Summary
With a shift towards less-invasive approaches to care, oncologists across specialties are committed to providing effective treatments while not subjecting patients to unnecessary procedures.
For instance, the role of breast surgery in exceptional responders is an area that has been gaining momentum in recent years. “This is a burgeoning area of research,” noted Henry M. Kuerer, MD, PhD, FACS, Executive Director, Breast Programs, MD Anderson Cancer Network. “Can we avoid surgery in patients who have a complete response with neoadjuvant systemic therapy?”
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Original Article
Can Breast Surgery Be Avoided in Exceptional Responders?
Oncology Times
By Catlin Nalley
With a shift towards less-invasive approaches to care, oncologists across specialties are committed to providing effective treatments while not subjecting patients to unnecessary procedures.
For instance, the role of breast surgery in exceptional responders is an area that has been gaining momentum in recent years. “This is a burgeoning area of research,” noted Henry M. Kuerer, MD, PhD, FACS, Executive Director, Breast Programs, MD Anderson Cancer Network. “Can we avoid surgery in patients who have a complete response with neoadjuvant systemic therapy?”
At the Miami Breast Cancer Conference, Kuerer took a closer look at this question during his session, “The Future of Breast Surgery in Exceptional Responders.”
A New Approach
The current therapeutic approach to breast cancer integrates surgery, radiation, and systemic treatment. “The aim is to combine and sequence these different treatments according to each patient’s needs and preferences and to de-escalate treatment whenever possible while preserving oncological safety,” according to Heil et al (Ann Oncol 2020;31(1):61-71).
“We have very effective chemotherapy and systemic targeted therapy, particularly for HER2 patients,” Kuerer explained. “As a result, about half of patients don’t have any cancer left when we go to surgery.
“Therefore, we have been doing less and less surgery in those cases because the tumors are generally shrinking,” he continued. “This has also led to the development and implementation of new surgical techniques that better suit the needs of our patients.”
Kuerer and his team have been studying this approach for a number of years, looking for a way to identify patients without residual disease. “We came up with the idea that we could follow the patients by breast imaging,” he explained. “Instead of taking the patients to surgery, we would conduct an image-guided biopsy. Our findings showed that we could identify residual disease with an accuracy of 98 percent.”
Just over 2 years ago, they opened a clinical trial for patients with triple-negative or HER2-positive disease who started with tumors that were less than 5 centimeters, according to Kuerer. “If the tumor shrunk down on imaging to less than 2 centimeters, patients were allowed to have a biopsy, and if no cancer was seen, then they skipped the surgery and went on to radiotherapy.”
The study, which is still recruiting participants, currently has approximately 38 of 50 patients, Kuerer said. There are a number of interesting questions to derive from this study, including the patient perspective on this approach.
“How does the patient feel about this? Do they have any regrets?” asked Kuerer. “We are conducting a variety of quality-of-life testing with patients. We also look at cost. Are we potentially saving money for the patient and the health care systems?”
Looking Forward
With a variety of studies underway, where does the research stand? As these papers are published, reviewed and validated, the oncology community will gain a better understanding about this method of care.
The key takeaway, Kuerer said, is that this approach must still be proven effective. While he would not yet offer this to a patient outside of a clinical trial, there is significant potential. “I believe this is a viable option for certain patients,” he said. “However, we must be very selective with a focus on safety.
“De-escalation in exceptional responders is the key to modern medicine and value-based health care,” he concluded. “We want to ensure the best outcomes for our patients, but the complications and adverse events are a huge cost to them personally as well as to the health care system. Therefore, if we're able to deescalate therapies with the same outcome or better without as many side effects, that's where I think all of medicine is heading.”
Catlin Nalley is a contributing writer.