Newman Discusses De-escalating Breast Cancer Surgery

Lisa A. Newman, MD

In an effort to minimize the extent of surgery, targeted axillary dissection is being explored following surgery in patients with node-positive breast cancer—an exciting precision medicine approach for this population, said Lisa A. Newman, MD.

“Full axillary lymph node dissection is an operation that has potential lifelong sequela,” explained Newman. “Every opportunity that we can identify alternatives to full axillary lymph node dissection that are safe and control the cancer with lesser extent of surgery is a surgical advance.”

OncLive: You spoke on targeted axillary surgery for patients with breast cancer. What is important to highlight here?

In an interview during the 2018 OncLive^® State of the Science Summit™ on Breast Cancer, Newman, director of the Breast Oncology Program at Henry Ford Cancer Institute, discussed de-escalation strategies emerging in breast cancer surgery.Newman: We are in an era where everybody talks about precision medicine. Precision medicine is very exciting with targeted therapies. We often get into a conversation about de-escalating therapy. One of the main promises of precision medicine is trying to narrow down the treatment patients need, so that they get the targeted treatment for their specific type of breast cancer with less toxicity. Targeted therapy and de-escalating therapy is very important in medical oncology. We're also trying to de-escalate therapy when it comes to local regional management of breast cancer.

I gave an overview of how we're trying to de-escalate the axillary surgery needs of our patients. We are looking at novel ways of de-escalating axillary surgery in conjunction with neoadjuvant chemotherapy.

One of the ways that we can narrow down the extent of axillary surgery that a patient needs after neoadjuvant chemotherapy is with targeted axillary dissection. This is an enhanced way of doing a sentinel lymph node biopsy. Many patients who receive neoadjuvant chemotherapy are receiving it because they’ve already been found to have node-positive disease, which is metastatic disease in the axilla. This has been diagnosed by a core needle biopsy at the time of the patient's diagnosis.

In the past, all of those patients were routinely recommended to undergo a full axillary lymph node dissection, which has a lot of long-term adverse events (AEs), most notably lymphedema. After targeted axillary dissection and chemotherapy, we are able to perform a sentinel lymph node biopsy using blue dye and a radiotracer. We also perform some type of radiographic evaluation of the resected lymph node tissue to make sure that the originally biopsied metastatic lymph node has also been excised.

Is this a widespread approach?

There are a lot of different strategies for performing targeted axillary dissection. We covered different strategies to avoid patients having to undergo the full axillary lymph node dissection. There are some ongoing hurdles in making targeted axillary lymph node dissection widely available across all of the healthcare facilities in the United States and beyond. It is necessary for more surgical care providers in the breast cancer arena to become familiar with the technology.

It's also important for our breast imaging colleagues to become familiar with this technology. Once a patient is diagnosed with breast cancer, [they may undergo] an axillary ultrasound to evaluate the lymph nodes of the underarm. If they see an abnormal lymph node and that lymph node is biopsied showing cancer, it's essential that the radiologist insert some type of radiopaque clip in that lymph node. This is so that the lymph node can be identified after chemotherapy has been delivered at the time of the targeted dissection.

Are there other scenarios in which targeted axillary dissection may be useful?

It’s extremely necessary for the surgeon and the breast imagers to work in partnership in order to improve access to this advance in surgical management. Yes. One of the newest frontiers in de-escalating local regional management of breast cancer is in women who have residual disease in the axilla after they have received neoadjuvant chemotherapy. We are trying to determine whether or not these patients consistently need to have a full axillary lymph node dissection, or if some of these patients can be managed with radiation to the nodal basins.

What are the quality-of-life differences between axillary surgery and targeted axillary surgery?

There is a very exciting clinical trial that is being conducted by the Alliance Cooperative Group. Patients who are found to have residual disease in the axilla by sentinel lymph node biopsy after neoadjuvant chemotherapy are randomized to axillary lymph node dissection. This is followed by regional radiation or radiation therapy. This will be a very important trial designed to determine whether or not we can replace the axillary lymph node dissection with radiation therapy. It's extremely important that we identify as many accurate and safe strategies as possible to avoid standard, anatomically designed axillary lymph node dissection. Axillary lymph node dissection is one of the oldest components of surgical management of breast cancer, but it carries the burden of many unwanted AEs. The most significant or the most commonly cited AE is the lifelong risk of lymphedema, which has been quoted as occurring in 10% to 50% of patients with breast cancer after axillary lymph node dissection.

Are there other de-escalating strategies?

How have you seen surgery evolve over the years?

Women will also often have an uncomfortable sense of shoulder disability. They can have stiffness at the shoulder.We are starting to explore opportunities for de-escalating the extent of breast surgery that is necessary in women who receive neoadjuvant chemotherapy. There are ongoing trials looking at whether or not there are some women who can completely avoid breast surgery if we can accurately identify those women whose cancer has been completely melted away or sterilized by the neoadjuvant chemotherapy.Surgery is constantly evolving for the better in patients with breast cancer. On the one hand, we have many women who are opting for prophylactic bilateral mastectomy. This is either because they have hereditary susceptibility and no breast cancer at all, or they have early-stage disease but are interested in bilateral mastectomy to reduce their chances of repeating their experience in the future.

For those women, we have wonderful advances in breast reconstruction. Often, these patients can have nipple sparing mastectomy with immediate breast reconstruction. On one end of the spectrum, we have wonderful advances in what we can offer the women who choose to have mastectomy surgery.

At the other end of the spectrum, for those women who have been diagnosed, we have very exciting strategies to try to minimize the extent of their surgical needs to improve their eligibility for lumpectomy and breast-conserving surgery.