Opinion: Breast-cancer Treatment and De-escalation of Care

By Dr. Holly Mason, section chief for Breast Surgery, Baystate Health

It was not all that long ago when all breast-cancer patients received a radical mastectomy no matter what the size of the cancer, the belief being that more surgery was better. For nearly 100 years, the radical mastectomy was the standard of care for breast cancer, and many women were left disfigured from this procedure.

Back in the 1970s and 1980s, however, new research showed that such aggressive surgery was not absolutely necessary. Those researchers were met with doubt and rebuke, but fortunately breast conservation (or breast preservation) came into the realm of acceptable treatment for breast cancer — because the research showed that it was indeed safe.

We then saw research that showed that women did not need all of the lymph nodes removed from under the arm, a procedure known as a node dissection. This procedure can result in lymphedema, a chronic swelling of the arm that can be both disfiguring and debilitating. In the late ’90s, the sentinel-node biopsy procedure was developed so that only a few nodes were removed, thereby decreasing the risk of lymphedema. Recently, research has shown that older patients with small, slow-growing tumors and normal nodes on clinical examination can safely avoid lymph-node removal altogether.

The same can be said for medical therapy for breast cancer. We have gone from the days when no medical therapy was available to the belief that almost every patient with breast cancer needed chemotherapy. Now, we can provide tailored and targeted medical therapy so that a patient can know that the recommended treatment is the correct medicine to treat her or his particular tumor.

We now have many tools in our toolbox, including endocrine/anti-hormone treatment, medication to treat the cancers that have the Her-2 growth factor, medication specific for cancer associated with the BRCA gene mutation, and more. There is even a test called molecular profiling that can help sort out the benefit of chemotherapy in addition to the benefit that is obtained from endocrine therapy so that, if chemotherapy is recommended, there is actual, specific data to support that recommendation, not just a best guess.

Even breast radiation has been modified from a six-week regimen so that many women now only need four to five weeks of radiation.

What does this all mean for a patient who is newly diagnosed with breast cancer?

It means that we can think about de-escalating care for many patients. We can optimize which treatments are recommended to provide optimal cancer benefit while balancing issues such as quality of life.

It means that we know when we can safely avoid certain procedures because there won’t be a benefit.

It means that we can avoid chemotherapy in many patients who would have previously been prescribed it.

It also means that, when chemotherapy is recommended, there is a real reason to consider it.

It means that some patients who choose a lumpectomy may be able to avoid radiation.

In a nutshell, it means there are options to be considered.

We have come a long way from where we once were, but we still have more to learn. The good news is that our understanding of breast cancer continues to make progress.

My advice to you is to work with your cancer team to understand the recommendations they give to you so that you feel comfortable that you are making the right choice for you.