Neoadjuvant Therapy and Surgical Advances Continue to Shift Treatment Options for Breast Cancer

Jeannie Shen, MD

The de-escalation of medical and surgical therapies for patients with breast cancer has helped shift the treatment paradigm for patients with breast cancer, according to Jeannie Shen, MD. She added that screening remains the best way to identify disease early and provide patients with the most options for treatment.

“[Patients cannot] let fear that we are going to find something keep them from coming in [for screening]. If breast cancer is caught early, the treatments that can be minimally invasive and still provide the highest success rate,” said Shen, medical director for the Breast Program at Huntington Hospital, an affiliate of Cedars-Sinai in Los Angeles, California.

In an interview with OncLive^®, Shen discussed the shifts in surgical practice for patients with breast cancer, the need for a multidisciplinary approach to optimize treatment for individual patients, and ongoing efforts at Huntington Hospital and Cedars-Sinai to increase awareness and improve care for these patients.

OncLive^®: What have been some of the recent key changes in the surgical space for breast cancer?

Shen: As a whole, breast cancer treatment has had a movement toward de-escalation. [This involves] less breast surgery, less lymph node surgery, less radiation, and less chemotherapy, and a movement toward more personalized treatment planning. It is not a one-size-fits-all [approach].

As a general trend, different specialists in breast cancer oncology have seen that shift. In the world of surgery, there is an increasing use of not only breast conserving surgery, which is lumpectomy, but we are also things called oncoplastic breast conserving surgery, where we work with plastic reconstructive surgeons. Ultimately, the goal is to get a good cancer operation, but you would like to try to give the patient a nice cosmetic result. Depending on the tumor size and location or distribution, the patient’s natural breast shape and size, [breast surgeons] cannot always do that on our own. We often employ the help of our plastic surgeons, and we can therefore offer more breast conserving surgery because we can come up with these newer ways to reshape and model the breasts.

[Things have also changed] for patients who need mastectomy. When I first started in my fellowship, we learned about what is called a skin-sparing mastectomy, where you would take [remove] the nipple. Shortly after, there was a lot of interest toward nipple-sparing mastectomy. The data for that have continued to mature, and now [data] show that can be an oncologically safe procedure. We are getting better at them with better results. Plastic surgeons are happy, and patients are happier.

We are a way off from eliminating surgery [in breast cancer]. Breast surgery will always be part of breast cancer treatment, but I do believe that in the future, possibly in my lifetime, there will be select patients where we may be able to avoid surgery altogether. There is now research looking at ablative therapy and cryoablation, which is the freezing of the tumor. Studies are showing carefully selected patients may benefit [from ablative therapy] in lieu of surgery. There are now studies also suggesting that not everyone needs to have surgery. For smaller tumors that are not aggressive, maybe we can avoid [surgery] altogether.

When I chose to specialize in breast cancer, there was an attending surgeon who said, ‘Oh, breast cancer can be cured in 20 years. We'll be out of a job.’ I said if that happens, I would [will] happily train for something new. I am 18 years inin, and we are not quite there yet, but it is exciting. Even in just 18 years of practice, shifts have been made, and [there are options that] I am able to offer now that I could not offer at the early part of my career.

What are some of the factors to consider when weighing breast preservation surgery vs mastectomy?

When I am explaining things with patients, I always say that both the patient and I will have some input. There can be medical factors, and then there are the patient’s's own feelings and her desires. [Regarding] medical factors, based on the tumor size, location, and distribution, do I feel confident I am able to get rid of all the cancer with a clear margin and still give her a nice, cosmetic result? Is the patient willing and able to do radiation therapy? Is the patient willing to ensure she will come back for follow-up? The patients that who have not had a mammogram for 15 years or intermittently come and go, I explain to them [breast preservation] is successful, but their ongoing follow-up is an important part of their aftercare and survivorship.

Maximum criteria are based on the tumor-to-breast-size ratio. For a 3 cm tumor, if [a patient] is an AA cup, that is awfully big. But if a patient is a DD cup, [3 cm] is nothing. It is not a one-size-fits-all [approach]. We look at the tumor-to-breast-size ratio, and the location of a tumor can be important for us. Tumors that are located on the upper outer quadrant, where there is more to work with, we can take the lump out and easily rearrange to fix the defect. For tumors on the bottom of breast, we may not be able to achieve that. We might need plastic surgerysurgery, or a patient might have more of a deformity.

The patient’'s own desires [can be just as important] because there are times where I will offer or recommend breast conservation, and the patient herself will say that she wants to avoid radiation if [possible]. Or there are patients who [may consider themselves] anxious people and are worriers by nature. [They might say] the thought of getting a mammogram just gives them heart palpitations. [They may] want the mastectomy for their own peace of mind. And that can be the right decision for a patient.

NowadaysAs as a doctor, and especially as a breast cancer surgeon, a large part of my job is simply educating patients and helping them make an informed decision. Oftentimes, the gut reaction for a patient is to cut it all off. Then by the time I have a chance to go through everything, and they realize that [breast preservation] is safe and successful with the same survival [rate], many do not want to cut it all off if they do not have to.

How do you go about educatingeducate patients with breast cancer about their potential surgical options?

I spend a lot of my time educating patients. An initial consult when I first started in practice was maybe a little under an hour. An average initial consult nowadays is at least an hour and a half, and if they have a more complicated case where they might need [neoadjuvant] therapy, those can be over 2-hour consults. There are a lot more treatment options available and a lot more tools.

Patients also come in much more educated themselves, and they ask good questions. That has been a great and challenging part of being a breast oncologist in modern times. I want to make sure patients do not feel rushed. They need the chance to have everything explained and have all their questions answered.

For example, I had a patient who I spent two 2 hours with, and I thought I exhaustively covered everything she could possibly need to know. I asked if she had any more questions, and she had 2 pages, typed, single spaced, and my eyes popped open. We went through every single question. That definitely has changed. There is so much more information for patients, and they want to know more and deserve to know more. When [a patient] understands more, they are going to be a little less scared.

Given all the surgical changes and the evolving treatment options for breast cancer, how important is a multidisciplinary approach to tailor treatment for these patients?

I probably speak to my medical oncologist at least 3 to 4 times a week, if not every day or multiple times a day. There are neoadjuvant therapies, especially for patients with HER2-positive breast cancer or triple-negative breast cancer [TNBC], that are increasingly being used especially for anyone that who has, at the very least, a stage II or above breast cancer. Those are patients where we want to coordinate with the medical oncologists.

Interestingly though, 75% of breast cancers are still estrogen receptor– or progesterone receptor–positive, HER2-negative. Most breast cancers are not TNBC or HER2-positive. The treatment of those patients has changed and evolved. When I began practicing, [the consensus was that] anybody who was stage II would automatically [receive] chemotherapy. If you knew a patient was going to need chemotherapy, then part of the thought process [was considering] whether to do it before or after surgery. For those patients now, they have a lot more options. Chemotherapy is not automatic.

I am lucky here at the Cedars-Sinai and Huntington Cancer Center since I work with a lot of very experienced specialists in breast oncology. There is a plethora of experienced, knowledgeable breast medical oncologists that I can call on, and they understand treatment is not one size fits all. Everybody is different, so working with a multidisciplinary approach is important early on with the surgeon and the medical oncologist, even if it is just trying to coordinate and streamline care. We are trying to minimize the number of visits, so how do we get together all the information we need, but not make them run back and forth to every single different appointment? Being able to coordinate [between specialists] can be helpful. For some of the more complicated things, bringing in a radiation oncologist up-front is helpful.

I am knowledgeable about breast surgery, but as a breast cancer surgeon, you cannot only know surgery. You have to understand what the medical oncologists and radiation oncologists do. I do understand what they do and how decisions are made, but I constantly learn from them. They are a wonderful resource, and when I read about a new study and I am not sure how to incorporate it into our current practice, I can call upon a couple different specialists to get their take.

Could you highlight some of the ongoing efforts at Huntington Hospital and Cedars-Sinai to promote awareness and improve care for patients with breast cancer?

We work closely with the Huntington-Hill Breast Center and Randall Breast Center for breast cancer screening. I would highlight that screening centers are open. Throughout COVID, a lot of that shut down or patients were scared to come in. It is safe. They have a lot of protocols in place to protect our patients, our staff, our doctors, and our nurses. I would encourage patients who are overdue [to receive screening]. If it has been a year and a day and a patient is due for a mammogram, they need to come in and get a mammogram. While they are not perfect, mammograms for the general average risk population are still the best tool we have to screen. Out of every 1000 mammograms, we will diagnose 2 to 3 breast cancers.

I am also 1 of 3 breast cancer specialists in breast cancer surgery, and we will be working with the surgeons over at Cedars Sinai, looking at some clinical trials, looking toward de-escalation—, whether this is less surgery or maybe less or omitting radiation therapy. We have ongoing studies looking at limiting the extent of lymph node surgery. Of everything I do, the surgery that causes the most [adverse] effects is lymph node surgery. There are some studies looking at maybe de-escalating and minimizing lymph node surgery, even in women who already have some lymph node involvement.

We are also working with our radiation partners on some of the newer protocols that [have been implemented] in the United Kingdom that we’'re hoping to bring here. We are hoping that these are going to be as effective, but maybe more convenient for patients, [delivered in] with a shorter time period and [delivering] the same results.

Another part of our program that is unique for a larger community cancer center would be our integrative oncology program. We have oncologists integrating complementary alternative medicine into cancer treatment. We have a nurse practitioner, Suzie Kline, PhD, who leads that program.

We provide acupuncture services. We have a massage therapist here 5 days a week. We have hypnotherapy sessions. There is music, writing, exercise, and yoga. The supportive services for patients on treatment, and even survivors, are important.

I am the medical director for the breast cancer program, and a couple other programs that I am hoping to develop in the next in the coming year or two include a survivorship program for breast cancer survivors. Once patients are done with active treatments, some need follow-up. Follow-up guidelines keep changing, depending on emerging data. Survivors can also live with adverse effects, and [we need to help] manage them.

[We also want to develop a] high -risk program, and that is increasingly common. One in 8 women are at risk of developing breast cancer in their lifetime, and most of it is not hereditary. So, an average woman has a 12.8% lifetime risk of breast cancer. That risk can be modified upward, depending on an individual’'s risk.

There are all these risk-assessment programs out there, and our breast cancer center routinely runs a risk assessment for every patient coming in. They will identify women who are at higher lifetime risk of breast cancer. Imaging wise, they may need more aggressive screening, but do they need genetic counseling or testing?

And just because a patient is at higher risk doesn’'t mean they are going to get it. What can these patients do to lower their risk? What kind of lifestyle, diet, exercise, or medications [could help lower risk]? There is an increasing group of these higher-risk patients who are stuck in limbo. They do not have cancer, so do not need an oncologist per se, but they are at higher risk and maybe need more than what their primary care is providing. That group of patients also deserves expertise.