Research published by Melchior et al in Cancer Medicine has indicated that starting chemotherapy before surgery does not expedite the start or completion of treatment for breast cancer vs performing surgery first.

Richard Bleicher, MD, FACS

“Increasingly, patients are given [neoadjuvant] chemotherapy…This is done for breast cancers of certain types and appropriately done to treat certain types of breast cancer having certain characteristics,” said senior study author Richard Bleicher, MD, FACS, Professor in the Department of Surgical Oncology at Fox Chase Cancer Center. “But increasingly, some clinicians give chemotherapy before surgery solely because they believe that giving it preoperatively either expedites the start of treatment or shortens the time of a patient’s total treatment course. This has been an assumption, based upon no studies, and so we evaluated this and found that these assumptions are not correct.”

Study Background

Dr. Bleicher and colleagues reviewed information from the National Cancer Database on 155,606 women over the age of 18 who were treated at 1,500 facilities. All patients in the study had been diagnosed with stage II–III breast cancer between 2004 and 2015, and their treatment included both surgery and chemotherapy.

Of those women, 28,241 received neoadjuvant chemotherapy, while 127,365 patients were given adjuvant chemotherapy. The researchers then examined how quickly the recipients of neoadjuvant chemotherapy started their treatment vs how quickly those treated with adjuvant chemotherapy started treatment. They also looked at the total time needed to complete treatment and whether the time was delayed because of hospital readmissions.

Findings

The study found that the average time between diagnosis and the start of treatment was 33.4 days for those in the adjuvant chemotherapy group vs 35.6 days for those in the neoadjuvant chemotherapy group. When adjusted for other factors, it was 35.4 days vs 36.1 days. Patients in the neoadjuvant chemotherapy group had higher clinical T and N stages.

“Although it takes an average of 1 to 2 days longer to start chemotherapy in the United States, this is not clinically significant and does not suggest that chemotherapy first provides a disadvantage…. But what this does indicate to us is that while we have assumed that neoadjuvant chemotherapy expedites the start of treatment relative to surgery, this is not true,” said Dr. Bleicher.

The researchers also evaluated the time from diagnosis to endocrine therapy, which is the last treatment many of these patients receive, and found that in those having surgery first, the time to start of endocrine therapy was 268.3 days vs 305.4 days in those receiving neoadjuvant chemotherapy. When adjusting for other factors, it was 275.7 days vs 301.6 days.

In order to determine if differences in timing were due to complication-related delays, the researchers analyzed the length of hospital stay, readmission rates, and 30- and 90-day morality rates. They found no relationship to when chemotherapy was given, either before or after surgery.

“The bottom line is that, in the United States, if you give chemotherapy first as opposed to performing surgery first, do you start your treatment faster and do you complete your course of treatment faster? Neither,” concluded Dr. Bleicher. “So while moving chemotherapy up before surgery may be advisable for certain clinical situations, unless there is a specific surgical delay you’re trying to avoid, physicians shouldn’t change the order of treatment just because they assume it’s more efficient.”

The study authors concluded, “Compared to patients receiving adjuvant chemotherapy, those receiving neoadjuvant chemotherapy do not start treatment sooner. In addition, patients receiving neoadjuvant chemotherapy do not complete treatment faster. Although there are clear indications for administering neoadjuvant chemotherapy vs adjuvant chemotherapy, rapidity of treatment should not be considered a benefit of giving chemotherapy preoperatively.”

Disclosure: For full disclosures of the study authors, visit onlinelibrary.wiley.com.