Has the time come for de-escalation in oncoplastic breast conserving surgery?

George Hourston, Sandeep Joglekar, Sue Down, Sarah Downey, Jerome Pereira

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Achieving safe oncological outcomes while preserving breast tissue and maintaining acceptable cosmesis is the primary objective of breast cancer treatment. One strategy to minimise the morbidity associated with breast cancer treatment has been to de-escalate oncological therapies by using targeted chemotherapy and focused radiotherapy. As advanced neo-adjuvant chemotherapeutic regimens are becoming more successful, we are able to offer more limited breast conserving surgery associated with less surgical morbidity.

Chemotherapy is currently first-line treatment for patients with larger tumours which are triple negative or HER2 (human epidermal growth factor receptor 2) positive, and these molecular characteristics are crucial in targeting and focusing our treatment. Advances in molecular analysis of patients' tumours has made this possible, for instance appropriate chemotherapy is administered according to the patient oncotype score and genomic profiling. The ongoing PRIMETIME study is also assessing whether the presence or absence of Ki67 can selectively target patients who may be able to avoid radiotherapy, reducing the burden of this treatment for those patients who would receive no benefit. Hormonal treatment too is limited to those patients whose tumours are sufficiently positive for hormone receptors under immunohistochemical analysis. Indeed the morbidity of extensive axillary surgery has been recognised; radical surgery has left patients with profound sequelae including lymphoedema, seroma and paraesthesia. It is current best practice to perform the least extensive but safe surgery in the axilla, starting with biopsy of the sentinel node and proceeding to node clearance only in the presence of confirmed disease.

Just as the combination of oncological therapies is personalised to individuals according to patient tolerance and tumour type, we should aim for the personalisation of surgical approach, relevant to tumour position and patients’ native breast characteristics such as breast size and degree of ptosis, patient choice and co-morbidities, with the aim of maximising the benefits of conservative breast surgery. We suggest that oncoplastic breast surgery is the final domain in the treatment of breast cancer which should trend towards this policy of de-escalation. We define the de-escalation of surgery as an important component of modern breast cancer treatment, which reduces surgical morbidity while achieving maximal oncological and cosmetic benefit. This is particularly relevant given that despite recent data suggesting that in early breast cancer there is a survival advantage of breast-conserving surgery with radiotherapy compared with mastectomy, there has been a paradoxical rise in mastectomy rates.

Read full article here: https://pubmed.ncbi.nlm.nih.gov/34740479/ 

Jasmine Walter

Content Editor, Mark Allen Group

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