Dr Borgen on the Need for Improved Risk Stratification in Early-Stage Breast Cancer

"We need better ways to predict comprehensive risk in early stage breast cancer. It can't be that all stage 1 and 2 [diagnoses] are good guys, they're not. Our challenge for the future is, how do we identify the higher risk subset of patients in stage 1 and stage 2 so they don't fall behind?"

Patrick I. Borgen, MD, chair of the Department of Surgery and head of the Maimonides Breast Center at Maimonides Medical Center, discusses the need for improved risk stratification in early-stage breast cancer and the challenge of identifying high-risk subsets of patients with stage I and II disease. Specifically, Borgen highlights a recent analysis published in the Journal of the National Cancer Institute by Lajos Pusztai, MD, DPhil, of Yale Cancer Center, and colleagues examining breast cancer outcomes spanning 5 decades, highlighting a critical gap in treatment advancements for early-stage patients.

Borgen explains that although breast cancer treatment has evolved significantly since the emergence of HER2-targeted therapies, novel endocrine agents, immune checkpoint inhibitors, and CDK4/6 inhibitors, these advancements have primarily benefited patients with stage III and IV disease. In contrast, treatment options for early-stage breast cancer have seen the same magnitude of progress.

In the analysis by Pusztai et al, they examined SEER database trends from 2000 to 2017, findings revealed that more than 60% of breast cancer–related deaths are accounted for by patients initially diagnosed with stage I or II disease due to higher volume. Notably, the contribution of breast cancer–related deaths for patients initially diagnosed with stage I disease increased from 16.2% to 23.1% in 2017; this rate increased from 30.7% in 200 to 39.5% in 2017 for patients with stage II disease.

Traditional staging methods assume a uniformly favorable prognosis for patients with stage I and II breast cancers; however, emerging evidence suggests significant heterogeneity within these groups, Borgen continues. Not all early-stage cancers behave indolently, and a subset exhibit aggressive biology. Identifying these high-risk patients earlier in the disease course is essential to optimizing treatment decisions, Borgen emphasizes.

Molecular profiling, genomic assays, and biomarker-driven approaches are being explored as tools to enhance risk stratification in early-stage breast cancer. Integrating these advanced diagnostics into routine clinical practice could help distinguish patients who would benefit from escalated therapy from those who may safely avoid overtreatment. Additionally, liquid biopsy techniques, artificial intelligence-driven prognostic models, and novel imaging modalities may further refine risk assessment, improving the precision of treatment selection.

As breast cancer management moves toward more personalized approaches, improving risk stratification in early-stage disease remains essential for reducing recurrence rates and improving long-term outcomes, Borgen concludes.