Why Neoadjuvant?



I use the term “neoadjuvant” throughout.  This means doing a portion of your drug therapies in advance of breast surgery, otherwise known as pre-op treatments.  This is a “newer” protocol that became possible with the introduction of anti-Her2 drugs, the first being Herceptin and now the addition of Perjeta.  As of today, it almost always includes taking at least one chemotherapy drug along with one or more anti-Her2 drugs via IV, otherwise known as infusion treatments.  Although the day is coming when no chemo drugs need be combined with anti-Her2 agents.

The advantages of neoadjuvant treatment are:

  1. Sets the stage for possible minimalist breast surgery to include lumpectomy + bi-lateral breast conservatory/reduction (including the possibility of saving the nipples).
  2. Provides a testable indicator to ascertain whether the HER2 cancer is being responsive to drug treatments before removal of tumors.
  3. Increases the probability of pathological complete response (pCR) – meaning the tumors are 100% gone at the point of surgery.
  4. Increases the probability of disease-free survival (DFS) and overall survival (OS).
  5. Provides treatment protocols that reduce exposure to biologically harsh chemotherapy dominated regimes.

Before neoadjuvant treatment became an option, we women were exclusively treated post-operatively (adjuvant).  The urge to do double mastectomy surgery was great. Having no real immediate markers the doctors were compelled to prescribe chemotherapy cocktails for extended periods of time hoping these were killing any and all extraneous cancer cells that might have moved into other body parts and/or preventing cancer from coming back after surgery.

I can’t begin to express just how wonderful it was to hear my doctor explain the new protocol.  I have mentioned several times how much his advocating the addition of Perjeta to the Herceptin regime meant.  The pathological complete response (pCR) rates when adding Perjeta go from around 21% to around 40% according to the study that the FDA relied upon.  Other studies are saying that up to 75% of patients receiving two anti-Her2 drugs are experiencing pCR.  The second doctor we saw said some studies are saying numbers as high as 90%.  No matter the study, these are “cry your eyes out” remarkable.  Without anti-HER2 drugs, using chemo only drugs only, the rates are in the 17% range.

The future is upon us.  In clinical trials as many as 30% of the patients responded with 100% pathological response (cPR) on just the anti-Her2 drugs (no chemo drugs given).  That’s significant.  Let me repeat – without any old school chemotherapy drugs 30% of patients are shrinking their tumors to nothing.  One of the jobs at hand must be to develop a simple test for us to determine if we fit into the 30% profile.  Imagine that – no more chemotherapy drugs needed to heal before surgery.  Until then all of us look at the current study ranges of 40% to 90%, when taking two anti-Her2 drugs in combination with chemotherapy drugs, and we realize we have ridiculously great odds of kicking cancer in the butt.

Now that’s good news!


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