Should breast cancer patients have chemotherapy before or after surgery?

That's a tricky question and, ultimately, each woman needs to make that decision with her doctor. But there are some advantages to having chemotherapy first.

It may be a good option "in women who have a tumor that is too big in relation to the breast size for conservative surgery[lumpectomy] but who want to have conservative surgery," said Dr. Eric Winer, director of breast cancer oncology at Dana-Farber Cancer Institute. In these cases, chemotherapy can often shrink a tumor enough to allow breast-conserving surgery. Women who get such surgery typically get radiation afterward to prevent local and regional recurrence.

If it's clear, on the basis of various tests, that a woman is going to need chemotherapy regardless of what kind of surgery she has, having chemotherapy before surgery may also allow her to avoid radiation therapy, said Dr. Kuan Yu, an assistant professor of radiation oncology at M.D. Anderson Cancer Center in Houston. Yu is the lead author of a paper recently presented at a meeting of the American Society of Therapeutic Radiology and Oncology in Boston. Pre-op chemotherapy appears to allow a woman to skip radiation only if she has a mastectomy, not a lumpectomy, Yu said.

Although pre-op chemotherapy is increasingly being used, "there are still many unanswered questions" about it, said Winer. Some clinical trials routinely use pre-op chemotherapy. Whether or not a woman is in a clinical trial, he said, it's crucial for her to discuss all the treatment options with her doctor, he said.

Judy Foreman

E-mail health questions to foreman@globe.com.