All recent trials in early breast cancer have been focusing on doing as minimal surgery as possible both for the primary and for the axilla prioritising cosmetic outcomes and quality of life. This article elaborates on the findings in these trials and research published in the last 5 years in support of this.

When Indian scientists launched the satellite to the moon there where many pessimists who said that a country in which a significant number of people do not have access to basic healthcare, sanitation, and education should not be indulging in such luxuries. The same dilemma is also faced by oncologists in treating breast cancer.

Cost, time of treatment, and access to hospitals govern breast cancer treatments for majority of patients in India as compared to the West where quality of life, cosmesis determine the treatment. This is changing rapidly as is evidenced by the increasing number of breast conservation surgeries being performed in India every year. There are a good number of breast cancer patients now in India who, like female patients in the West, are bothered about the quality of life and cosmesis rather than just survival from the cancer. This makes it imperative for Indian doctors to know the latest developments in breast cancer.

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When William Halstead enunciated the principles of breast cancer treatment in the late 19th century he believed breast cancer to be a local disease which spread contiguously and was to be treated as radically as possible to prevent recurrence. The severe disability caused by radical mastectomy, was in Halstead’s own words a small price to pay for the life of the patient.

Breast cancer surgery has evolved many fold from the Halstead time. Dr Bernard Fisher with his extensive research concluded that outcomes of breast cancer depended on the biologic principles rather than anatomic. This meant that breast cancer was a systemic disease and even small tumours can metastasize. This raised doubts on the utility of the radical surgery proposed by Halstead and brought in the era of minimalistic surgery combined with systemic therapy.

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Axillary radiation for patients with positive sentinel node

The benefit of sentinel node biopsy has been established for quite some time now. For patients who have positive sentinel node, axillary dissection was considered standard option. The AMAROS trial published in 2013 concluded that for patients with positive sentinel node if axillary radiation was offered instead of lymph node dissection there was less chances of lymphedema of the hand.

The same trial followed up the randomised patients and published the 10 year survival results in 2018. The locoregional control, distant metastases free survival and overall survival were all not significantly different in the two groups. With less lymphedema in the axillary radiotherapy arm this will have to be considered as standard procedure for patients with positive sentinel node.

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Ideal lumpectomy margins margins in breast conservation surgery

There has been considerable debate regarding optimal margins for breast conservation surgery. If the margins are positive then the chances of recurrence are high and patients are usually advised reexcision. Unnecessary large margins lead to poor cosmetic outcomes.

Further conclusions of the study were that the margins need not be larger for a triple negative tumour. It also states that adjuvant radiation or chemotherapy should not be dictated by close margins so long as it is free.

The traditional thinking in breast conservation surgery was that more the margins better the local control. This trial has challenged this thinking. With the publication of this trial the aim of the surgeon should be to give the minimal negative margin. At the same time the trial confirms that positive margin is not acceptable.

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Targeted axillary dissection (TAD): A new technique for axillary lymph node evaluation post neoadjuvant chemotherapy

In patients with breast cancer with positive axillary nodes the standard treatment after neoadjuvant chemotherapy is to perform axillary dissection. This is because it is difficult to predict the response of the axillary lymph nodes to neoadjuvant chemotherapy. In many studies as many as 40 to 70 percent of patients turn lymph node negative following chemotherapy thus questioning the need to do axillary dissection in these patients.

A new type of surgery known as targeted axillary lymph node (TAD) dissection is being tried in university of Texas, MD Anderson Centre in which fewer lymph nodes are removed in patients who were lymph node positive, following neoadjuvant chemotherapy.

In this study patients who had biopsy proven axillary node metastases were chosen and a clip was placed in the positive node. The patient then underwent neoadjuvant chemotherapy. About 1-5 days prior to the surgery a radioiodine seed was placed within the previously clipped node. At the time of surgery along with the sentinel node this clipped node was removed.

The results showed that the false negative rate for sentinel node biopsy alone was 10.1% that for TAD surgery was 4.2%. Though the sample size was small and the patients were not randomised, TAD has the potential for avoiding axillary dissection in as many as 40% of the patients.

The traditional treatment for locally advanced breast cancer with axillary metastases was to do a complete axillary dissection. Doing sentinel node in locally advanced breast cancer post chemotherapy has been a controversial topic. This novel method of surgery offers an alternative. It however, still has to stand the test of randomised control trial before it is fully accepted in clinical practice.

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Factors linked to risk of invasive breast cancer recurrence after DCIS

With the increase in females undergoing screening mammograms there has been a high increase in the number of patients diagnosed with DCIS (Ductal carcinoma in situ). Currently, the treatment recommendation is to treat all patients with DCIS, with surgery and radiation. There has however always been a question as to whether all DCIS patients require this treatment.

Is there a role for less aggressive treatment in some of the patients with DCIS?

In an attempt to study which factors are associated with higher risk of invasive cancer in patients diagnosed with DCIS, researchers analysed the results of 17 studies published between 1970 and 2018 looking at the risk of invasive breast cancer coming back in the same breast after a diagnosis of DCIS.

Out of the 26 factors which they studied 6 were found to be statistically significant:

• Positive margins
• Being premenopausal
• Being African-American
• DCIS found by a doctor’s examination
• High grade DCIS
• High p16 levels

Identification of these factors helps us with better understanding of DCIS so that in the future, treatment for DCIS can be personalised.

This meta-analysis is an attempt to define which factors are important in deciding treatment of DCIS. This is very important because of the huge number of DCIS which are now diagnosed based on screening mammograms. Many oncologists feel that we are over treating DCIS and quite a few of them are actually harmless . If further randomised trials are designed based on these factors we might have an answer in the future as to which DCIS can be observed and which need treatment.

In addition to this, FDA has put up a warning that safety of robotic mastectomies is yet to be established.

These are some of the trials published in the last few years with regards to surgery for breast cancer. As we see the trend is clearly towards performing as minimal surgery as possible for both the primary and the axilla. At the same time new challenges have emerged in terms of genetic testing and screening-detected abnormalities. Prophylactic mastectomies have more than tripled in the last decade. New studies will be needed for these patients to assess the need and extent of surgery.

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This article is part of a early breast cancer management series. To read the other articles, click below.

Early breast cancer (EBC)- Personalise approach using predictive and prognostic factors: Dr. Vishwanath S

Imaging modalities for Stage 0 and Stage 1 breast cancer: Dr. Govindarajan MJ

'Radiotherapy in breast cancer: How much is too much?'- Dr. Bindu Venugopal

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Anil Kamath is Senior Consultant Surgical Oncologist at Apollo Hospital, Bengaluru. Dr Kamath has many publications and book chapters to his credit and is also a member of many national and international oncology associations.