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October 27, 2022

Do all breast cancer patients need surgery? Maybe not.

Daily Briefing

    While conventional treatments for breast cancer typically involve deploying "all the tools modern medicine has to offer," including surgery, a new study published Tuesday in The Lancet Oncology suggests that chemotherapy alone might be sufficient for some patients, Roni Caryn Rabin writes for the New York Times.

    Infographic: Envisioning the future of cancer care

    Study details and key findings

    For the study, researchers followed 50 patients through an early-stage clinical trial that evaluated the efficacy of neoadjuvant systemic therapy (NST) for triple-negative breast cancer and HER2-positive breast cancer patients.  

    To be eligible for the trial, patients had to be at least 40 years old with a diagnosis of unicentric cT1–2N0–1M0 triple-negative breast cancer or HER2-positive breast cancer and a residual breast lesion smaller than two centimeters.

    From March 6, 2017, to Nov. 9, 2021, 50 patients participated in the trial. The average age of trial participants was 62 years old. Forty-two percent of the patients had triple-negative breast cancer and 58% had HER2-positive breast cancer. Each patient underwent vacuum-assisted core biopsy (VACB) after receiving NST to evaluate their response to the treatment.

    Over an average 26-month follow-up period, 31 patients—roughly 60%—had a positive response and were able to avoid surgery, according to the researchers.

    Commentary

    According to Henry Kuerer, a professor of breast surgical oncology at the University of Texas MD Anderson Cancer Center and the principal investigator of the study, avoiding surgery for invasive breast cancer is "the ultimate form of breast-conserving therapy."

    "Breast surgery can lead to complications like infections, and even breast-conserving procedures like lumpectomy can change the shape of the breast, leave scars or indentations, a tugging sensation or lasting nerve pain," Rabin writes.

    Kuerer noted that some patients prefer radical surgery even if it does not increase their survival rate. However, others find minor surgery "emotionally grueling" even if the procedure is successful, Rabin writes.

    "Breast cancer is so common, and there are always going to be people who would rather not have surgery," Kuerer added.

    For instance, trial patient Pamela Romero, who was eligible to forgo surgery, wanted to avoid the procedure after doctors found a HER2-positive tumor roughly the size of a grape.

    "The doctor asked, 'How do you feel about surgery?' and I said, 'I'm scared to death of it,'" Romero said. "I said, 'If I can get rid of the cancer without having surgery, I'm all for it.'"

    "I did not want to be put under, or go under the knife," added Romero, who had never had surgery.

    Romero's tumor shrunk by about 85% after she underwent four chemotherapy infusions, which allowed her to forgo surgery. Two treatments later, her regimen was complete. She recently celebrated her third anniversary of completing treatment and is still disease-free today.

    The work is part of a de-escalation approach to cancer therapy, individualizing treatment to achieve the same results with less treatments and fewer interventions, Rabin writes.

    "What I really appreciate about the study is that it takes the next step and asks a bold question: How do we take all the advances that we've made in more tailored and specific cancer therapy, and convert that to reducing the number and types of interventions any one patient needs to incur?" said Karen Knudsen, CEO of the American Cancer Society.

    "Asking whether we can scale back surgery is a reasonable next consideration for the future of cancer care," she added.

    While the study followed patients for a significant period, experts noted that a larger trial with a comparison group would be necessary to determine whether changes in medical practice are warranted, Rabin writes.

    "The big picture is that this is a tiny study," said Monica Morrow, the chief of breast surgery at Memorial Sloan Kettering Cancer Center. "It is in no way definitive. It will in no way change practice."

    Separately, Kuerer said that while the results of the trial were promising, most breast cancer patients will still need surgery. "It's important for patients to know that this is the very beginning of a new type of treatment for select patients," he said. (Rabin, New York Times, 10/25; Kuerer et al., The Lancet Oncology, 10/25)

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