Breast cancer has a strange way of being both familiar and frightening. Almost everyone knows someone who has battled it, and yet the details of treatment often sound like an alien language. According to the World Health Organisation, breast cancer is the most common cancer among women worldwide, with 2.3 million new cases in 2022 alone. Among these, about 15 to 20 per cent are HER2-positive, the type that is fast-moving, aggressive, and hard to ignore. Increasingly, the doctors are turning to a strategy that feels a bit like hitting “pause” before the main act—neoadjuvant therapy.What Makes HER2-Positive Breast Cancer TrickyHER2 (human epidermal growth factor receptor 2) is a protein that helps cells grow. In HER2-positive breast cancer, the cells get an overdose of this protein. As a result, the cancer multiplies faster than usual and is often linked to poorer outcomes.“HER2-positive breast cancer is an aggressive type,” explains Dr Mandeep Singh Malhotra, co-founder, Art Of Healing Cancer. “It is very important to give the right information to patients and their families for better outcomes. With the right treatment sequence, it is possible to offer better treatment to patients.”What Is Neoadjuvant Therapy?Neoadjuvant therapy (NT) is like a warm-up session but for cancer treatment. Instead of rushing into surgery to remove the tumour, doctors first administer chemotherapy and targeted drugs. The idea is to shrink the tumour, make surgery easier, and gather valuable intel on how the cancer responds.“Nowadays, when we talk about HER2-positive breast cancer, we talk about targeted therapy and dual targeted therapy involving both trastuzumab and pertuzumab,” says Dr Malhotra. Both are monoclonal antibodies, meaning they are lab-made molecules designed to stick to specific parts of cancer cells. Together with chemotherapy, they not only shrink tumours but also improve surgical outcomes.Why Doctors Like ItOne of the superpowers of neoadjuvant therapy is its ability to act as a kind of crystal ball. By giving treatment before surgery, doctors can tell which patients are “responders” and which are not.“As Dr Malhotra puts it, “Even at early stages, if we give NT and then operate, we are able to prognosticate. Responders have a better prognosis. Non-responders have poorer prognosis and a higher chance of the cancer coming back.”This ability to sort patients into risk categories allows doctors to tailor follow-up care more precisely. For example, non-responders may be put on more aggressive treatments, offered newer diagnostic tests like liquid biopsy, or monitored more closely.The Big Advantage Over Surgery-FirstSurgery-first and neoadjuvant-first have similar survival data, but the latter provides an extra layer of information.“If we do upfront surgery in these patients, we lose the chance of prognostication,” says Dr Malhotra. “Secondly, even if we do the upfront surgery, we will still have to give chemo with targeted therapy after surgery. So the treatment does not change; the sequence changes. And with neoadjuvant therapy, we get the added benefit of knowing who is high risk and who is low risk.”In other words, neoadjuvant therapy is not just about shrinking tumours; it is about outsmarting them.What Patients Need to Keep in MindFor patients, all of this can feel overwhelming. Surgery often seems like the most direct way to “get rid” of cancer, so the idea of delaying it can cause anxiety. But Dr Malhotra reassures patients that this approach is carefully designed.“Even in very early-stage breast cancer, with a less than 1 cm tumour, I will not go for surgery first,” he says. “I will first give targeted chemotherapy. The reason is I see a lot of patients who have already had surgery and then are given the option of dual therapy. They are confused and afraid that the cancer will come back if they cannot afford either trastuzumab or pertuzumab.”Interestingly, cost can also play a role. If patients achieve a complete response, meaning no invasive cancer remains after neoadjuvant therapy, sometimes treatment can be stopped earlier, sparing both physical and financial strain. “We lose this opportunity if surgery is opted for first,” Dr Malhotra adds.The Future of HER2-Positive Breast Cancer TreatmentThe shift towards neoadjuvant therapy represents a significant change in how doctors approach HER2-positive breast cancer. Instead of rushing in with surgery, the modern strategy is more like a chess game, carefully setting up each move to give patients the best possible outcome.By combining chemotherapy with targeted drugs like trastuzumab and pertuzumab before surgery, doctors can shrink tumours, assess risk, personalise treatment, and often improve long-term survival.Breast cancer treatment has always been a mix of science, strategy, and courage. Neoadjuvant therapy, especially in HER2-positive cases, is proving to be more than just a pre-surgery step. It is a game-changer, giving both patients and doctors a crucial edge in the fight.As Dr Malhotra puts it, “Neoadjuvant therapy is not an inferior modality. With current data, we feel it is a superior one.”
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