‘Nudging’ Surgeons and Patients to De-Escalation of Surgery for Breast Cancer

Excerpt

This year, the 19th Annual Meeting of the American Society of Breast Surgeons, held in Orlando, Florida, had an attendance of 1660 people from across 41 countries. A theme seen in many talks of the meeting was the de-escalation of surgery to less-extensive procedures, or to no surgery at all, for breast disease. The meeting opened with the “John Wayne Cancer Critical Issues Forum: The Changing Paradigm for Breast Cancer Surgery”, supported by the John Wayne Cancer Foundation. Four speakers presented data on studies that are currently examining the omission of surgery for the surgical treatment of breast cancer. Dr. Shelley Hwang presented the COMET trial (the Comparison of Operative to Monitoring and Endocrine Therapy Trial for Low Risk Ductal Carcinoma In Situ1; NCT02926911), a large clinical trial of observation of ductal carcinoma in situ (DCIS) being conducted in the United States; Dr. Henry Kuerer discussed trials examining the omission of surgery in patients with an imaging and needle biopsy complete response to neoadjuvant therapy; Dr. David Brenin presented data on the ablation of breast tumors (FROST, Sanarus Technologies, Inc., NCT01992250; IceCure Medical Ltd, NCT02200705);1 and Dr. David Ollila presented data from clinical trials where patients did not undergo any axillary staging procedures despite having invasive cancer.2^–5 Later in the day, the issue of whether surgical excision is needed for all cases of atypical ductal hyperplasia (ADH) was debated. A prospective study of 125 observed patients with ADH on percutaneous needle biopsy showed that only 5.6% of these patients developed cancer and only one cancer was at the biopsy site,6 arguing that routine excision of ADH would not have prevented the majority of these cancers. Further reduction in the use of routine completion axillary node dissection was discussed at the session titled “Updates on Locoregional Therapy”. The American College of Surgeons Oncology Group (ACOSOG) Z1071 trial,7 and the Sentinel Node Biopsy Following Neoadjuvant Chemotherapy (SN FNAC)8,9 and Sentinel Lymph Node Biopsy in Patients with Breast Cancer Before and After Neoadjuvant Chemotherapy (SENTINA) trials10 demonstrated that sentinel lymph node (SLN) surgery is feasible to assess for residual disease for patients diagnosed with node-positive breast cancer treated with neoadjuvant chemotherapy. Furthermore, the Alliance A011202 trial (NCT01901094)1 is currently evaluating whether completion axillary lymph node dissection can be omitted in patients with a positive SLN after neoadjuvant chemotherapy in lieu of axillary radiation. …