What should come first in breast cancer: Chemo after Radiation or Radiation after Chemo?

Cancer has a profound impact on individuals and their loved ones, posing significant physical, emotional, and psychological challenges. The journey through diagnosis, treatment, and recovery can be incredibly demanding, affecting all aspects of life. Patients often face side effects from treatments, changes in physical appearance, and the emotional burden of coping with the disease and understanding the treatment process.

Despite these challenges, ongoing medical advancements are revolutionizing our approach to cancer. Innovations in early detection, personalized treatment plans (including sequencing of surgery, radiation therapy and systemic therapies), targeted therapies, and immunotherapy are changing the landscape of treatment. These developments are not only improving survival rates but also enhancing the quality of life for our patients.

According to MACS Clinic , a well-known cancer treatment centre in Bangalore:

“Cancer treatment has advanced significantly, providing patients with a range of options customized to their unique needs. For breast cancer, chemotherapy and radiation therapy are among the most commonly used treatments, each playing a vital role in managing the disease. Often times our patients are confused as to why and how a certain sequencing of these treatments are chosen for them. Understanding these treatments and their appropriate sequencing is essential for achieving the best possible outcomes.”

Dr. Nayak is among the preferred doctors for people seeking breast cancer treatment in Bangalore.

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Have you ever wondered what should come first in breast cancer treatment? Let’s delve into this topic to gain clarity. But first, let’s understand what Chemotherapy and radiation therapy are.

Chemotherapy involves administering potent drugs designed to target and destroy rapidly dividing cancer cells throughout the body. These drugs can be taken orally or administered intravenously, allowing them to circulate through the bloodstream and reach cancer cells that may have metastasized beyond the original tumor site in the breast. This systemic approach makes chemotherapy effective for treating not only localized tumors but also potential microscopic disease that could exist elsewhere in the body.

Chemotherapy is often employed in different phases of breast cancer treatment. It can be used as a “neoadjuvant therapy” to shrink tumors before surgery, making it easier to remove them and potentially allowing for less extensive surgery, such as breast-conserving surgery instead of mastectomy. Post-surgery, chemotherapy can serve as adjuvant therapy, targeting potential residual cancer cells that might not have been removed during the surgical procedure. This adjuvant or add-on approach helps reduce the risk of cancer recurrence and spread, significantly improving long-term survival outcomes.

As per Dr Suresh Babu, a veteran medical oncologist at MACS clinic – “The choice of chemotherapy drugs and the specific regimen depend on various factors, including the type and stage of breast cancer, the patient’s overall health, and the cancer’s hormone receptor and HER2 status. We at MACS clinic carefully tailor chemotherapy plans to each patient’s unique situation, balancing effectiveness with potential side effects. While chemotherapy can be a challenging treatment due to side effects like fatigue, nausea, hair loss, and increased infection risk, it remains a cornerstone of breast cancer management, offering hope and extending survival for many patients”.

This is for a specific situation where chemo and RT are offered after surgery.

Have you ever wondered what should come first in breast cancer treatment? Let’s delve into this topic to gain clarity. But first, let’s understand what Chemotherapy and radiation therapy are.

Radiation therapy employs high-energy beams, such as X-rays or protons, to precisely target and destroy cancer cells in a specific region of the body. This treatment modality is particularly useful for addressing cancer cells that may linger in the breast or nearby tissues following surgery. By focusing on a well-defined area, radiation therapy aims to minimize the risk of cancer recurrence, providing an additional layer of control against the disease.

Typically, radiation therapy is used as an adjuvant treatment after surgery. In cases where breast-conserving surgery (such as a lumpectomy) is performed, radiation therapy is almost always recommended to treat the remaining breast tissue, reducing the likelihood of local recurrence. It may also be used after a mastectomy in patients with a higher risk of recurrence due to factors like large tumor size, positive lymph nodes, or close surgical margins.

The treatment is highly localized, meaning it concentrates the radiation dose on the area where the cancer was located, sparing the surrounding healthy tissues as much as possible. This targeted approach helps minimize the side effects often associated with radiation exposure, such as skin irritation, fatigue, and changes in breast texture or appearance.

As per Dr Nisha Vishnu, who is a leading Radiation oncologist of team MACS “Radiation therapy is typically delivered over several weeks, with daily sessions allowing for the total radiation dose to be divided into smaller fractions. This fractionation helps protect normal tissues while effectively targeting cancer cells. The precision of modern radiation techniques, such as intensity-modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT), has further enhanced the ability to deliver high doses to cancerous areas while sparing healthy tissues”.

Overall, radiation therapy plays a crucial role in comprehensive breast cancer treatment plans, working alongside surgery and systemic therapies like chemotherapy and hormone therapy to provide the best possible outcomes for patients.

In some breast cancer treatment situations, chemotherapy and radiation therapy, both are indicated after the surgery. This creates a lot of confusion in patients especially when they get differing opinions from different sources. Let’s explore whether the order of these treatments after surgery can make a difference in the outcome.

As per all the studies done in this regard, the sequencing of radiation and chemotherapy does not matter from a ‘clinical outcome’ point of view in breast cancer. Hence the decision on the sequencing of chemotherapy and radiation therapy should be individualized based on the patient’s specific clinical circumstances, including the presence of residual disease, risk of recurrence, and potential toxicities. The studies collectively suggest that the timing and sequencing of these treatments can be flexible, provided that critical time windows, such as initiating radiation within a certain time after surgery, are respected. This flexibility allows for tailoring treatment plans to optimize patient outcomes and manage side effects effectively.

In our clinical practice we offer chemotherapy first followed by radiation therapy. This is more from a perspective that chemotherapy works both locally and on distant microscopic disease. However there are select situations where in we offer radiotherapy first.

1. Local more important than distant -> When local control becomes a primary concern, such as in cases where a surgeon has performed a margin-positive surgery (And a re-surgery is not feasible)—meaning the tumor has been removed but there is a significant risk of residual cancerous tissue. The challenge of ensuring complete local eradication of cancer outweighs the risk of distant metastasis and hence radiation is given before the chemotherapy.
2. Buying some time -> In certain early-stage breast cancer cases, additional genetic tests such as Oncotype DX or MammaPrint are utilized to determine the necessity of chemotherapy. These tests assess the tumor’s genetic profile to predict the risk of recurrence and the potential benefit of chemotherapy. While waiting for the results, which can take some time, radiation therapy may be initiated. This approach allows for the optimal use of time, ensuring that the treatment process continues efficiently without unnecessary delays. By starting radiation therapy during the waiting period for test results, patients can progress with their treatment plan, potentially minimizing the overall duration of therapy and managing the disease more effectively.
3. Patient logistics -> In some cases, patients request that radiation therapy, which requires daily travel, be completed first to minimize logistical challenges. This preference often arises because radiation therapy involves frequent visits, while chemotherapy typically requires travel only once every 2-3 weeks. For many patients, managing daily commitments and travel arrangements can be difficult, and prioritizing radiation therapy helps them better organize their schedule and household responsibilities. Since clinical studies have shown that the sequencing of chemotherapy and radiation therapy does not significantly impact treatment outcomes, as healthcare providers we accommodate these requests.

For patients with estrogen receptor (ER) and progesterone receptor (PR) positive breast cancer, hormonal therapy is a common treatment approach. This therapy is typically initiated after the completion of chemotherapy and radiation therapy. Hormonal therapy aims to reduce the risk of cancer recurrence by blocking the hormones that fuel the growth of hormone receptor-positive breast cancer cells. The treatment usually lasts for 5-10 years, depending on the individual patient’s risk factors and response to therapy.

In cases where the cancer is also HER2-positive, targeted therapies are often added to the treatment regimen. These therapies, such as trastuzumab (Herceptin), are designed to target the HER2 protein, which promotes the growth of cancer cells. Unlike hormonal therapy, targeted therapies can be administered concurrently with chemotherapy and radiation therapy. The duration of targeted therapy typically extends beyond the completion of chemotherapy and radiation, often continuing for a year or more, depending on the specific treatment protocol and the patient’s response.

“Combined approach of hormonal therapy and targeted therapies is tailored to each patient’s specific type of breast cancer and aims to improve overall survival and reduce the risk of recurrence. By addressing different aspects of the cancer’s biology, these treatments offer a comprehensive strategy for managing and treating breast cancer” Says Dr Suresh Babu.

The sequencing of chemotherapy and radiation therapy in breast cancer treatment has been a subject of extensive research. Studies have generally concluded that, while the specific order of these treatments does not significantly affect overall survival or recurrence rates, careful consideration of timing and patient-specific factors remains essential. The primary goal is to optimize the effectiveness of both therapies while minimizing side effects and addressing patient logistics.

As per Dr Sandeep Nayak – “New research is continually emerging in this area, reflecting the ongoing commitment to refining breast cancer treatment protocols. These studies aim to explore various sequences, combinations, and timing of treatments to improve outcomes, reduce toxicities, and enhance patient quality of life. The incorporation of targeted therapies and immunotherapies alongside traditional chemotherapy and radiation is also an area of active investigation, particularly for subtypes like HER2-positive breast cancer.”

“A personalized approach to cancer treatment is increasingly emphasized, recognizing that each patient’s disease biology, overall health, and personal preferences are unique. This individualized strategy allows for tailored treatment plans that consider factors such as hormone receptor status, HER2 status, and genetic profiles. As research continues to advance, healthcare providers are better equipped to make informed decisions that align with the latest evidence, offering patients the most effective and personalized care options available.”, says Dr Nisha Vishnu.

Overall, the landscape of breast cancer treatment is evolving, with ongoing studies and clinical trials contributing to a deeper understanding of how to best sequence therapies for optimal patient outcomes. This dynamic field underscores the importance of personalized medicine and the continuous adaptation of treatment protocols to meet the specific needs of each patient.