As part of Breast Cancer Awareness Month, CancerNetwork® spoke with Deborah M. Axelrod, MD, about developments within the surgical breast cancer space, including decreasing the need for re-excision and full lymph node dissection.
In an interview with CancerNetwork® as part of Breast Cancer Awareness Month, Deborah M. Axelrod, MD, professor of the Department of Surgery at New York University Grossman School of Medicine, and founder and director of Community Outreach and Education Programs at the Perlmutter Cancer Center, spoke about how surgical treatment of breast cancer has evolved over the years and the growing plausibility of de-escalation breast cancer surgery strategies.
“In the country, there are some ongoing studies looking at if someone appears to have completely responded to trastuzumab [Herceptin]–based chemotherapy, do you even need surgery?” Axelrod said during the interview. “That’s unbelievable de-escalation of treatment for a surgeon. These are the things that we’re going to be hearing more about. We’re going to be hearing more about not even doing the sentinel node if someone has a very favorable cancer. We’re looking at possibly giving less and less radiation to the point of maybe no radiation with particularly favorable cancers.”
Axelrod also detailed how her role as a surgeon allows her to be well positioned to help inform and reassure patients about their condition, as well as how surgical intervention for high-risk lesions has changed.
Axelrod: I have been in practice for a number of years, and the treatment of breast cancer has changed a lot. The way we diagnose breast cancer has also changed and the information that we get has changed a great deal. My job is to process all the information that comes in. Patients are very overwhelmed; it is overwhelming because you’re getting a lot of medical terms, and expected be an expert in this field in a few weeks. I always say that at the end of the treatment of breast cancer, when everything is now on a maintenance, I always say the patients know as much as the medical students and the younger residents. It’s true that it’s mind-boggling how women can adapt, and process information. And I’m not talking about people who are physicians because it’s even mind-boggling for physicians.
When I talk to patients, whether they’re in the health care field or not, I’m going to talk to them like they know absolutely nothing about breast cancer. And a lot of people have heard numerous things [about breast cancer] that may or may not be true. They’ve read things that [make them] think that everything that you can read about breast cancer is applicable to themselves, which is also not true. That’s why this one-size-fits-all [perception] is really a misnomer. It’s not like that anymore. In addition to being a surgeon and taking care of patients longitudinally, I still have to complete the follow-up after diagnosis and treatment. I see them every year or every 6 months.
The big breakthroughs are trying to do less in the operating room with the information that you have. For instance, if a woman is diagnosed with breast cancer, and it’s spread to the lymph nodes, we don’t always take out most of the lymph nodes now. We try to temper it and be very thoughtful about whether we’re going to do a full axillary dissection. In every modality in breast cancer treatment, [doctors are] de-escalating treatment. They’re trying to get the same result, but with less damage, less surgery, less chemotherapy, and less radiation. It’s no different in surgery. We’re trying to do less as well.
We now know that we don’t need those 1 cm margins. There are many studies out [indicating] that the recurrence of breast cancer locally is the same if it’s a millimeter with invasive cancer or if it’s a centimeter. That has really cut down our re-excision rates; we’re using new methods and new apparatus in the operating room to tell if we need to take out more tissue. We use the margin probe, for example. By accepting a thinner margin, that has decreased our revisits to the operating room. By accepting that the survival rate doesn’t change in women who have up to 2 nodes [in terms of doing] a full dissection vs no nodes at all, we know that we don’t have to do that full dissection, which significantly increases someone’s risk of lymphedema.
Let’s talk about high-risk lesions. We know that breast cancer and fibrocystic changes are a spectrum of disease. Most fibrocystic changes don’t increase your risk of breast cancer. About 5% of fibrocystic changes are atypical, such as atypical ductal hyperplasia, atypical lobular hyperplasia, or lobular carcinoma in situ. Those changes are thought to increase someone’s risk of developing breast cancer. The American Society of Breast Surgeons, in a consensus statement [from 2016], looked at high-risk lesions [and] whether you need to take someone to the operating room to take it out. Is the risk that they’re going to actually have a breast cancer significant enough to recommend surgery?
Well, there are some atypical changes that don’t need to be taken out, for instance, atypical lobular hyperplasia. A woman, for instance, [might have] a needle biopsy of calcifications, and it shows it’s benign, and there is some atypical lobular hyperplasia or lobular carcinoma in situ. Two years ago, we would absolutely take that woman to the operating room. Now what we do is look and see if the pathology is concordant with the imaging. Concordance is really important, and we rely on that to decide whether or not we do surgery. If someone has a lesion or calcifications that are atypical lobular hyperplasia, the pathologist and the radiologists are going to speak to one another. They’re going to say, ‘Does this make sense? Does this agree with what you’re seeing?’ If it is in agreement, and [the pathology] is concordant and benign, the upgrade rate is usually less than 5%. That’s very low. If you offer up that information, the patient may say, ‘I don’t want to do surgery for that.’
What I like to do is usually order an MRI and send them to a risk specialist who will look at their risk for breast cancer and other cancers [who] may or may not do a blood test for a genetic analysis. The treatment of lobular carcinoma in situ and atypical lobular hyperplasia has changed. More and more, we are not offering surgery if the results are concordant and the woman feels comfortable with close surveillance. Close surveillance is usually mammograms when you’re supposed to get them, maybe an MRI, and also visits to a clinician who specializes in breast disease. That has changed.
Some of the other things that have also changed [is that] we have been offering more and more women systemic therapy up front to try to shrink their tumor or just to see what kind of response they have if they have a particularly aggressive cancer. That’s really important. That’s something that we’ve been doing more and more of, especially if they’re HER2 positive. About 20% of breast cancer is HER2 positive. We have monoclonal antibodies, and not only trastuzumab [Herceptin], but we have many others now. We sometimes give that up front. We’ve had wonderful results. We then take the patient to surgery afterwards.