Expert Explains State of Surgery in Nonmetastatic Breast Cancer

Maggie DiNome, MD, associate professor of oncology and urology at Johns Hopkins Medicine

Maggie DiNome, MD

The approach and technique with surgery for nonmetastatic breast cancer have evolved since its advent as the primary method of treatment; however, Maggie DiNome, MD, said that although axillary dissection may become a thing of the past, surgery is still a key part of a multimodality treatment approach.

Although the treatment of these patients still includes surgery, the current paradigm has adopted other treatment modalities, which DiNome said control the disease in the axilla just as well as surgery, and possibly with less morbidity.

Clinical trials continue to explore whether surgeons can now do less, given the emergence of effective systemic therapies. DiNome explained that by the time patients with positive lymph nodes receive neoadjuvant chemotherapy and proceed to surgery, 40% to 70% of those patients show no evidence of residual tumor in their lymph nodes. More patients with early-stage breast cancer are surviving, which has enabled surgeons to focus on not only delivering good survival outcomes but good aesthetic outcomes as well, said DiNome.

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Is the treatment approach to be more minimally invasive?

In an interview during the 2018 OncLive^® State of the Science Summit^TM on Breast Cancer, DiNome, associate professor of surgery, of the University of California, Los Angeles Medical Center, discussed the evolution of surgical approaches in patients with early-stage breast cancer.DiNome: I spoke about the surgical management of early-stage breast cancer. One of the most fascinating things I find is that it has evolved significantly over the past century. We started off with surgery being the primary treatment for patients with breast cancer. Over the last several decades, we have learned that the biology of the cancer helps us determine the treatment approach. Now, surgery is only 1 part of a multimodality treatment strategy. We're doing good things, but we're learning that more surgery is not [necessarily] better surgery, and our treatment approach is paralleling that. What we are understanding is that more surgery is not better. You don’t get a better survival outcome by doing a bigger surgery, and you also don’t get a worse survival outcome by doing a smaller surgery. Most of our patients are surviving breast cancer—certainly early-stage breast cancer. We're finding [the cancer] earlier, and we're treating it better. The systemic therapies given by our medical oncology colleagues are so much more effective, so people are living for long periods of time.

What percentage of patients receive mastectomy versus lumpectomy?

Now, it’s incumbent upon us as surgeons to be focused on quality-of-life and survivorship issues for patients. We want to restore a woman's sense of self-worth, their femininity, and how they feel about themselves—and preserve their breast if we can. If we need to remove the breast, [we want to make] it look as natural as possible. We're moving toward that direction, so it's exciting. We're focusing a lot on the aesthetic outcomes of breast cancer surgery. [We’re] trying not to take out more than we need to, so that we [don’t have to] change the appearance of the breast so much. We're doing that with our other oncology colleagues, who help us to get both a good survival outcome as well as a good aesthetic outcome. For most early-stage breast cancers, you can opt for either breast-conservation surgery or mastectomy. Most postmenopausal women who have a choice will opt for the easier surgery, so they end up doing a lumpectomy. A good number of women who are diagnosed at a young age tend to opt a little bit more as a group for not only unilateral mastectomy, but bilateral mastectomy.

What is the typical recovery time for both of those surgeries?

These patients are at a different stage in their life; they have different priorities, a longer life span ahead of them, and may be looking at possible increased risk of second cancers. It's not the survival benefit that they're getting in doing that, but it addresses other concerns that they have in terms of their current and future priorities. It's hard to quantify. I would say that most older patients will choose lumpectomy. Most younger patients will choose lumpectomy, but a [high] percentage do opt for mastectomy. Recovery is a lot easier with a lumpectomy because it’s a much smaller surgery. It's an outpatient surgery, and people recover in a number of days to maybe 1 or 2 weeks. Most people do a mastectomy with reconstruction now, and that has a much more extensive recovery. [Recovery time is] based on the type of reconstruction, as well. If we did a simple mastectomy where we're not reconstructing, the recovery period may be about 2 weeks. [Patients] have a drain in for about 1 week or 10 days; these patients are pretty much recovered by 2 weeks.

Prior to surgery, what neoadjuvant therapies are most patients on?

Following surgery, is there a standard dose of radiation therapy administered?

A [tissue expander] is a 2-stage procedure that involves a much greater recovery upfront. You might be talking 6 weeks after the first surgery, 3 months of expansion in between and a 2-week recovery after the second surgery. An autologous tissue reconstruction—where we take tissue from another part of the body and rebuilding the breast—is a much longer surgery upfront and [results in a] much longer hospital stay. Generally, you'll have a 6- or possibly 8-week recovery, but you don't have that second surgery to look forward to. It varies based on whether or not you do dual surgery and what the reconstruction involves. Certainly, a lumpectomy is much easier to recover from. [Though] you go home the same day and you have much less pain, you do look forward to radiation therapy.For a certain subset of patients, upfront surgery is still the way to go. We've identified a group of patients who seem to benefit from doing chemotherapy and systemic treatment first before surgery. For patients who have triple-negative breast cancer, or HER2-overexpressing tumors, we lean towards upfront chemotherapy followed by surgery. They'll have had their medical treatment and then come to surgery. Mostly every other patient undergoes upfront surgery. The results of the surgery also help determine what additional therapies are recommended afterward. The doses for radiation are generally standard. Whole breast radiation is the standard treatment for radiation, and that's given outside the breast going inward. It used to be roughly 6.5 weeks—about 33 daily treatments, Monday through Friday. That [regimen] gives [patients] the full dose of radiation.

That's generally still the standard for most premenopausal women, women with positive lymph nodes, etc. There have been newer data [in support of] shortened courses of radiation for postmenopausal women with negative lymph nodes. They've shortened the course down to about 3 weeks or 16 treatments; that is now the newer standard for postmenopausal women.

What does the future hold for surgery in this field?

There are other more targeted ways of delivering radiation. There are variations that might be given twice daily for 5 days or once daily for 10 days. However, the general standard dosing of whole breast radiation is usually either 6 or 3 weeks.For surgery, we are always looking at what is safe to get away with. We started off with big surgery because that's all we knew; that's what we thought was the way to go. Over the course of time, all of the clinical trials were asking whether or not we could get by with doing less. We are still asking those questions.

Now, we're asking whether or not patients still need to have all of their lymph nodes removed [when there is] significant morbidity of lymphedema, arm swelling, numbness, and pain. There are current clinical trials moving in that direction. We are going to come to a point where we're likely not going to be doing much in the way of axillary surgery at all. We're finding that other treatment modalities control the disease in the axilla just as well as surgery with less morbidity.