Can Chemotherapy Be Avoided in Early Breast Cancer?

Chemotherapy can be avoided in selected women with early breast cancer. When the tumour is hormone-receptor positive, HER2-negative and T1 or T2 in size, a genomic risk test separates high-risk from low-risk disease. Dr. Rajesh Kumar Jain has used these tests for seven to eight years, and around 50 to 60% of such patients in his practice have avoided adjuvant chemotherapy, receiving hormone therapy instead.

This decision sits inside a wider plan. After surgery for early breast cancer, a tumour board decides which adjuvant treatments, meaning treatments given after the operation, each patient needs: chemotherapy, hormone therapy, HER2-targeted therapy and radiotherapy. This article sets out how Dr. Rajesh Kumar Jain, Principal Director - Surgical Oncology, BLK-Max Super Speciality Hospital, New Delhi, India, sequences them, and what follows once treatment ends: survival by stage, follow-up and rehabilitation. Diagnosis and surgery are covered in the complete guide to breast cancer diagnosis and surgery.

From pathology report to tumour board

After surgery, Dr. Jain waits around 10 days for the full pathology report. The case is then presented at the tumour board, where surgeons, medical oncologists, radiation oncologists and pathologists plan adjuvant treatment together. Adjuvant treatment usually begins two to four weeks after surgery.

The pathology report answers the questions that drive the plan: the final tumour size, the number of axillary nodes involved, the margins, and the receptor status. Each adjuvant treatment has its own indications.

Who needs adjuvant chemotherapy

In Dr. Jain's practice, adjuvant chemotherapy is given when:

• axillary nodes are positive, for example two or three involved nodes, or more;
• the tumour is larger than T2 size;
• the tumour is T2 even with no nodes involved on pathology (T2 N0);
• in some cases, the tumour is T1 with no nodes involved (T1 N0).

The question that genomic testing answers is which patients, among those who would otherwise receive chemotherapy, can safely be spared.

Can chemotherapy be avoided? Genomic risk tests decide

Chemotherapy can be avoided when a genomic risk test classifies the tumour as low risk. The candidates for testing are women with very early breast cancer that is strongly hormone-receptor positive:

• oestrogen receptor (ER) and progesterone receptor (PR) positive;
• HER2 negative;
• tumour size T1 or T2.

For these women, Dr. Jain uses a genomic risk stratification test on the tumour tissue. Several such tests exist, including Oncotype DX, EndoPredict and CanAssist Breast. Each analyses biological markers in the tumour tissue and classifies the patient as high risk or low risk of recurrence. Low-risk patients receive hormone therapy alone; high-risk patients receive chemotherapy as well.

Dr. Jain's own experience shows the effect. Over the seven to eight years he has used them, around 50 to 60% of patients in this group, hormone-receptor strongly positive and HER2 negative, avoided adjuvant chemotherapy. His message to referring doctors was to make a point of identifying the patients in whom chemotherapy can be avoided, rather than giving it to every hormone-positive patient by default.

Hormone therapy for breast cancer: tablets for 10 years

Every patient whose tumour is ER or PR positive receives hormone therapy, which Dr. Jain generally gives for 10 years. International guidelines recommend at least five years of endocrine therapy, with extension to 10 years for many women, particularly those at higher risk. The drug depends on menopausal status.

• Premenopausal women: tamoxifen, 20 mg daily, is the usual choice.
• Postmenopausal women: tamoxifen or an aromatase inhibitor (a drug that blocks the production of oestrogen in body tissues after menopause), such as anastrozole or letrozole.

Why aromatase inhibitors need ovarian suppression in younger women

Aromatase inhibitors work only in postmenopausal women. If an aromatase inhibitor is to be used in a premenopausal woman with hormone-positive disease, she must first be made postmenopausal. Dr. Jain described two routes:

1. Surgical: removal of both ovaries, which can be done laparoscopically.
2. Medical: injections that suppress ovarian function.

The logic is simple. Hormone-positive breast cancer is driven by oestrogen, and the ovaries are the main source of oestrogen before menopause. Removing or silencing the ovaries stops that supply, which benefits the patient and allows an aromatase inhibitor to be used.

In answer to a question in the live discussion about a young woman with early disease, Dr. Jain said that starting tamoxifen before surgery is not a good idea.

HER2-positive breast cancer: FISH testing and trastuzumab

HER2-positive breast cancer needs trastuzumab, given every three weeks for about one year, and an equivocal HER2 result is settled by a FISH test. HER2 status is tested by immunohistochemistry alongside ER and PR. Sometimes the immunohistochemistry result is equivocal: it cannot say whether HER2 is positive or negative. In that case a fluorescence in situ hybridisation (FISH) test is required to settle it.

A positive HER2 result has two implications. First, the patient is high risk: in Dr. Jain's words, any HER2 positivity makes a patient high risk. Second, she needs anti-HER2 targeted therapy with trastuzumab, which is given every three weeks for a total of about one year (17 cycles). Because it is a long treatment, trastuzumab is one of the parts of the plan that can often be given in the patient's home country.

Adjuvant radiotherapy: Dr. Jain's five indications

Not every patient needs adjuvant radiotherapy. Dr. Jain's indications are:

1. Every patient who has had breast conservation surgery. Radiotherapy is mandatory after conservation.
2. Mastectomy with a positive margin. The options are further surgery to achieve a clear margin, or radiotherapy.
3. A tumour larger than 5 cm (T3 or above), even after mastectomy.
4. More than one positive axillary node. With a single positive node, radiotherapy is generally avoided.
5. Extranodal extension, meaning cancer that has broken through the capsule of a lymph node. Here the axilla is irradiated as well as the chest wall.

What is the definitive treatment for breast cancer?

Asked what the definitive treatment for breast cancer is, Dr. Jain answered that there is no single one. Breast cancer is a solid tumour, and curative treatment of a solid tumour is multimodal. Chemotherapy alone, radiotherapy alone or hormone therapy alone cannot cure it. Surgery must be part of the plan, but surgery alone is also usually not enough: it is combined with hormone tablets, chemotherapy, radiotherapy, or occasionally nothing further, according to the pathology. Surgery with appropriate adjuvant treatment is, in his view, the definitive treatment of breast cancer.

Breast cancer survival rates by stage

Five-year survival ranges from 97 to 98% at stage I to around 25 to 30% at stage IV, in the figures Dr. Jain gave. He described breast cancer as a success story of oncology, with prognosis improving year on year as surgical technique, radiotherapy and drug treatment, including newer immunotherapy drugs, have advanced. By stage, five-year survival is approximately:

The condition attached to the stage I figure matters: treatment has to be adequate. Dr. Jain singled out two groups for particular care, triple-negative breast cancer and locally advanced breast cancer, because they carry a higher risk of recurrence. In these patients follow-up has to be stringent, so that any recurrence is identified at the earliest point, when it can still be treated.

Follow-up and rehabilitation after breast cancer

Asked whether rehabilitation is necessary, Dr. Jain's answer was that it is mandatory. Some women he operated on 28 to 29 years ago still come to see him, and he regards follow-up as an essential part of treatment. In his view, the surgery and drug treatment are only around 5% of cancer management; rehabilitation is the other 95%. He sees rehabilitation as having four dimensions.

Physical rehabilitation of the arm

The arm on the operated side is the first priority, because many patients develop lymphoedema after axillary surgery. His instructions are:

• regular arm exercises and physiotherapy;
• no bangles or rings on the operated side, for life;
• no needles, blood tests or blood pressure measurement in the affected arm;
• a sensible diet, and hormone tablets taken on time.

The LYMPHA technique that Dr. Jain adds to axillary dissection is aimed at preventing lymphoedema from the outset.

Psychological rehabilitation

A diagnosis of breast cancer leaves many survivors psychologically distressed. Dr. Jain believes the surgeon who operated is the best person to provide that psychological support.

Social rehabilitation

In poorer countries, patients may lose their jobs because of cancer and its treatment. Rehabilitation includes helping them find appropriate work again.

Marital rehabilitation

In some settings, a breast cancer diagnosis can lead to the breakdown of a marriage, and Dr. Jain counts support through that as part of the doctor's role. For him, rehabilitation is a whole chapter of breast cancer care, and the treating doctor is the main person who helps the patient through it.

Dr. Jain's profile and other masterclasses include his September 2026 session on recent trends in surgical oncology. Indicative costs of chemotherapy and radiotherapy, from the doctor's own estimates, are in the complete guide to breast cancer diagnosis and surgery; procedure-level figures are on the chemotherapy cost page and the radiotherapy cost page, and related guides sit in the oncology specialty hub.