Breast cancer surgeons from around the world convene every Spring for the American Society of Breast Surgeons’ Meeting to discuss the latest trends in breast cancer management. This year’s meeting was different – of course, it was virtual. But what made it stand out, even more, was the focus on patient-centered care and the de-escalation of therapy.
The keynote address was particularly compelling. As in previous years, it was given by a breast surgeon; but this year’s speaker, Dr. Liz O’Riordan, is also a breast cancer survivor. She was diagnosed with Stage III breast cancer in 2015 and had a recurrence 2 years later. Her message was loud and clear: as breast cancer surgeons, no matter how empathic and caring we may be, we have no clue what it’s really like to be a patient — to actually receive a cancer diagnosis — and have your entire life turned upside down. She asked breast cancer surgeons to promise to focus not only on improving patient outcomes but on improving the patient care experience, emphasizing that for patients, the little things really do matter. Dr. O’ Riordan challenged the audience to ensure that their team not only addresses each patient’s quality of life but empowers each patient to regain control after a cancer diagnosis. She noted how important it is for doctors to talk to their patients about the studies showing that exercise can reduce side effects such as fatigue and weight gain, improve mental health, as well as decrease the risk of recurrence.
Dr. O’Riordan also insisted that it was critical that we educate our patients about the ways chemical or surgical menopause can affect their sex lives and that we make talking about the use of dilators, water-based lubricants, and the option of topical estrogen cream routine. If you aren’t listening to your patients, she said, you are not hearing from a key part of the healthcare team.
The underlying theme of the meeting was that the time for the de-escalation of breast cancer treatment is here. Managing breast cancer during Covid advanced our understanding of the role of neoadjuvant therapy—giving chemotherapy or endocrine (anti-estrogen) therapy before surgery. Covid pushed this forward because we wanted to start our patients on treatment, but the operating rooms were not available. Eventually, when we did do surgery, we found that for many of our patients, the treatment had eradicated the tumor. As a result, studies are now looking at whether there are exceptional responders to neoadjuvant treatment who may be able to forego breast and axillary surgery altogether.
By learning more about the genetic makeup of cancer cells, researchers and clinicians have revolutionized breast cancer management. We often think of this in terms of what therapies to give, but it affects surgical decision-making as well. For example, genomic assays are helping to determine which postmenopausal patients with invasive breast cancer do not need a sentinel lymph node dissection. They are also helping us to determine which patients may forego radiation therapy after a lumpectomy.
I was most excited by the studies that showed that neoadjuvant chemotherapy in properly selected patients, including patients with HER2 positive and triple negative disease, led to improved survival. Part of the improvement in survival was due to the fact that giving treatment before surgery allowed doctors to see how the tumor was responding. Treatment could be de-escalated for those who had a full response, which portended a good prognosis. Meanwhile, additional treatment could be given to those whose tumors were not responding — improving survival in this group.
The “Best Papers of 2020” talk was given by Dr. Helen Pass, who discussed an important study published in The New England Journal of Medicine in February 2020. It showed that in HER2 positive metastatic breast cancer patients who had already tried other treatments, including those with brain metastases, adding tucatinib to a regimen of Herceptin and capecitabine improved progression-free survival and overall survival compared to Herceptin and capecitabine alone. These findings are “unprecedented” in this patient population.
Dr. Rutgers, from the Netherlands, reminded us that when it comes to treating breast cancer, doing less tends to make us uneasy. As a breast cancer surgeon and survivor myself, I fully relate to that. There is a fear of not going “all out,” even when the studies may show there is no benefit from doing so.
As the meeting concluded, I was filled with optimism. I am encouraged that through evidence-based molecular medicine we can offer patient-centered care that results in improved outcomes while reducing collateral damage. Together with researchers and clinicians worldwide, I am hopeful that we at the Dr. Susan Love Foundation can encourage patients and providers to consider de-escalation and to choose wisely. For so long, we were told to “do as much as you can”. But now science is proving that oftentimes less is more.