The Difference Between Neoadjuvant Therapy and Adjuvant Therapy

by Jane Ashley

When we think of cancer treatment, chemotherapy is probably the first thing that comes to mind. Chemo makes the news almost every day, in part because of its sometimes brutal side effects including hair loss, nausea/vomiting, fatigue and weight loss/weight gain. There are just over 250 chemotherapy drugs that are utilized in the treatment of all different types of cancer. 

Neo Adjuvant

We may think, “Well, chemo is chemo.”

That’s true, but chemotherapy is used in different ways for different patients. Perhaps, you’ve heard these terms used in your infusion center or in articles you’ve read. So let’s look at the different scenarios where chemotherapy is utilized.

Neoadjuvant Therapy/Chemotherapy

Neoadjuvant (pronounced NEE-oh-A-joo-vant) chemotherapy is given as the first treatment to shrink the primary tumor before surgery. Radiation is also used as neoadjuvant therapy. This approach offers several advantages:
• Allows the surgery to be less invasive
• May convert a tumor thought to be inoperable to operable
• May allow the surgeon to get clean margins
• Makes it easier for the surgeon to distinguish between cancerous tissue and normal tissue
• Offers potential control of the development of distant metastatic disease when the tumor is locally advanced and/or there is lymph node involvement

Most patients who receive neoadjuvant chemotherapy benefit by having a shorter surgical recovery with fewer complications and with a better long-term result. 

Your surgeon and oncologist will carefully weigh the benefits and risks when they develop your personalized treatment plan. There are pros and cons. Here’s my story.

A board-certified colorectal surgeon diagnosed my Stage IV rectal cancer after I began to experience rectal bleeding. The biopsy of my tumor after my colonoscopy revealed that the tumor was cancerous. The surgeon ordered staging scans of my lungs, abdomen and pelvis and a rectal MRI. My husband and I were shocked to learn that the cancer had already spread to my lungs and pelvic lymph nodes.

We sat quietly and listened as he discussed options. He immediately brought up the use of neoadjuvant chemotherapy as the first step. He explained that the chemo would shrink the tumor and that would make my surgery “easier” in terms of invasiveness and recovery time. Chemo before surgery also helps limit the additional spread of the cancer. It was interesting to hear a surgeon suggest chemotherapy as the first step because many cancer patients want surgery ASAP to get the cancer gone.

He confided that he had seen patients who had surgery first sometimes experience a surgical complication and became too sick for chemotherapy afterward. He believed that having chemo first was a prudent first step in their treatment. My husband and I agreed that his approach sounded reasonable, and he referred us to an oncologist with expertise in rectal cancer.

At the end of our first oncology appointment, she recommended neoadjuvant chemotherapy too. She informed us that at the end of five cycles of chemo, I would have scans to evaluate if my tumor was shrinking. She even said that just a 20 percent shrinkage would be a good response, and in that situation, she would take my case to the tumor committee.

Neoadjuvant chemotherapy can be a two-edged sword. Chemo sometimes has serious side effects, and some patients may become too weak for surgery afterward. 

Many patients benefit from a second opinion before beginning treatment. Unless you have been advised that your cancer is aggressive and you need to begin treatment immediately, don’t worry about the slight delay in treatment when you seek a second opinion. Having peace of mind is paramount.

Adjuvant Therapy/Chemotherapy

Adjuvant therapy (which includes chemotherapy, targeted therapy, hormone therapy or radiation therapy) is given to patients after surgery to help prevent a recurrence. Sometimes, cancer cells escape and form micrometastasis that can’t be seen on scans.
Adjuvant chemo is also known as “mop-up” chemo. The concept is similar to military mopping-up operations. Soldiers and aircraft search for the last pockets of resistance from enemy forces and destroy them. Whatever the stage, most cancer patients realize that if just one cancer cell remains, we are at risk for recurrence. 

Every type of cancer has different recommendations on whether adjuvant chemotherapy is recommended. Some types of cancers are more likely to spread. Pathology reports may influence the decision to have adjuvant chemo too – poorly differentiated cells or a tumor that has almost penetrated the colon or uterine wall or the presence of positive lymph nodes. 

Patients are often faced with a difficult decision after surgery. They might be given three choices:
1. Do nothing. Wait and see.
2. Have a short round of a milder chemotherapy drug.
3. Have a longer round of strong chemotherapy. 

These are situations when obtaining a second opinion is a wise choice.

Patients and their healthcare professionals have to weigh the benefits against the risks. Adjuvant therapies carry risks and side effects so they must be weighed against the risk of recurrence. A number of factors influence our decisions.

• Cancer Type. For cancers such as breast and colorectal cancer, adjuvant seems to have positive benefits in helping prevent the cancer from recurring.
• Stage. Early stage cancers aren’t as likely to recur so there is less benefit. Patients with more advanced stage cancers, especially where there may be lymph node involvement, are likely to benefit from adjuvant therapies.
• The number of Lymph Nodes. The more lymph nodes involved, the more likely a cancer is to recur after surgery.
• Hormone Receptivity. Breast cancer patients who test positive for hormone sensitivity are ideal candidates for adjuvant hormone therapy after surgery.

Unfortunately, receiving adjuvant chemo or other therapies does not guarantee that your cancer won’t return, but it increases the odds in your favor. 

For your peace of mind, get a second opinion if you feel conflicted over the decision to receive adjuvant chemotherapy.

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