Chemo first vs Surgery first?

Hello @journey99
This is just one opinion, but the best doctor I ever had told me that the only decision is an informed decision. Since that day, I have firmly believed in gathering every bit of possible information before making treatment decisions.
Looking at the nodes is really all about the information gathering. Sentinel node dissection “just the nodes first in line from the tumor”. Tells you if this cancer has tried to spread beyond the breast. I would consider this a vital piece of information before making other treatment decisions.
Has your doctor made a recommendation about node dissection?

How high was your estrogen score?

It's tough when your Oncotype is higher than 26 but by 4 points. Are you post-menopausal?

It seems you are going to do chemo so the question is whether to do it before or after. If you do it before, will you be able to see how effective it is?

What does your doc say? If you want a second opinion, go for it. I had 4 opinions! I know you have a time crunch. Hoping you feel good about whatever you decide!

I chose surgery first, because I did not want to delay removal of the cancer by more than a month. The microinvasion was about 2mm, as determined by the biopsy, so the oncologist agreed to do chemo later, if necessary, based on what they see in the sample collected during surgery. I really don't like the approach of using the human body as a petri dish to see if the cancer reacts to a particular chemo. In Europe they test the sample collected at biopsy for different chemo sensitivity, in Canada they treat the patient instead, but for me the risk of exposing my body to chemo outweighed the benefit. I don't know if anyone can recommend a private lab that could analyze chemo sensitivity in a biopsy sample like they do in Europe.

I think all oncology docs have their own plan. My process was start with chemo to shrink size of lymph nodes; mastectomy; then radiation. I also had a DIEP flap surgery with the plastic surgeon for my right breast. I had 17 lymph nodes removed but I am now healthy after 5 years and so thankful for my oncologist and surgeon. i believe you have to have a trust but certainly it doesn't dimimish the constant fear during this process. All women are so different with this so follow your "gut"!

I did chemo first. I also had lymph node positive for ER+ cancer, oncotype score of 28. My surgeon is the one who suggested I do chemo first in hopes of having a lesser surgery. I saw the oncologist a week later who did the oncotype DX test on my original biopsy, and also started me on Letrozole for 3 weeks. My KI67 score responded well during those 3 weeks but because of the lymph node involvement and high oncotype DX my oncologist said I would benefit from chemo. He agreed with to surgeon to do chemo first. Because my cancer isn’t palpable I had a breast MRI done last week, after AC chemo and before Taxol. My cancer has shrunk significantly.
Bottom line, my medical oncologist was a huge help in helping me decide what route to take. I asked questions and he helped me understand the treatment plan and then I was comfortable with going through chemo. I didn’t want to have chemo at first but it is doable and gives the best chance for a cure so I’m good now.

OK. So, not sure what type of bc you have, but I can say that "in hindsight" (always 20/20) I would have gone for whatever they could give me to assure the best outcome possible. When I got a second opinion for aftercare (after all the surgery, chemo and radiation was done), the oncologist said "I just would have done one thing differently" and in that case, it was doing a little chemo before surgery because even after a PET scan, and MRI (where they kind of knew how advanced everything was) -- they did the surgery first [5 breast tumors, 10 out of 16 nodes diseased]. I don't know if this would have made a difference, and I need to say I was blessed with a very skilled surgeon. But anybody who has ever read anything I've written on here knows, I always go for "pulling out all the stops" when it comes to types of surgery, chemo, radiation and hormone suppressing maintenance drugs. I wish you the very best in your decision making.

My dr wants to treat my stage 2B IDC with node involvement HR+ HER2 - cancer with chemo first approach then surgery then radiation. While I wait for an apt with her March 28th, trying to understand rational to do chemo first Vs surgery first.

Logically I feel like removing the primary tumour then treating the body makes more sense to me. My breast can’t be saved as the tumor is surrounded by calcifications that cover over a third of my b cup breast.

Any insight you can share would be much appreciated. Thanks in advance.

@lesleyjt I noticed you are on a couple other pages since your diagnosis, welcome to the club you never wanted to join. You will meet the nicest people here. 😁
Sometimes a doctor will recommend shrinking the tumor with chemotherapy first. A few reasons might be aggressive looking cells in the tumor. The large size of the tumor, or it might be something completely different. This has been studied extensively and certain cancers do have better outcomes with this plan.
I know the situation is a little different but here is a link to another recent post about chemo before surgery.
https://connect.mayoclinic.org/discussion/lymph-nodes-surgery-first-or-chemo-first/
Did your doctor explain a reasoning behind this choice? Are you comfortable asking?

Thanks so much for the reply. I am meeting with the dr March 28th and will ask her then for sure.

Perhaps they want you to have chemo first because they know you have cancerous cells within your lymph nodes. They might want to begin chemotherapy treatment to reduce the risk of having those cells circulating throughout the body.

Also, for some of us (I was Her2+), having chemo first helps gauge how effective treatment is/was for our tumors.

Hope this helps. ♥️