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Dr West

FAQ: What is Neoadjuvant Therapy and Why Would We Want to Give it?

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The cornerstone of treatment of an earlier stage cancer is a local therapy such as surgery or radiation, which is meant to remove or destroy the cancer that is limited to a specific area. We know, however, that people who have undergone complete resection or what should be complete destruction of a tumor by radiation will too often have their cancer return, sometimes near the area where it first appeared, but often in a distant location.  When we see the cancer recur in a distant site, we can presume that this was mediated by “micrometastatic” disease, circulating tumor cells that were too small to be seen on any scans or by a surgeon directly at the time of surgery, but which must have remained in the body after a good local treatment removed or destroyed all evidence of visible disease. In order to combat this risk and try to treat potential micrometastatic disease, we often give systemic therapy before and/or after the local therapy.  A particularly common approach is to follow surgery with chemotherapy, which is called adjuvant therapy, with adjuvant meaning “helper”.  Systemic therapy before surgery or possibly before radiation is typically termed neoadjuvant therapy, and there are a few reasons why we might prefer to give systemic therapy at the earliest opportunity, rather than having it follow the potentially curative local therapy.

 

First, we might be concerned about the potential for cancer to spread during the time between the initial diagnosis and the time when a patient is ready to start systemic therapy after recovering from surgery. Neoadjuvant therapy provides an opportunity to treat both the visible and potential invisible cancer at the earliest time point.

Second, it is possible to assess the response to an initial systemic therapy in order to get a sense of whether the treatment worked well, and this can help inform a decision about whether any further systemic therapy, whether the same or a different kind, would be beneficial to give after surgery or radiation, in the adjuvant setting. If a patient undergoes surgery, it is even possible to see at the tissue and molecular level how the preoperative therapy affected the tumor tissue. This sometimes leads to “window of opportunity” trials in which a novel therapy is given prior to planned surgery in order to assess how cancer responds, both in terms of imaging after the preoperative therapy and in effects observed directly on the tumor tissue under a microscope.

Third, it is sometimes possible to shrink a cancer with neoadjuvant therapy that makes it possible for a patient to undergo a less extensive surgery (or smaller radiation field), or to undergo a surgery for which he or she was a marginal candidate because of the large size of the cancer initially. 

Finally, the local therapy itself, particularly surgery, can often be very challenging and pose risks of a difficult recovery. If we know that we want to give a combination of systemic therapy and local therapy, it is most reliable to give the systemic therapy first, after which very few patients will miss an opportunity for the local therapy, in contrast with starting with the challenging surgery and then having a significant subset of patients not recover well enough to pursue the tended systemic therapy.

The leading concern about giving systemic therapy first in patients who are candidates for a curative local therapy right at the time of diagnosis is that a small minority of patients may demonstrate progression systemic therapy and demonstrate a larger tumor or metastatic disease after neoadjuvant therapy. While this would translate to having a lower or no chance for cure, such patients would be extremely unlikely to be cured with immediate surgery as well, likely demonstrating the same progression before even recovering from their local therapy.

Neoadjuvant therapy is employed for many cancers, including lung, breast, colorectal, and several others, as an optimal strategy for many patients.


9 Responses to FAQ: What is Neoadjuvant Therapy and Why Would We Want to Give it?

  • cubangem says:

    Hi Dr West,

    My husband was diagnosed with NSLC Stage IIB back in May, 2014. They tried doing VATS surgery in July but the tumor was too big and inoperable. He has no metastasis and no lymph node involvement anywhere. He was treated with 7 rounds of carbo/taxol chemo very aggressive then had 3 more rounds of chemo (smaller dose) concurrent with 35 radiation treatments. Radiation Onc wanted him to continue the chemo while on radiation but his body was not opt to it (74 years) so we are thankful he was able to complete all the radiation. The doctors at the time thought he was NED. He also developed radiation pneumonitis which they are treating with prednisone.

    Subsequent they did a PET SCAN one month later and found it inconclusive so they sent him to a pulmonologist for a bronchoscopy and biopsy to make sure.

    Today we got the results and it seems they were not able to get rid of the tumor completely and there are still cancerous cells. (adenocarcinoma). His oncologist wants him now to start chemo treatment with Alimta once every 3 weeks for 6 months or possibly a year to be able to get rid of the whole thing. My question is once you start on Alimta is that for curable purposes is there still chance of complete remission or just maintenance?

    Thank you,
    Martha

  • Dr West
    Dr West says:

    While there are circumstances in which chemotherapy is given with curative intent after surgery or chemo/radiation, I’m afraid I don’t think it’s realistic to expect that chemotherapy can eradicate all evidence of cancer if there is biopsy-proven residual viable cancer after chemo and radiation.

    Good luck.

    -Dr. West

  • cubangem says:

    So sorry to hear that. Then the intent is for just maintenance? He can’t be on this chemo forever. So what you are saying that it’s just a matter of time before it starts spreading after all treatment is over? He is so hoping for a complete recovery.

  • Dr West
    Dr West says:

    The intent from his doctor may well be to eradicate the cancer, but I don’t think that’s possible in this situation, receiving chemotherapy alone. The cancer may well shrink, some of it may be killed by the chemo, but chemotherapy would not realistically be able to eradicate all of the viable cancer.

    -Dr. West

  • cubangem says:

    Hi Dr West, it’s me again. Just for a follow up, my husband had 3 rounds of Alimta and they did another CT SCAN with contrast. What ever he had left has diminished like 50 % or more according to his Onc. there is very little left like residual, keep in mind that his tumor was never a mass but rather like a spider web, but he changed his chemo now to Taxotere (4 infustions) which he had this past Monday and seems to be doing great. He practically has no SOB anymore and his cough has disappeared. I asked his Onc again about a complete cure and apparently this is what he is going for and seems to think we can achieve it. I know you have said it is impossible in his situation but there are exceptions for everything. Do you still feel it is impossible?
    Thank you for your time.
    Martha Ginory

  • Dr West
    Dr West says:

    I think almost anything is possible in cancer and cancer treatment.

    Good luck.

  • cubangem says:

    Thank you for your prompt reply, I really appreciate it. You must be a very busy person and any replies coming from you are really a blessing. Anyway, like his Onc said your Cancer is individual to you, each Cancer is and every person and body react differently. To add another incredible story, I was diagnosed with breat cancer 21 years ago, they did a complete mastectomy and lymph node resection under my left arm. Out of 11 lymph nodes 10 were positive. I received a very aggressive treatment which my Onc, Dr Luis Villa, acquired from Duke University, it was supposed to be a clinical trial which at the time my insurance covered it (the whole thing) and I was able to select the dosage I wanted which was very strong (4 dosages) every three weeks. The dosage was so strong the hospital pharmacy did not want to approve it. To make a long story short, I’m still here. I was 44 yrs old at the time. My tumor was progesterone negative so tamoxafin, which was new back then, was not an option. BIG SURVIVOR. Like you said anything is possible in Cancer.
    Thank you,
    Martha Ginory

  • cubangem says:

    Hi Dr West it’s me again.
    My husband was finally given a clear signal. As of the last CT SCAN 9/15 everything is clear no evidence of cancer and even his pneumonitis is getting better so the dr said no more chemo just monitoring you for now and he lowered his prednisone dosage to 1 a day with alternating half of one this is a 20mg so 20 one day and 10 the other day. He was very happy but the problem is that it’s been already a month and he still feels SOB he doesn’t feel like he is getting any better. He was informed by his cardiologist this week that his Thryroid level was very high on his blood results (something new for him, never had thyroid problems) so he was doing the blood work again and possibly give him medicine for that he went on to say that this may be the reason why he feels so tired. My question is when will he start feeling stronger and is the SOB every going to go away. He is very frustrated and feels emotionally terrible. He is seeing his Onc tomorrow had a scheduled appointment. He is at the point now that he doesn’t believe anything they tell him. He just wants to feel good. I don’t know what to do.

  • Dr West
    Dr West says:

    I’m afraid that while I’d like to be able to help, his case is clearly too complicated for me to offer any assessment online. I could only make up an answer. His oncologist is really the person in a position to provide a more meaningful and reliable assessment of the possible cause and anticipated changes over time.

    Good luck.

    -Dr. West

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