When most people hear the word “cancer,” one of the first treatments that comes to mind is chemotherapy. For decades, chemotherapy has been one of the most widely known and commonly used cancer therapies, associated with powerful drugs, long hospital visits, hair loss and severe side effects. While it has saved millions of lives by destroying fast-growing cancer cells and preventing tumors from spreading, it is no longer seen as the automatic next step for every cancer patient.
In reality, cancer treatment is far from one-size-fits-all. Yet a widespread belief persists that a cancer diagnosis, especially breast cancer, inevitably leads to chemotherapy. According to Dr. Rohan Khandelwal, Head of the Breast Centre at CK Birla Hospital in Gurugram, this misconception causes significant anxiety among newly diagnosed patients.
“Almost every patient who walks in is worried about whether they will have to undergo chemotherapy,” Dr. Khandelwal told TOI Health. “They are well aware of the side effects and how deeply chemotherapy can affect quality of life. Many assume it is mandatory for everyone, regardless of the stage or nature of the cancer.”
However, advances in medical science are now allowing doctors to take a far more personalized approach, especially for early-stage breast cancer. Dr. Khandelwal explained that the decision to use chemotherapy depends heavily on the stage of the disease and the biological behavior of the tumor.
“In later-stage cancers with aggressive tumor biology, we usually begin with chemotherapy followed by surgery,” he said. “But for patients diagnosed at an early stage with favorable tumor biology, chemotherapy may not be necessary. In some cases, we perform surgery first and then evaluate whether chemotherapy or radiotherapy would provide any meaningful benefit.”
The goal, he added, is not simply to treat the disease but to ensure long-term survival and quality of life. Large clinical trials have shown that treatment decisions should be guided by how much they improve disease-free survival and overall survival. “If chemotherapy offers a clear, substantial benefit, then the patient should receive it. But if there is little or no advantage, there is no justification for exposing them to its potentially severe side effects,” Dr. Khandelwal said.
This shift toward what doctors call “de-escalation” of chemotherapy is becoming increasingly common. One example Dr. Khandelwal shared involved a 52-year-old woman with early-stage breast cancer who developed dangerously high blood pressure and suffered a minor stroke during her recovery from surgery. Molecular testing of her tumor showed it was low risk, allowing doctors to safely avoid chemotherapy without compromising her prognosis.
“These treatments are now biology-driven,” he explained. “For certain early-stage, hormone-positive breast cancers, molecular tests can predict the risk of recurrence. If those tests show the risk is low, chemotherapy can often be avoided.”
For patients, this change is welcome news. Chemotherapy remains one of the most feared aspects of cancer care, particularly because of side effects such as hair loss, fatigue and long-term health complications. While hair loss is usually temporary, its emotional impact can be profound, especially for women undergoing breast cancer treatment.
“If chemotherapy does not add a real benefit for a particular patient, then avoiding it can mean a much better quality of life,” Dr. Khandelwal said. “As long as decisions are supported by strong scientific evidence, reducing or eliminating unnecessary treatment is always in the patient’s best interest.”
As personalized medicine continues to advance, more breast cancer patients—particularly those diagnosed early—now have the opportunity to receive treatment tailored to their individual risk, rather than defaulting to chemotherapy. This marks a significant step forward in making cancer care both more effective and more humane.
