowth of the HER2 protein
• Presence of inherited breast cancer mutations (BRCA1 and BRCA2)
• The tumor’s genetic profile. This is done using tumor profiling tools like Oncotype DX.

Breast Cancer Staging

While the timing of cancer removal surgery is specific to each person, the stage of breast cancer plays an important role.

Breast cancer can be categorized into five stages. Stage 0 is referred to as non-invasive ductal carcinoma in situ (DCIS) and may not even require surgery. Stages 1-4 are referred to as invasive breast cancer. Most of the time, surgery is required for stages 1-4.

• If you have early-stage breast cancer (Stage I) and are healthy enough to undergo surgery, the team may recommend surgery before other treatments, with radiation therapy and possibly other treatments afterward.
• Stages 2-3 may require some treatments to shrink the tumor before surgery is performed to reduce the amount of tissue that’s removed and lower the chance of cancer cells spreading. However, this is not always the case.
• Stage 4 breast cancer will usually require systemic treatments first, such as chemotherapy, because the cancer has spread to other areas of the body. Not all stage 4 breast cancer patients have surgery.

Everyone’s situation is different, and your breast cancer care team will make the decision with you about the necessity of surgery and its timing.

Pre vs Post Menopause Status

When a patient has hormone-positive breast cancer, hormone therapy is likely to be a part of the treatment process. Most often, this is given after surgery, although not always. The dosing and length of time the medicines are given will depend on whether the patient is pre- or post-menopausal.

What Type of Surgeries Are Used for Breast Cancer?

The surgeon will recommend a specific type of breast cancer surgery based on scientific data and their experience with your specific type of breast cancer. Beforehand, the surgeon and the medical oncologist will review your case. Each physician will have input on the treatments they provide and the best timing for each.

Lumpectomy/Partial Mastectomy - Breast-Conserving Surgery

During a lumpectomy, the surgeon removes only the tumor and some of the surrounding tissue to ensure it has not spread into other areas. When possible, they will use oncoplastic techniques to improve the appearance of the breast after surgery. These techniques can help prevent indentations, minimize scar visibility, and enhance the shape if the procedure alters it.

Depending on the stage and hormone receptor status, a patient may only need radiation therapy as a follow-up treatment after surgery. Others may require additional treatments to be sure the cancer cells are destroyed in the lymph nodes and to lower the hormone levels that fuel the cancer.

Mastectomy - Breast Removal Surgery

A mastectomy is a surgery to remove all of the breast tissue and possibly some of the chest muscle. Your surgeon will also remove a few lymph nodes near the tumor. They will be tested to see if cancer has started developing there, since breast cancer usually spreads to the lymph nodes first.

There are several different types of mastectomy. The breast surgeon will provide recommendations based on their expertise, allowing each patient to decide which option is best for them.

Most of the time, patients undergoing mastectomy won’t have radiation therapy afterward. If cancer is in the lymph nodes, additional treatments will be needed to ensure all of the breast cancer cells in the body are treated. The medical oncologist will recommend a combination of treatments that can include chemotherapy, targeted therapy, hormone therapy, and/or immunotherapy.

Personalized Breast Cancer Treatment at Willamette Valley Cancer Institute

The breast cancer specialists at WVCI work with each patient to develop a personalized treatment plan tailored to their specific needs. Our care team provides patients with the most comprehensive breast cancer treatments, access to clinical research, and a team of breast cancer surgeons.

If you or a loved one were diagnosed with breast cancer, request an appointment with one of our breast cancer oncologists or breast cancer surgeons. They are available to see patients in Albany, Corvallis, Eugene, Newport, and Springfield, Oregon. During your consultation, you will discuss your surgery options and other treatments. You can also receive a second opinion on the timing of breast cancer treatments and surgeries. We want every patient to feel well-informed about the decisions they have about their breast cancer treatment plan.