Neoadjuvant Chemotherapy

Chemotherapy uses drugs to destroy cancer cells, stop their growth, or ameliorate symptoms. In neoadjuvant (also called preoperative or primary) chemotherapy, drug treatment takes place before surgical extraction of a tumor. This is in contrast with adjuvant chemotherapy, which is drug treatment after surgery. Oncologists administer neoadjuvant therapy with the objective of reducing tumor size. Reduction of tumor mass decreases the extent and invasiveness of a surgery and makes it easier for the surgeon to distinguish between normal and cancerous tissue. In tumors initially diagnosed as non-operable or of borderline respectability, shrinking of the cancerous lesion can enable surgery and allow for adequate clean margins. The neoadjuvant chemotherapy not only facilitates the procedure but can also improve postoperative recovery and the long-term outcome for the patient.

The choice of a systemic treatment, such as chemotherapy, also depends on the perceived risk of distant metastasis. Particularly in locally advanced tumors with high metastatic potential, neoadjuvant chemotherapy offers the possibility to treat both primary lesions and micrometastases at distant sites. Unfortunately, chemotherapy is associated with serious side effects which can aggravate the overall health status of patients. There is a risk that the chemotherapy will make the patient so much sicker, he or she becomes unfit for surgery. This is a risk that the supervising doctor must weigh.

Neoadjuvant chemotherapy is usually given for inoperable breast, colorectal and lung cancers1-4 and it is a treatment option for many other solid tumors. Systemic preoperative treatment is employed in breast-conserving surgery1, tumors with borderline resectability 2,5 and locally advanced cancers6. Recent review articles published in the Journal of Surgical Oncology and related clinical journals show that neoadjuvant chemotherapy is being evaluated in different settings of esophageal, gastric, pancreatic, prostate, soft-tissue sarcoma, ovarian and cervical cancers7-13. In some disease settings, the primary neoadjuvant treatment is radiotherapy and chemotherapy can be administered concurrently or in sequence with radiation, in chemoradiation regimens.

The administration of neoadjuvant chemotherapy is performed in cycles, with each cycle consisting of a treatment period followed by a resting phase. Chemotherapy agents can be given orally or intravenously during a variable number of cycles14-16. Response to chemotherapy and patient fitness are important criteria in determining patient eligibility for surgery17. In some patients, surgery can be performed only weeks after the last cycle of preoperative chemotherapy.

man received adjuvant chemotherapyThe long-term benefits of neoadjuvant therapy plus surgery compared with surgery alone are a source of debate. In gastric, esophageal and cervical cancers only modest survival improvements have been observed with unclear risk-benefit ratios18-20. Significant survival benefits have been established in breast21 and lung22,23 cancers. Translation of clinical trial results to medical practice can be complex and depends on many factors. For example, in breast cancer, preoperative chemotherapy is currently recommended in locally advanced tumors21,24; however, the best course of treatment for early stages of the disease is unclear25.

Induction Chemotherapy

So is induction chemotherapy the same as neoadjuvant chemotherapy?  The difference lies in the intent of the doctors planning treatment.  If the chemotherapy is the primary treatment, intended to be the only treatment, it is called induction chemotherapy. The word neoadjuvant applies only if there is subsequent treatment of a different modality. And some insist the word neoadjuvant should be used only if the subsequent treatment is surgery, while the words induction and inductive can still be employed if the subsequent treatment is chemotherapy.

If a chemotherapy course is given prior to surgery, that chemo is called neoadjuvant. If a chemotherapy course is given prior to radiotherapy, some purists insist that chemo should not be called neoadjuvant but induction. Others will use neoadjuvant in both cases.

Chemotherapy: Before or after surgery?

The scheduling of chemotherapy relative to the surgical intervention is an area of active research in many cancers. Despite potential benefits, neoadjuvant chemotherapy also has risks when compared to systemic treatment in the postoperative setting (adjuvant chemotherapy). For one thing, delaying surgery allows potential metastasis of the cancer and spread to other parts of the body – making the disease more intractable26. For breast cancer, analysis of several clinical trials has not found significant differences between the efficacy of chemotherapy given before or after surgery27. Recent results from large clinical trials show that adjuvant and neoadjuvant chemotherapy regimens result in similar survival outcomes, but breast-conservation rates are improved with neoadjuvant chemotherapy28.

In lung cancer, the scheduling of chemotherapy is a subject of debate29. Adjuvant or neoadjuvant?  There is lack of conclusive evidence supporting either approach, leading many to think that a general solution to the question might not be found30. As with other cancers (including breast and colorectal), the research is focusing on the development of personalized strategies that take into account many prognostic factors31.

This page in Spanish.



Michael C Perry, The Chemotherapy Source Book, Lippincott Williams & Wilkins; Fourth Edition edition (October 1, 2007).

B. Sevin, P. Knapstein, O. Kochli, R. Angioli, Multimodality Therapy in Gynecologic Oncology, Thieme Medical Publishers; 1st edition (January 15, 1996).


MD Anderson Cancer Center


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[IM1]This is because the inflammation that is associated with tumor growth is alleviated.

[IM2]Healthy tissue surrounding tumor. Failure to use adequate clean margins has been associated with recurrence.

[IM3]Specifically, the theoretical advantages of neoadjuvant chemotherapy are related to the potential establishment of metastatic sites at microscopic level (micro metastases).

Micro-metastases cannot be detected by current diagnostic tools. In general metasases cannot be treated surgically. Therefore they can only be treated by systemic therapies.

Since micro-metastases cannot be detected, this specific argument is based on a prophylactic concept. Some question the value of considering a prophylactic measure in the evaluation of the use of toxic therapies.

[IM4]Non-small cell lung cancer

[IM5]eg, curative surgery


[IM7]fit patients

[IM8]normally a month for breast cancer if blood analyses show regular results after chemotherapy

[IM9]in come cases chemotherapy can be given before and after surgery.