• Turning Point 2014

    To Each Her Own

    By Elizabeth Dougherty

    With some women choosing a radical approach to breast cancer surgery and others opting for conservative techniques, surgeons tailor the latest methods to the medical and personal needs of each patient.

    Stella Barbosa has experienced both ends of the spectrum when it comes to surgery for breast cancer: first, a lumpectomy for a small tumor she says was the "size of a pea," and, 22 years later, a mastectomy for inflammatory breast cancer, an aggressive type of cancer that almost always requires a radical approach.

    Surgeon Mehra Golshan, MD (right), and his colleagues offer patients like Stella Barbosa (left) a plan that is best for them.Surgeon Mehra Golshan, MD (right), and his colleagues offer patients like Stella Barbosa (left) a plan that is best for them. 

    Rebecca Matchett, on the other hand, had both breasts removed after learning she had the same type of early cancer Barbosa had the first time. She'd inherited an elevated risk for breast cancer, as had her sister, and, most likely, her late mother, grandmother, and great-grandmother, and had been considering the radical procedure as a cautionary measure. "Once I was diagnosed, I said 'definitely,'" she recalls.

    While science guides the options best suited to each woman, patients themselves play a pivotal decision making role. "We're seeing trends toward less invasive types of surgery, but we're also seeing the reverse," says Mehra Golshan, MD, director of Breast Surgical Services at the Susan F. Smith Center for Women's Cancers at Dana-Farber.

    As a result, the breast cancer team at the Susan F. Smith Center is advancing surgery on both fronts. They have expertise in performing mastectomies that preserve as much of the breast shell as possible and allow for the most realistic reconstruction. At the same time, the group has several clinical trials underway to determine the least invasive approach for certain patients.

    The goal is to individualize treatment, a familiar theme among medical oncologists who match patients to appropriate drug regimens, but equally important in the surgical arena.

    When Less Is More

    In 2010, a clinical trial in the U.S. and Canada changed the practice of lymph node removal in breast cancer surgery. The trial included women with early stage breast cancer undergoing lumpectomy and radiation therapy. The results showed that axillary lymph node dissection (removal of lymph nodes in the underarm and nodes just above them) is unnecessary even when sentinel lymph nodes (those closest to the breast) have cancer cells in them.

    Laura Dominici, MD (left), Samantha Morrison-Ma, ANP-C (center), and Faina Nakhlis, MD (right), offer innovative approaches to women with a wide range of breast cancers and personal preferences.Laura Dominici, MD (left), Samantha Morrison-Ma, ANP-C (center), and Faina Nakhlis, MD (right), offer innovative approaches to women with a wide range of breast cancers and personal preferences. 

    By skipping the additional surgery, the risk of permanent arm swelling, seen in 15 to 20 percent of women who go through axillary lymph node dissection, is reduced without significantly increasing the risk of recurrence. "We learned that less is more," says breast surgeon Faina Nakhlis, MD. "The benefit to patients has been very obvious."

    For Dr. Nakhlis, who was a trainee while this trial was underway, the findings were career-shaping. Her research revolves around identifying interventions that may be excessive. "Clinical evidence has helped physicians tailor their recommendations to each individual," says Dr. Nakhlis.

    For instance, in patients with lobular neoplasia (precancerous breast lesions), experts disagree on the need for a follow-up surgical biopsy in addition to the needle biopsy used for diagnosis. While relatively minor, this surgery requires anesthesia and leaves a scar.

    So, Dr. Nakhlis launched a study to determine how often the additional procedure uncovers cancer. While the findings are not yet published, early results suggest the rate of cancer detection is very low. "We hope to provide quality data to surgeons, so they can be armed with evidence in favor of sparing their patients unnecessary surgery," she says.

    Another early stage cancer that may be overtreated is ductal carcinoma in situ (DCIS), a noninvasive breast cancer confined to the milk ducts – the type of cancer Matchett had, and Barbosa had the first time. Treatment for DCIS has historically been lumpectomy and radiation, or mastectomy.

    Dr. Golshan is the local leader of a national trial looking to determine if a more minimally invasive approach is possible, offering women with estrogen receptor-positive DCIS six months of therapy with an aromatase inhibitor to shrink the tumor, followed by surgery. This medication blocks estrogen, which can cause cancer cells to grow. "We may end up removing less tissue and leaving patients with a better cosmetic result," Dr. Golshan says.

    When More Is More

    For women who choose mastectomy and reconstruction, Dr. Golshan and his colleagues use a one-step procedure whenever possible. Women go in for their mastectomy and wake up with fully reconstructed breasts. Matchett chose to travel to Boston from New York City to have Dr. Golshan perform her surgery, in part for this reason. "I wanted to get it over with in one surgery," says Matchett, who recovered in just six weeks. "The scarring is so small, when I look in the mirror, I don't notice it."

    In some cases, surgery is rarely recommended – for example, in women with stage IV breast cancer, in which the cancer has invaded other parts of the body. However, recent evidence suggests removing the primary breast tumor might improve outcomes by eliminating the source of spreading cancer cells.

    Dr. Golshan is helping lead a trial that will compare the outcomes of women who undergo surgery with those who don't. "Hopefully there will be a subset of women who potentially can have their tumor removed and improve their survival," says Dr. Golshan, who will be looking for indicators, called biomarkers, that can identify women for whom surgery is a good option.

    With a two-pronged approach to breast surgery – to be as minimal as possible for women undergoing a breast conserving approach, and as comprehensive as possible for women who choose mastectomy – most studies have focused on cancer outcomes and safety, not quality of life. This study is especially important as evidence mounts from many cancer centers that nipple-sparing mastectomy is safe for an increasingly wide patient population, including some patients with more advanced disease.

    So, while the cosmetic results of nipple-sparing mastectomy are considered to be quite good, very little is known about how patients feel about their appearance. To explore the area more, Laura Dominici, MD, a breast surgical oncologist, launched a study to survey women before and after the procedure to see how they feel about the changes in their bodies.

    She plans to expand her studies to find out how women feel after a lumpectomy or radiation. She is also focusing on women who test positive for a BRCA mutation and have elective surgery to manage their inherited risk of breast cancer. "We'll soon have a much larger panel of research looking at quality of life and patient satisfaction in breast cancer surgery," Dr. Dominici says.

    Drugs First, Surgery Second

    Neoadjuvant therapy, which is also called up-front therapy because patients are treated with drugs ahead of surgery, got its start decades ago, when doctors realized that surgery alone did not always prevent cancer from coming back. Later, around 2000, a national clinical trial showed that up-front therapy didn’t lead to better long-term results, but it did mean that a woman who might have needed a mastectomy could instead have a lumpectomy.

    Digging deeper into the trial data, however, researchers noticed that women whose tumors disappeared in response to up-front therapy fared better than women who had cancer remaining in the breast at the time of surgery. "This suggested that up-front therapy could be used to evaluate new agents, and help predict if these agents would be effective in large trials," says Harold Burstein, MD, PhD.

    As a result, clinical researchers have capitalized on this approach and designed multiple trials using up-front therapy. The hope is that responses to this therapy – whether the drugs are conventional or experimental – will help guide the next steps more precisely.

    "The beauty of the neoadjuvant model is that the tumor is there for sampling," says Dr. Burstein. "We’d like to begin to use the information that the tumor holds to direct the next steps of patient care. That’s the next big challenge."

    Turning Point 2014 Table of Contents 

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