Better Cancer Drugs May Lead to Omitting Breast Surgery

Omitting surgery after receiving initial treatment with systemic therapy offered positive results for patients with invasive forms of breast cancer, according to results from a recent trial.

A study published on JAMA Network Open delved into findings from a clinical trial in which patients with triple-negative disease or ERBB2-positive disease had an overall positive experience, notably with health-related quality of life (HRQOL) with a quicker recovery from side effects from systemic therapy.

Triple-negative breast cancer refers to a type of breast cancer where “tumor cells do not have estrogen receptors, progesterone receptors, or large amounts of HER2/neu protein on their surface,” according to National Cancer Institute.

ERBB2-positive, also known as HER2-positive, refers to a type of protein on a cell. However, when cancer cells produce too much ERBB2, they may grow rapidly and could spread to other parts of the body, as the National Cancer Institute explained.

The trial included 31 total patients: 15 patients had triple-negative breast cancer and 16 had ERBB2-positive breast cancer. Of the patients with ERBB2-positive disease, nine had hormone receptor-negative disease and seven had hormone receptor-positive disease.

“What we found over the years is that as the drugs are getting better and better, when we go do the surgery, we often don't find any cancer cells at all because it's been killed,” Dr. Henry Kuerer, co-author of the study, professor of surgery and executive director of the MD Anderson Cancer Network Breast Programs, said during an interview with CURE®. “Nowadays, we can see what's called pathologic complete response — or complete elimination of the cancer — in up to 70% of patients with these types of cancers treated with standards.”

Kuerer emphasized that because there have been significant improvements to drugs, breast surgery may not be necessary for patients with invasive breast cancers such as triple negative or ERBB2-positive breast cancers.

“(Chemotherapy) has shown to decrease the amount of surgery and we have taken it to the ultimate level and said, ‘Well, do we really need to do surgery at all if there's nothing there?’” Kuerer explained. “So, we had to come up with a reasonable safe way to select these patients because our mammograms, ultrasounds and MRIs are not sufficiently accurate enough to tell us if there's disease or no disease.”

Instead, Kuerer noted that using a biopsy technique called an image-guided biopsy could be a more effective approach. With this technique, doctors stick a thin needle in the specific area of the breast to collect a sample and determine whether there was any evidence of cancer cells.

Based on the study, the researchers found that patients demonstrated improvements in making decisions comfortably and overall HRQOL with side effects from therapy that were minimal-lasting. Kuerer established that in the clinical trial, it was important to ensure patients did not feel fear of cancer recurrence because of the omission of surgery. He noted that their nervousness could certainly impact their quality of life negatively.

“Patients in this study had the standard radiotherapy. So, after a lumpectomy radiotherapy is given to prevent local recurrence,” Kuerer described. “We eliminated the surgery, but they received the standard. So, if you have two breasts, one breast will be radiated and the other one will not. It's likely there will be some radiation changes, particularly six months and 12 months, which is consistent with having surgery or not having surgery, which we found, and we (also) found that (this) improved with time.”

Although this trial was small, there is potential for larger studies in the future regarding breast surgery omission, Kurer said.

“We do believe that with more studies, this will become an interventional standard, mostly because we know the drugs are getting better,” he explained. “And our ability to detect residual disease, minimal residual disease is also getting better. So, I think for patients, they need to understand what their options (are) in all the parts of it: the radiation output to surgery options, the systemic therapy, because some of them are targeted. They need to know, what are their options, what are the potential side effects and how do we minimize that?”

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