Benefits of Neoadjuvant Chemotherapy

The pandemic has made doctors rethink the order of these treatments. Now, many oncologists are delaying surgery in favor of neoadjuvant chemotherapy, or chemo before surgery, until it is safer to perform.

"What is happening now, during COVID, is we’re seeing a greater shift into doing the neoadjuvant chemotherapy," says Dr. Adam ElNaggar, gynecologic oncologist at West Cancer Center in Memphis, Tennessee. "We can postpone people from needing to go to the hospital by giving them the chemotherapy upfront. And if we can move their surgery back a few months, maybe conditions will be better when it’s time to go to surgery."

Neoadjuvant chemotherapy uses strong drugs that kill cancer cells to reduce the tumor volume before surgery. One benefit of operating on a smaller tumor is that it can make for an easier procedure. "The surgery that is required may be less aggressive," Dr. ElNaggar says. A less-extensive surgery may require a shorter hospital say, and reduce the need for limited resources like intensive care units (ICUs), ventilators, and blood products, which doctors are trying to reserve in case they’re needed for very sick COVID patients.

Some research suggests that there's little difference in outcomes between the two approaches. In one European study, survival rates didn't vary much between women with advanced ovarian cancer who had neoadjuvant chemotherapy and those who had surgery first. Neoadjuvant chemotherapy actually led to better survival in women with stage IV disease.

How You Get Neoadjuvant Chemotherapy

Neoadjuvant chemotherapy usually involves a combination of a platinum drug like cisplatin or carboplatin, with a taxane chemo drug such as paclitaxel (Taxol) or docetaxel (Taxotere). Combining two types of chemotherapy seems to work better at shrinking the cancer than one drug alone.

You get these drugs through an IV into a vein every three to four weeks. In total, expect to receive about three cycles of chemotherapy before being evaluated again for surgery. "After those three cycles have gone by, imaging is done. And then the disease is reassessed," Dr. ElNaggar says.

Your doctor will determine how well your cancer has responded to the treatment, and if surgery at this point is likely to eliminate all or most of the remaining cancer. Another important question is whether you're healthy enough for surgery. If you had any issues that might have made a surgical procedure too dangerous, like malnutrition, frailty, or build up of fluid in your abdomen (ascites), your doctor will want to know that they’ve been resolved to the point where you're now a good surgical candidate.

If your cancer and overall health haven't improved enough, you'll have additional rounds of chemotherapy. Once you've completed this next bout of treatment, your doctor will assess you again to see if surgery has become a more realistic option. The most common schedule is three rounds of chemotherapy, surgery, and then three additional rounds of chemotherapy.

At a time when doctors and hospitals are preoccupied with COVID-19, neoadjuvant chemotherapy can buy you time — helping you delay surgery until it's safer to perform. And as an added bonus, this treatment might shrink your tumor to the point where you can get away with having a less invasive procedure.

Chemotherapy does have side effects that you should be aware of, which include nausea, fatigue, GI issues, low blood cell counts and other longer lasting issues such as neuropathy, or a tingling and numbness in your fingers and toes. Know that if you do experience these side effects, your doctor can recommend ways to try to manage them.

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