Many patients assume that surgery is the first step towards treatment, and this is true in that doctors do typically recommend surgery to remove a tumor for both early-stage invasive breast cancer and DCIS.
For larger tumors, or those that are growing more quickly, doctors may recommend systemic treatment with chemotherapy or hormonal therapy before performing surgery, which is referred to as neoadjuvant therapy.
Now, thanks to advances in early detection, systemic agents, and image-guided biopsy, researchers are revisiting whether it’s safe to forego surgery in a select group of breast cancer patients who receive neoadjuvant therapy.
Specifically, a clinical trial has been studying if it’s feasible to avoid surgery if a patient who has had neoadjuvant systemic therapy has a pathological complete response (pCR), which is generally defined as the absence of invasive disease in the breast and axillary nodes resulting from the therapy.
As an example, a patient with Triple Negative breast cancer who was enrolled in the trial had a clearly visible tumor on mammography before neoadjuvant chemotherapy. After chemotherapy, mammography and image-guided needle biopsy showed no residual tumor.
HER2-Positive & Triple Negative Breast Cancers
Patients with Triple Negative (i.e., negative for estrogen receptor, progesterone receptor, and HER2) breast cancer and patients with HER2-positive (human epidermal growth factor receptor 2) breast cancer are particularly sensitive to systemic therapy.
It’s estimated that at least 50% of patients who have Triple Negative and HER2-positive tumors and who receive neoadjuvant systemic therapy have a pathological complete response. The patients who have a complete response are also less likely to have a recurrence and are more likely to have long-term survival.
Knowing that, surgeons have questioned for years the necessity of performing surgery on these patients to remove a tumor that may not be there anymore.
Until recently, the problem has been that the only way to identify whether a patient had a pathological complete response to systemic therapy was by a pathological assessment of a specimen removed from the tumor site, which required surgery.
Physical examination of the breast and axilla to determine clinical response is known to be inaccurate. Even though breast imaging methods have improved substantially, they have not been sensitive or specific enough to confirm the absence of residual disease after systemic therapy.
Plus, high rates of reappearance of cancer on the ipsilateral chest wall (or locoregional recurrence) thwarted attempts to forego surgery. However, these recurrences were likely due to weakly effective systemic agents and insufficient imaging tools for accurately assessing treatment response.
A New Way To Measure Response
In order to more accurately assess treatment response, researchers in the clinical trial turned to image-guided fine-needle biopsy. In this procedure, a needle is inserted through the breast into the tumor region under ultrasonography or mammography guidance and then rotated to collect about a dozen samples from different sites.
The researchers performed preoperative image-guided biopsies on 40 patients with triple-negative or HER2-positive breast cancer after they had received neoadjuvant systemic therapy, and then compared the results with those from traditional examination of the patients’ surgical specimens.
The results showed that image-guided biopsy was 98% accurate in identifying residual disease. For the other 2%, only a tiny amount of residual disease remained, which the researchers determined radiation could easily eradicate.
The results of the trial indicate that we’re reaching a point where improvements in systemic treatments and in detection may eliminate surgery for invasive breast cancer for some patients.
If this approach is proven to be safe and sustainable, it could change the course of treatment for patients with HER2-positive and triple negative breast cancer.
As always, I’m very encouraged by the ongoing research and developments in treating breast cancer, and I remain steadfastly committed to providing the most advanced treatments for my patients.
If you’d like to discuss the treatment options for breast cancer, I am happy to consult with you. Or, if you’ve recently been diagnosed with breast cancer or are wondering if you should seek a second opinion on your diagnosis or surgical plan, I am also happy to consult with you. I have an office at Tennova Turkey Creek in West Knoxville and an office adjacent to Tennova North Knoxville Medical Center just off of Emory Road in Powell.
My extensive research and dedication to continual learning, including Certification in Oncoplastic Surgery, have distinguished me as a leader in the field of specialized breast cancer oncology. To learn more about my compassionate surgical care approach, visit www.aaronmd.com or call (865) 692-1610.
