This relatively small study was designed to investigate the prognostic relevance of pathological complete response to primary chemotherapy before surgery for breast cancer. The study included 58 women with stage IIIB breast cancer treated between 1996 and 2001 who had less than a pathological complete response, i.e., who had residual breast cancer after chemotherapy. The patients had been administered a chemotherapy regimen for up to six cycles before surgery (Herceptin was not available at the beginning of the study). After surgery, residual disease was found in 14 women only in the breast, in 40 of the women in both the breast and axillary lymph nodes, and in four women only in axillary lymph nodes. The estimated 10-year disease-free survival rate was 37.6% and the overall survival rate was 50.3% after an average follow-up period of 99 months (range: 72 to 134 months). Women with greater than three axillary nodes involved were found to have a 10-year disease-free survival rate of 28.9%. Patients with hormone receptor negative tumors (ER-/PR-) had a 10-year disease-free survival rate of 17.3%. Overall, the triple-negative group (ER-/PR-/not HER2 overexpressing) was found to have only a slightly worse overall survival rate. HER-2 status alone, even in the absence of Herceptin, did not appear to significantly influence outcomes.

Findings confirm other studies

Previous studies have found that the degree of pathological response to pre-operative chemotherapy is related to prognostic factors such as initial tumor size, so it is not surprising that those who do not obtain pathological complete response are more likely to have lymph node involvement and are less likely to survive for 10 years. The question for those diagnosed with breast cancer is how to improve their potential outcomes. The majority of women are not offered chemotherapy before breast cancer surgery, but for those who are, below are some suggestions for obtaining the best possible outcomes.

Before chemotherapy

Women (and men) who have recently been diagnosed with breast cancer are in an understandable state of shock and grief, so that it may be difficult to take on additional burdens. However, this initial period is a time of opportunity, and there are some steps that can be taken immediately to potentially improve the outcome of chemotherapy:

• Stop all multivitamin and antioxidant supplements and any herbal formulations that may contain phytoestrogens. This is to avoid inadvertently enabling cancer cells to survive chemotherapy
• Have your level of vitamin D checked and improve it if necessary
• Adopt a bland diet that will support your energy and overall health while maximizing the cancer-killing potential of your chemotherapy regimen. There are some foods which specifically can increase the potency of chemotherapy and others that have been shown to reduce its effectiveness (please see our article on what to eat during chemotherapy)
• Avoid consuming the foods on our list of foods to avoid. This list is the result of focused research on each food and how it relates to breast cancer risk
• If you are not already doing so, start a program of moderate regular exercise that you anticipate being able to continue when not feeling well
• Consider arranging to get temporary disability payments so you can stop working during chemotherapy, as well as a temporary handicap placard (this may eliminate parking costs at your hospital and in some other facilities)
• Be prepared for changes (both good and bad) in your relationships and try to evaluate whether your emotional support system is strong. In any case, consider joining a cancer support group (even if you are normally not a "joiner"). Having an emotional support system is important and has been shown to be associated with better outcomes
• Assemble your team. Your oncologist will refer you to a surgeon and other cancer specialists. If you are not entirely satisfied with your primary care physician, ask your oncologist for a referral to an internist who will serve as your new primary care physician and interface with the oncological team. If your are not satisfied with your oncologist, switch now. Once you're selected your oncologist, try to develop a good relationship in which you display trust but also feel free to ask questions and focus on your own wellbeing.

During chemotherapy

The goal during chemotherapy is to complete all the treatments and maximize their effectiveness:

• Try to avoid gaining weight, since this is not favorable for your prognosis. While it is true that people with terminal cancer eventually lose weight, it is actually common for women to gain weight during chemotherapy for breast cancer
• Continue eating a bland chemotherapy diet and avoid the foods on our avoid list (switch to recommended foods list after surgery)
• Check with your oncologist regarding taking any supplements
• Follow the advice of your oncology nurses and others on your team to help you feel as well as possible. Be sure to report any symptoms, such as shortness of breath, that could indicate a potentially serious side effect
• Accept the fact that your hair will fall out and you won't feel well. Things may not seem bad after the first treatment or two, but the negative effects tend to build over time. Remember that your cancer cells are suffering more than the rest of you: when chemotherapy is over, you'll start to feel better, they'll mostly be dead
• Avoid getting influenza or any other infectious illness by staying away from crowded areas and taking steps such as frequent hand washing. Illness makes it likely to have a delay in your chemotherapy treatments, which is not optimal
• Continue moderate regular exercise to the extent possible. This has been shown to reduce fatigue in those on chemotherapy and may help you avoid gaining weight
• Discuss the strategy that will be used to perform pathology on the breast and axillary lymph node tissue removed during surgery with your oncologist. Consider asking that pathology be performed not just on the primary tumor but also on any lymph node metastases. This is because the hormone receptor status and other factors that are important to designing any further treatment should take into account the characteristics of any metastases. Breast cancer cells that have already demonstrated the ability to metastasize to lymph nodes presumably are the most capable of forming metastases in other parts of the body. See our write-up on discordant receptor status
• If you are fortunate enough to be assigned to get a lumpectomy instead of more extensive breast surgery after chemotherapy, explore the possibility of having it done without full anesthesia and do not use morphine or other opiates afterwards to relieve pain. This is because there is some evidence that breast cancer patients who are administered local rather than general anesthesia have fewer recurrences. Morphine has been found to increase tumor cell proliferation, inhibit the immune response, and promote angiogenesis in the laboratory. Although it may involve more emotional distress than surgery in other parts of the body, a lumpectomy is not a gruesomely painful surgery because it does not involve cutting into bone or muscle. That it why it is typically an outpatient surgery and it does not necessarily require general anesthesia.

Repeat surgery of you do not have clean margins

If you do not obtain clean margins after lumpectomy or other breast-conserving surgery, you will probably be advised to have another surgery. By clean margins, we mean no invasive or in situ cancer at the edges of the tissue that was removed during surgery (the status of the margins will be mentioned in the pathology report). Breast cancer at the margins is not visible to the naked eye, so not getting clean margins is a frequent occurrence. Removing the primary tumor is the most important part of treatment for breast cancer and has been shown to have a positive influence on length of survival even for those with Stage IV breast cancer.

Adopt a positive attitude if you feel like it

Women who get breast cancer are often encouraged to adopt a positive attitude. There is debate as to whether this has an influence on survival. Certainly, those around a woman going through cancer treatment might prefer for her to downplay her predicament (on the other hand, they might find it upsetting if it seems out of character). Complaining frequently probably won't work for most women. Here's what we think: Whether to adopt a positive public attitude is up to you. What is important is to make up your mind to make the best of your situation and focus your energy on improving your chances of remission and survival. Having said that, quickly forgive yourself and others for any lapses or mistakes and move forward.

If you do not obtain pathological complete response

The majority of women who undergo pre-operative chemotherapy do not get a pathologically complete response, but they do go into remission for a period of time or permanently. Remission means that there are no symptoms or signs of breast cancer. What is required at this stage is permanent vigilance. Breast cancer recurrence tends to peak between two to three years after diagnosis, but there appears to be another, smaller peak between nine and 10 years out. After surgery and during any follow-on treatment such as radiation or treatment with an aromatase inhibitor, follow the recommendations in this website to reduce breast cancer risk and follow the schedule of visits and tests outlined by your oncologist and surgeon after treatment.