Surgery or chemotherapy first?

Diagnosed with breast cancer DCIS/LCIS
1

Hello, my sister who is younger than I am was recently diagnosed with stage 2 breast cancer.
I live in the USA, but my Sister lives on a small Caribbean Island. She wants to get a mastectomy done ASAP, however her Oncologist wants her to go through 8 rounds of Chemotherapy, one every three weeks, so she will be finishing Chemo at the end of February 2025, then the Oncologist wants to do bloodwork and scans again, and then have my sister schedule with the breast surgeon for the surgery.
Our concern is that my Sister just wants the breast removed already since the cancer has not spread to Lymph nodes or other organs. We do not understand why the Oncologist wants her to wait for all this time with a proliferative tumor. Why does she have to Shrink or attempt to shrink the tumor first? My Sister is upset and scared that the cancer will spread in the meantime. We are very worried about this approach. Are we wrong in wanting the surgery first, and do the Chemo after? Please advise. We are desperate to take care of this as soon as possible. I would appreciate all the answers, ideas, and suggestions we can get. Thank you, and sorry for the long post.

This is her report. Sorry for bombarding you with all this information, but we need help.

SPECIMEN:

720/24, left breast mass core Bx

CLINICAL DIAG:

GROSS DESC:

See Note

r/o malignancy

3 tan tissue fragments measuring up to 8x1 mm (AE,3c)

BIOPSY OPINION

See Note

INVASIVE BREAST CARCINOMA, NOT OTHERWISE SPECIFIED (DUCTAL)

Nottingham score

  • tubule score 3
  • nuclear score 3
  • mitotic score 2

total score 8

overall Grade 3

no DCIS seen no lymphovascular invasion seen tumour infiltrating lymphocytes present

IHC 56-24 (ER, PR, HER-2, Ki67 on block 3)

Estrogen Receptor (ER) Status: Positive (greater than 10% of cells demonstrate nuclear positivity)

Percentage of Cells with Nuclear Positivity: 61-70%

Average Intensity of Staining: Strong

Scoring System: No separate scoring system used

Progesterone Receptor (PgR) Status: Positive

Percentage of Cells with Nuclear Positivity

Blockquote

: 11-20%

Average Intensity of Staining: Strong

Scoring System: No separate scoring system used

2

Hi, hopefully someone who has had treatment like this will pop on and help you. In the UK it is fairly common to have chemo first. Have a read of this information from Breast Cancer Now. Hopefully it might reassure your sister
https://breastcancernow.org/about-breast-cancer/treatment/chemotherapy/

1 Like
3

There will be a reason why they want to do it this way round - as has already been stated a lot of people have chemo first here but your sister needs to understand why so perhaps they should go through it again with her . People often don’t take things in the first time around so they should be happy to do this. It’s not just a case of chemo then surgery - your sister would be monitored whilst on chemo and scans done at a certain point to make sure that the chemo is working as expected . It would not be allowed to grow out of control during this time . I and probably all of us understand the urge to have it removed from our bodies as soon as possible but sometimes you just have to take the advice . Having said that if she isn’t happy then she should seek a second opinion. It might be worth posting this in the Ask the Nurses section as they may be able to shed more light on this particularly in relation to the pathology report . Wishing you both all the best for your sisters treatment and recovery .

4

Hello edp thank you for the information you provided. It means a lot to us. I hope you are in a good place with your health. All the best.
XOXO

5

Thank you JoanneN,
Your answer is reassuring because you know what you are talking about. This is our first experience with BC or any type of Cancer, so we are just going crazy. Thank you for taking the time to respond. We will take your advice.
I hope you are doing well with your health.
Thanks again.
XOXO

6

You are very welcome . I didn’t actually have chemo at all but I know that some people have it before surgery and that scans are usually done to assess progress . When your sister goes to her Oncologist she should have a list of questions written down for them to answer and make sure she understands the process and is happy that it’s safe for her . Xx

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7

Hello, I am new here.
And started chemo Tuesday,
I am in the same train than your sister apparently. I have a H2N0 (but one can only be sure after surgery) grade 3 invasive duct carcinoma Er+Pr+HER-
I will have 8 rounds of chemo! 4 with a double molecule (cyclophosphamide and epirubicin and 4 with paclitaxel) then surgery then radiotherapy then done. (I don’t know those molecules I know they are used around the world. What is an extraordinary situation for me is a common one for doctors.
Why chemo before surgery? To have a less invasive surgery I have been told during my appointment with my oncologist.
Does it make a difference cancer wise I have surgery or chemo first? I have been told no, but surgery outlook is defo better.
Chemo is a systemic treatment. It targets cancer cells everywhere so having it before surgery is as good as cutting the tumour out in terms of stopping the spread. Knowing that in both cases chemo will happen.
Hope this helps.
Good luck to your sister and to all those around her :muscle:t5:🩷

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8

Hi, no expert here. Her cancer is grade 3 and hornone positive her2-, no dcis, no lymph nodes spread and no lymphvascular involvement. Nottingham score is low at 3. Am i missing something above? Please correct me if I’ve misinterpreted.

I’m having chemo 6 rounds for grade 2 stage 2. Stage 2 is tumours between 20-50 mm, with lymph nodes and LVI, plus i have 4 areas of invasive and its all linked by dcis and lcis. Having a masectomy after chemo. The cancer won’t spead during chemo…it shrinks and doesnt grow further.

If her lump is small, a sentinel lymph node biopsy and lumpectomy could be done, then she could have an oncotype dx test if the lymph node is positive. This helps the dr know if chemo is needed. You could try putting her details into the NHS predict tool. I’ve added link. A benefit % score of 3 is often considerd for chemo. Let us know how she gets on. Xxx

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9

Sorry to hear about your sister’s diagnosis and that she’s worried about the plan. I had surgery first but I know having chemo first also happens a lot in the UK. I was told by a nurse that sometimes it’s because of the location or size of the tumour. E.g. if it is very close to a major blood vessel or in an awkward place for surgery, they prefer to shrink it first so the surgery will be more straightforward. I’ve seen some comments on here where ladies have had interim scans and seen how much the tumour has shrunk during pre-surgery chemo. This should hopefully be reassuring to you and your sister that the tumour should not grow during chemo. I definitely agree with others that she should go back to her oncologist or breast care nurse with her questions and ask for further explanation. No doubt they will have treated many similar cases before and will be able to justify their rationale. All the best.

10

Hi hibiscus55,

There is no written rule on whether chemotherapy is given before or after surgery in the UK. It is really dependent on the individual diagnosis.
I have had chemo pre-surgery. My cancer is her2+ and ER+ with no lymph node involvement. I have a 14mm lesion surrounded by a 10cm area of DCIS. The reason I had chemo first was because they weren’t sure if the DCIS area contained micro cancer cells that were too small be picked up with biopsies. It made sense to have chemo to kill any cancer that was present . I have had 8 rounds of chemo (4 x EC and 4x docetaxel). I have responded very well to chemo and a recent CT scan showed the lesion is gone. I’m thrilled that the chemo has worked. I’m due to have a mastectomy in 2 weeks and I’m hoping for a full pathological response.

I would say trust your sisters doctors as they have lots of experience but do always ask lots of question so you are reassured that the treatment is right for her.

Best of luck x

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11

Hi Vixter,
Thank you so much for explaining this so clearly. I have forwarded your response to my sister, and we are taking your advice.
I wish you complete healing, and a cancer free life.
XOXO

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12

Hi Pod123,
I am glad that you’ve had your surgery. I sincerely wish that all goes well, and you get complete healing, and cancer free. Thanks for your advice and encouragement. We will follow your advice.
Best wishes
XOXO

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13

Hi bluesatsuma,
So sorry to hear about your cancer diagnosis. I sincerely hope that you get a complete cancer free diagnosis at the completion of your treatment. You did not misinterpret my sister’s readings. You got it right. Thank you very much for all of your advice.
Also, thank you a million for the link that you attached.
All of you are making this journey a little more bearable.
Best wishes,
XOXO

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14

Hi Kokopelli,
Thank you so much for taking the time to respond, to share your story, and to give advice.
I am so sorry to hear about your diagnosis, and I wish you the very best, and a cancer free result.
All of your advice is helpful and has given us new perspectives to work with.
All the best,
XOXO

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15

Hi @hibiscus55. Thank you for your kind wishes and I certainly echo these back to your sister. I hope that she can get a treatment plan that is right. Is she british? It might be worth a second opinion here? Xxx

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16

Hi i was diagnosed with similar in June and told i had to have chemo first. I have had 4 rounds of chemo and the tumour which was 4cm has now shrunk and they have told me that they can save my breast. Ill have keyhole surgery in January and a scan to check that it hadnt spread, which up until now it hasnt. I was the same thinking why chemo first but now i understand. I hope this helps.

17

Chemo first is usually for cancers over 2 cm. I think it just makes it for a less risky surgery to try to reduce the tumor first. I also in general would prefer surgery first but they did treatments for 5 months first and then surgery. And in my case, the treatments completely removed the tumor and I had no cancer cells present on the surgery pathology report. This is a good prognosis. So there are pros and cons. And like someone said, they will monitor you on how the treatment is working. So don’t stress. I know it’s overwhelming at first and you can always try to get a second opinion, even if via Zoom. Sometimes such decision depends more on the hospital and doctor than your tumor markers. I hope your sister gets the right info that will ease her mind. She does have a few weeks ahead of her so no need to panic.