Q&A

On Cancer: The Future of Breast Cancer Surgery

By Media Staff  |  Friday, February 14, 2014
Monica Morrow, Chief of the Breast Surgical Service Monica Morrow, Chief of the Breast Surgical Service

At the annual San Antonio Breast Cancer Symposium in December 2013, Monica Morrow, Chief of our Breast Surgical Service, was honored with the William L. McGuire Memorial Lecture Award. In her address, Dr. Morrow discussed how surgery for breast cancer is evolving in the modern era of more-effective drug therapy. We asked Dr. Morrow to give us an overview of her lecture and to speak generally about the future of breast cancer surgery.

How is surgery used to treat breast cancer?

Surgery is usually the first treatment for breast cancer and is used to reduce the amount of cancer in the breast, known as the tumor burden, to the lowest possible level. Studies show that 75 to 80 percent of patients with small breast cancers that do not involve the lymph nodes will survive 20 years if treated with surgery alone. But surgery is not our only defense.

The last 30 years have given us a multitude of new medications — like hormone therapies and targeted drugs — that not only reduce the likelihood that cancer will return or spread to other parts of the body but also improve surgical outcomes by reducing local recurrence in the breast. In fact, the advent of effective systemic therapy has cut the likelihood of a local recurrence in half.

How is surgery for breast cancer evolving?

The combination of surgery plus systemic therapy has been very successful in reducing tumor burden, and it’s unlikely that efforts to surgically reduce tumor burden even more will improve outcomes. For example, several studies have shown that the use of MRI before surgery does not improve outcomes or reduce local recurrence, even though the expectation had been that MRI’s higher sensitivity for detecting tumors would lead to better selection of women for breast-conserving surgery. What MRI does do is increase the chances a patient will have a mastectomy, a much more burdensome operation than breast-conserving surgery but with similar outcomes.

What we need to ask now is, How can we take advantage of the benefits of drug therapy to improve our approach to breast surgery? Can we do less surgery on the breast or the underarm (axillary) lymph nodes to reduce the burden of treatment for patients while still maintaining good outcomes?

What can be done to lessen the burden of breast cancer surgery for patients?

First, there needs to be consensus on what constitutes an adequate margin [around the tumor]. Approximately 25 percent of women who undergo breast-conserving surgery return to the operating room for a reexcision because the margins around the tumor are considered too small. Repeat surgeries not only can be burdensome for patients and their families, but also can increase health risks and costs and produce worse cosmetic outcomes. Given what we now know about the use of systemic therapy and its ability to minimize the incidence of local recurrence, we need to develop guidelines on just how much breast tissue needs to be removed during breast-conserving surgery.

Earlier this week, a consensus statement jointly put together by the Society of Surgical Oncology and the American Society for Radiation Oncology stated that an adequate margin should be defined as no cancer cells touching the edge of the tissue removed; there is no clinical benefit to removing more tissue than that, and therefore no need to perform additional surgeries to obtain more widely clear margins. I hope that this statement, based on a meta-analysis of more than 30 studies, will lead to widespread adoption of this definition of a standard margin so patients can be spared the trauma of a second surgery.

Second, when possible we need to avoid axillary dissection [the removal of most of the underarm lymph nodes], which causes lymphedema, a sometimes-severe swelling of the arm. Newer research indicates that for women who undergo lumpectomy plus radiation and have only one or two positive sentinel nodes, axillary dissection offers no benefit. Many in the surgical community have questioned these results, but we accept that chemotherapy given before surgery can reduce axillary metastases, so why should the results be any different if chemotherapy is given postoperatively? At Memorial Sloan Kettering, we have verified these findings in our own prospective study and have adopted guidelines to include the selective use of axillary dissection in our clinical practice. This guideline spares approximately 85 percent of women who have a lumpectomy and whole-breast radiation from complete lymph node removal.

How do you see breast cancer surgery fitting into patients’ treatment plans in the future?

We are moving toward a more multimodality approach to treating breast cancer where local therapy, meaning surgery and radiation, and systemic therapy are considered together, rather than as three separate phases of treatment. We are also learning more about the biology of breast cancer, and future studies will need to address not only whether improvements in drug therapy will allow us to safely decrease the extent of surgery and radiation, but also how an individual patient’s biology should guide treatment decisions.

Comments

What can we do if the hospital is lacking of sentinel node ??? I have a lot of patients candidates to conservative surgery.

Sebastian, you can learn about the use of sentinel node to guide surgical decisions at Memorial Sloan Kettering at this link:

http://www.mskcc.org/cancer-care/adult/breast/surgical-options

Thank you for your comment.

Daughter diagnosed w/breast cancer (Las Vegas). No breast specialists in HMO plan. How can she best proceed?

Irene to learn about making an appointment with a Memorial Sloan Kettering physician, please call our Physician Referral Service at 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment. They can answer questions about insurance coverage as well. Thanks for your comment.

I hope they continue to make progress in fighting breast, and all other forms of, cancer.

My right. Breast was removed because they found that I have ductal carcinoma invasive,my limph nodes are clear even the doctor didn't check the sentinel.
My hormonal receptor test say: ER 80 strong positive;PR 30 strong positive and HER2 IHC 1+ negative.
I have a very strong family history of breast cancer,my mom,three sisters and three aunts.
My question could I have only hormone terapy and not the regular quimio?
My second language is English,but a will appreciated. If you can answer my question.

Ana Maria, we are not able to provide personal medical advice on our blog. If you'd like to make an appointment to speak with a Memorial Sloan Kettering doctor, you can call 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment for more information. You might also want to consider speaking to someone in our Clinical Genetics Service about your family history. You can reach them at 646-888-4050. Thank you for your comment.

I currently have stage 4 breast cancer that spread to my bones but has been stable for years. My original diagnosis was at age 34 in 1995 and although my lymph nodes were clear, the surgeon could not get clear margins after 2 lumpectomies so I had a mastectomy of my left breast. Two yrs. later in 1997 my cancer metasticized to by bones; my spine, some ribs, my right femur and my feet were main areas of disease and severe pain. My cancer has been stable for longer than any of my MSKCC doctors predicted based on facts and percentages of such a diagnosis. What is the future for someone with the current status of my situation? It is rare, I know to be stable considering that my future in 1997 was bleak. I stopped chemo with my dr's permission and understanding. I have had scans periodically with stable results. But will my cancer eventually win out and show-up again? Any precedent for me? I feel like I am in a holding pattern along with my permanent disabilities from my cancer, radiation effects, and permanent damages that came from a lot of chemotherapy. Will I eventually succumb to breast cancer? I have not seen my oncologist in years.

Dear Lois, we are sorry to hear about your diagnosis and all you've had to endure. Unfortunately, we can't answer personal medical questions on our blog. We would recommend you go back to your oncologist who can provide a more individualized assessment for you. Thank you for your comment.

Hello,
I'm 30 years old,negative for BRCA 1/2 but my mom died from breast cancer (she was diagnosed at the age of 44) and I was diagnosed with triple positive 0.8 cm (far from the nipple)high grade tumor,3 nodes were negative.
I had a lumpectomy,now I'm having ACTH treatment and I'm thinking to have a double mastectomy after chemo instead of the radiation.
What is your approach for nipple sparing mastectomy for patients who had cancer?

I would appreciate if you could respond.
THANK YOU.

Einat, to learn more about our approach to nipple-sparing mastectomy and breast reconstruction, you might find this article from "Center News" magazine useful: http://www.mskcc.org/magazine/october-2009/return-normal-collaborative-art-and-science-breast-reconstruction To make an appointment with a Memorial Sloan Kettering surgeon, you can call 800-525-2225 during regular business hours or go to http://www.mskcc.org/cancer-care/appointment for more information. Thank you for your comment.

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