neoadjuvant chemotherapy is most commonly used in cancers such as breast cancer that are triple negative, Her2 positive or have large, locally-advanced tumours. (this image is for illustrative purposes only. It does not represent an actual medical event, procedure or interaction between the healthcare professional and the patient.)
WE OFTEN think of chemotherapy as treatment given after surgery to destroy remaining cancer cells. While this is not incorrect, advances in cancer care have introduced another strategy: neoadjuvant chemotherapy.
This is given before surgery, and it is playing an increasingly vital role in improving outcomes for many cancer patients.
According to Hospital Picaso consultant clinical oncologist Dr Mastura Md Yusof, neoadjuvant chemotherapy refers to chemotherapy administered before surgery to help reduce the size of tumours and prepare for a more effective operation.
Neoadjuvant chemotherapy also reduces risk of recurrence.
“Think of it as a way to shrink the cancer before we physically remove it,” explains Hospital Picaso’s consultant breast and breast reconstructive surgeon Dr Ng Char Hong.
“It doesn’t take the place of surgery, but makes the ensuing surgery easier and safer.
“If the tumour has shrunk significantly, less tissue is excised, we have better outcomes, and it’s more pleasing aesthetically.”
When and why is it used?
Neoadjuvant chemotherapy is most commonly used in cancers such as breast cancer that are triple negative, HER2 positive or have large, locally-advanced tumours with involvement of lymph nodes, say Dr Mastura and Dr Ng.
Other cancers that it is used for include rectal cancer, oesophageal cancer and certain lung cancers.
Dr Mastura: neoadjuvant chemotherapyshrinks the tumour beforesurgery, making it easier toremove subsequently.
Dr Mastura says there are several key reasons why doctors choose this approach.
According to Dr Ng, “It shrinks the tumour before surgery, making it easier to remove subsequently.
“It also improves surgical outcomes by enabling less tissue to be excised. For example, allowing for a lumpectomy (removal of only the affected tissues) instead of a mastectomy (removal of the whole breast).”
Dr Mastura adds that while undergoing neoadjuvant chemo, some patients (who meet specific criteria) may be offered genetic testing to check for inherited mutations such as breast cancer (BRCA) 1 or 2. The results can influence future treatment decisions, including surgical options and additional therapies.
Certain women with breast cancer in our population are found to carry such genetic mutations, and their presence can significantly affect the way treatment is planned.
Modern cancer care is increasingly personalised, and genetic testing can play an important role in determining treatment priorities. “Genetic mutations help us predict which treatments will be more effective for patients,” says Dr Ng.
“Such testing is part of a more comprehensive risk management strategy in treating cancer,” notes Dr Mastura.
“Together with biomarkers such as oestrogen receptors, progesterone receptors, HER2 receptors, these are then taken into consideration when deciding the best course of treatment for the breast cancer patient,” she adds.
Importantly, genetic testing results can have implications for family members, who may carry the same mutations.
Dr Ng notes that family members who test positive for the genes need to take appropriate steps to monitor their health.
Dr Ng: If the tumour has shrunksignificantly, less tissue is excised,and we have better outcomes.
Their health check-ups will be different in the tests that are done, as well as the frequency with which these are carried out.
Hence, the decision to take a genetic test should not be made lightly, and Dr Ng advises that for those considering genetic testing, it’s important that they be counselled first before taking the test.
“Hospital Picaso has pre-test counselling for genetic testing to ensure those considering it are fully aware of the implications of such a test, to health, as well as insurance matters,” adds Dr Mastura.
Effectiveness and outcomes
The effectiveness of neoadjuvant chemotherapy is beyond doubt.
“Such treatment has consistently been shown to improve response rates to cancer therapy, reduce recurrence risk, as well as improve survival rate,” notes Dr Mastura. “We see particularly strong responses in certain subtypes of breast cancer, such as HER2-positive or triple-negative breast cancers, where neoadjuvant therapy can dramatically shrink tumours before surgery.”
Dr Ng notes: “If you look at even five years ago, most of our breast cancer patients would have had surgery first. Now, ask any breast surgeon and they will tell you that almost 60% of patients will have neoadjuvant chemo first instead of surgery.
“The outcomes have improved. The types of surgery we do after neoadjuvant chemo are less complicated. The cosmetic results are better.”
He adds: “In addition, while we’re administering neoadjuvant chemotherapy, we also have the option of giving targeted therapy or immunotherapy at the same time, depending on the situation.
“Such drugs are specifically given during this time to improve outcomes and survival rates.”
In effect, such considerations have to be offered to the patient to ensure the most effective care.
“This highlights the importance of a multidisciplinary team in the care of a patient,” Dr Mastura emphasises.
“Instead of just one doctor, we have a team comprising various specialities such as oncology, surgery, radiology, pathology, genetic counselling and so on, depending on the disease, who can tailor treatments for the patient to ensure good outcomes.”
She reminds that like all chemotherapy, neoadjuvant treatment comes with the usual side effects.
Common ones include fatigue, nausea and vomiting, hair loss, lowered immunity and risk of infection, and neuropathy (tingling or numbness in fingers and toes).
“If you give the neoadjuvant chemo with immunotherapy or targeted therapy, additional side effects are possible, depending on which treatment is added,” she says.
Other considerations in neoadjuvant chemotherapy
For younger patients, fertility is a significant concern when confronting cancer.
“In Malaysia, breast cancer is the most common cancer in women, and it is often diagnosed in women aged 40 and below.
“These are women in their childbearing age, and chemo can damage the ovaries, leading to infertility. Hence, fertility counselling has to be prioritised and practised as part of treatment,” notes Dr Mastura.
“Infertility risk will depend on the age of the patient and the treatment. For women below 30, the risk is very low. Between 30 and 34 years old, there’s a risk of 10-20% of facing infertility issues. Those above 35, the risk rises to 50%,” she adds.
Before starting neoadjuvant chemotherapy, depending on the patient, doctors may discuss fertility preservation options such as oocyte preservation, embryo cryopreservation or ovarian tissue preservation (in select cases).
“The challenge lies in balancing the urgency of treatment with the time required for fertility procedures. We work with fertility specialists to ensure patients don’t miss the window for effective cancer treatment,” say Dr Mastura and Dr Ng.
Patients also often ask about pregnancy after cancer treatment.
Typically, doctors recommend waiting at least two years after completing chemotherapy before trying to conceive, to better monitor for any early recurrences (in the first two to three years), while allowing the body to recover.
Misconceptions, advances and the future
Some patients worry that starting chemotherapy before surgery means delaying their chance to “remove the cancer immediately”.
In reality, the opposite is true, says Dr Ng. “The treatment is already attacking cancer cells throughout the body, even before the first incision,” he emphasises.
There are also misconceptions when patients undergo neoadjuvant chemotherapy.
“When going through neoadjuvant chemo and the tumour shrinks to such an extent that it can’t be felt by hand, patients may ask to stop treatment as they can’t feel the lump anymore. They may even refuse surgery as they feel the chemo has done the job,” shares Dr Mastura.
However, doctors are unable to evaluate for accurate tumour response to plan for further treatment if surgery is not undertaken. “So yes, surgery is still required,” she says.
Any misconception can be addressed if there’s a clear line of communication between doctor and patient. More so now when cancer care is evolving, and there are various newer drugs and treatments that aim to improve patient outcomes available. The patient needs to clearly understand the risks and benefits of the treatment formulated for them.
The future may offer more hope for patients, but for the present, Dr Ng and Dr Mastura emphasise the role of a multidisciplinary team to formulate treatment plans for patients. “Cancer is a complex disease. It has to be managed by a group of experts to optimise patient outcomes.”
Neoadjuvant chemotherapy has transformed how doctors approach cancer treatment.
It is not about delaying surgery, but about strengthening the overall treatment plan – shrinking tumours, improving surgical outcomes and tackling cancer at its earliest stages.
It provides more options – not fewer – in the fight against cancer. And with a multidisciplinary team providing care, treatments can be carried out more effectively than ever before.
For the patient, it can mean less invasive surgery, better chance of long-term survival, and opportunities to preserve fertility and quality of life.
Hospital Picaso is committed to delivering high-quality care through the latest advanced surgery and integrated oncology services, led by experienced breast specialists. To learn more, visit www.hospitalpicaso.com.
KKLIU 3081 / EXP Dec 31, 2027
