Individualized Approach Enables De-escalation of Breast Cancer Treatment: A Clinical Case History

MSK breast cancer patient Elizabeth Shelley

Advances in our understanding of the biology of breast cancer are guiding the development of individualized treatment plans, aiming to provide each patient with the best chance for a cure while optimizing their quality of life. The ideal approach can mean less treatment in some patients.

In the case of Elizabeth Shelley, a young woman with breast cancer, we determined that a nipple-sparing mastectomy followed by tamoxifen (Nolvadex®, Soltamox®) would provide her with the best treatment for her cancer, without chemotherapy and while minimizing potential side effects. Additionally, she benefited from fertility-preservation options before starting tamoxifen therapy.

The Diagnosis

In late 2014, Ms. Shelley, a 30-year-old woman, felt a lump in one of her breasts. In early 2015, she saw the staff doctor at her work site, who examined the lump and gave her a prescription for a mammogram. The imaging was done at a well-known healthcare facility. Ms. Shelley had the mammogram on April 24. A biopsy of the breast lump was performed on April 28. On May 1, the healthcare facility’s physician confirmed that the lump was breast cancer. At the same time Ms. Shelley was told that her only option was chemotherapy, and the physician advised her to begin treatment immediately.

The breast cancer diagnosis came out of the blue: Ms. Shelley had recently started a new job, she was preparing for final exams in a graduate school program, and she was training for a triathlon. She had no family history of breast cancer. Rather than start chemotherapy right away, Ms. Shelley decided to learn more about her cancer and investigate other treatment options.

She came to Memorial Sloan Kettering Cancer Center (MSK) for a second opinion. We pooled our breast surgical oncology, medical oncology, and reconstructive surgical expertise and developed the best possible treatment plan for her.

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Nipple-Sparing Mastectomy

Ms. Shelley’s cancer was at an early stage, so we determined that the best approach was not to have chemotherapy right away. She was an ideal candidate for a nipple-sparing mastectomy (NSM) as her tumor was not located near the nipple-areola complex. MSK surgeons pioneered NSM and have been performing the technique since 2000. (1) A 13-year review (2000 and 2013) of 728 NSMs in 413 MSK patients, published in Gland Surgery last year, showed (at median follow-up of 49 months) there were no known cases of local recurrence and only one case of regional recurrence. Immediate breast reconstruction was performed in 409 patients, most of whom underwent tissue expander/implant-based procedures (n=401). (2)

During the past two years, MSK has performed close to 200 NSMs.

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De-escalating Chemotherapy

Following NSM surgery, we tested Ms. Shelley’s tumor with the Oncotype DX genomic test and determined that she could forgo chemotherapy. Oncotype DX measures 21 genes — 16 cancer-related genes and five reference genes — and calculates a recurrence score (RS) that predicts the likelihood of distant recurrence and the benefit of chemotherapy for early-stage, estrogen receptor-positive, HER2 breast cancer. The RS ranges from 0 to 100, and patients are stratified as at a low, intermediate, or high risk of recurrence depending on the value.

Ms. Shelley’s score was under 18, in the low-risk category. Evidence shows that overall, patients with low scores do not benefit from chemotherapy. Therefore, we determined that the benefits of chemotherapy did not outweigh the risks in her case and that tamoxifen alone was the appropriate treatment for her cancer.

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Breast Reconstruction after NSM

The NSM left most of the skin over Ms. Shelley’s breast intact, including the nipple and areola, creating a covering for breast reconstruction. Ms. Shelley had consulted with our breast reconstruction team ahead of her mastectomy to better understand the process and knew what to expect. The first stage of her reconstructive surgery took place on the same day that she had her mastectomy. Her final reconstructive surgery took place in October 2015.

Our research has found that patients report higher psychosocial and sexual well-being following NSM compared with skin-sparing mastectomy and nipple reconstruction. By discussing the health-related quality-of-life outcomes with patients before surgery, we empower them. Including them in the decision-making process ensures that patients have realistic postoperative expectations. (3)

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Fertility Preservation

Given her young age and her desire to maintain her ability to have children in the future, Ms. Shelley received fertility counseling at MSK. We connected her with an appropriate external reproductive endocrinologist, and her eggs were harvested within a month of her NSM.

MSK has established a fertility preservation program within its Cancer Survivorship Initiative to provide information and resources to clinicians to help them initiate discussions with patients about fertility preservation.

Our research shows that an early referral by the breast surgical oncologist at the time of the initial visit helps patients increase their knowledge about their fertility preservation options while preventing delay in the initiation of systemic therapy. (4)

After her eggs were banked, Ms. Shelley started taking tamoxifen daily at the standard dose. This regimen will continue for ten years. This regimen is now standard of care, with ASCO recommending the change from five years in 2104.

She returns to MSK every six months for follow-up checkups with a medical oncologist. To date, Ms. Shelley’s cancer has not returned.

At MSK, we understand that every patient is unique, and therefore, a team approach is important in individualizing their cancer treatment based on the latest science and technology.

Watch this short film to see how we collaborated to provide Ms. Shelley with a treatment plan designed for her and helped her get her life back.

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  1. Garcia-Etienne CA, Cody HS III, Disa JJ, et al. Nipple-sparing mastectomy: initial experience at the Memorial Sloan Kettering Cancer Center and a comprehensive review of literature. Breast J. 2009 Jul-Aug; 15(4):440-9.

  2. Manning AT, Sacchini VS. Conservative mastectomies for breast cancer and risk-reducing surgery: The Memorial Sloan Kettering Cancer Center experience. Gland Surg. 2016;5(1):55-62.

  3. Wei CH, Scott AM, Price AN, et al. Psychosocial and Sexual Well-Being Following Nipple-Sparing Mastectomy and Reconstruction. Breast J. 2016;22(1):10-17.

  4. Goldfarb SB, Kamer SA, Oppong BA, et al. Fertility Preservation in the Young Breast Cancer Patient. Ann Surg Oncol. 2016;23(5):1530-1536.