Dr Alvarado on Selecting Breast Conservation Surgery vs Mastectomy After Neoadjuvant Therapy

Michael D. Alvarado, MD, professor, surgery, Division of Surgical Oncology, Director, Breast Surgery Oncology Fellowship, Department of Surgery, University of California, San Francisco School of Medicine, discusses key considerations that influence the decision to undergo breast conservation surgery vs mastectomy in patients with breast cancer who have undergone neoadjuvant therapy and have concerns about local recurrence.

Before initiating neoadjuvant therapy for patients with breast cancer, several factors are considered to tailor treatment plans and inform discussions with patients, Alvarado begins. These include clinical tumor size, nodal burden, and biological characteristics, such as hormone receptor status and HER2 expression, he expands. Patients with triple-negative breast cancer, for instance, are more likely to exhibit a favorable response with neoadjuvant therapy, potentially allowing them to choose breast-conserving surgery, Alvarado says.

Patients should discuss the possibility of breast conservation surgery with their oncologist, especially if their tumor shows a significant response to neoadjuvant therapy and shrinks to a size that is technically feasible for lumpectomy, Alvarado continues. For those with HER2-positive breast cancer subtypes, similar considerations are taken into account. The goal is to provide patients with options that optimize both oncological outcomes and quality of life, he emphasizes.

However, not all patients exhibiting a favorable response to neoadjuvant therapy may be suitable candidates for breast conservation surgery, Alvarado notes. In cases where the tumor exhibits a scattered or diffuse pattern of response, which Alvarado refers to as the "crumbled cookie effect," breast conservation surgery may not be technically feasible. In such instances, mastectomy may be recommended to ensure complete removal of the affected tissue and reduce the risk of recurrence, he explains.

Ultimately, the decision regarding the type of surgery is made collaboratively between the patient and the health care team, considering the patient’s preferences, treatment response, and surgical considerations, Alvarado states. The aim is to provide personalized care that optimizes outcomes and respects the patient's goals and preferences, he concludes.