Minimalism is a term most often used to describe architecture or interior design, but “less is more” can be readily applied to recent trends in surgery for breast cancer.
Developments in patient care in the late 1800s, such as the introduction of ether for anesthesia and antisepsis for prevention of infection, led to the establishment of the radical mastectomy as the gold standard of breast cancer treatment. This procedure included complete removal of the breast tissue, underlying chest wall muscle, and the lymph nodes in the armpit in one large piece. It was a very disfiguring and disabling surgery, and most women still ultimately died from recurrent cancer. The thought was that breast cancer spread in a “stepwise” fashion from the breast to surrounding tissues, then to the lymph nodes, before spreading to the rest of the body. In the 20th century, scientific advances led to the understanding that breast cancer is a systemic disease and that surgery alone is unlikely to cure most cancers. For that reason, adjunctive modalities such as chemotherapy, hormonal medications, and radiation are now typically included in treatment plans.
De-escalation, as it applies to breast cancer surgery, refers to the adoption of less intensive and less invasive treatment options in order to minimize complications and improve quality of life while maintaining oncologic outcomes. Surgical procedures evolved from radical mastectomy to simple mastectomy and then to lumpectomy (removal of only the cancer with a small margin of the surrounding breast tissue — thereby preserving the breast). Oncoplastic approaches combine the idea of cancer removal (onco-) with reshaping or reconstructing (-plastic) the breast in order to maintain or improve the appearance of the breast. In patients with larger masses, chemotherapy or hormonal therapy may be used prior to surgery (neoadjuvant) in order to make breast conservation more feasible.
The extent of axillary surgery has also seen significant improvements over the past 25 to 30 years. Lymph nodes under the arm (axilla) are usually the first place cancer cells travel when they metastasize. Surgical procedures, therefore, traditionally included removal of these lymph nodes. Once researchers confirmed the systemic nature of breast cancer, the axillary nodes were still removed in order to determine the stage of breast cancer, which would, in turn, guide treatment recommendations. Normal nodes were taken out in addition to any cancerous ones, and this extirpation resulted in complications with a significant impact on quality of life. The sentinel node technique, developed in the mid-1990s, involved a tracer that is injected into the breast tissue and gets taken up into the lymphatic channels just as cancer cells would. This allowed surgeons to identify the first few nodes that filter the tracer, which in turn would be the first sites of spread for breast cancer cells. In this manner, it became possible to determine the stage of disease with a much less invasive procedure. This became the new standard of care for early-stage breast cancer treatment. At first, the finding of cancer in any of the sentinel nodes meant moving ahead with more complete lymph node removal. Now, radiation can be used in lieu of full axillary dissection in many of these patients. Some studies have even been published in support of omitting axillary surgery altogether in selected older patients with small, favorable, early-stage cancers.
Hormonal therapy can also allow for the de-escalation of surgery in selected patients. Normal breast cells have proteins on the surface called receptors that bind to estrogen and/or progesterone (female sex hormones). The hormone binds to the receptor and causes changes inside the cell that can stimulate growth. In some cancers, these receptors are expressed on the surface of the cancer cells as well, and hormone-blocking medications can be used to inhibit growth. This strategy is most often used after breast surgery to lower the risk of breast cancer recurring elsewhere in the body. Instead, primary endocrine therapy (PET) offers a nonsurgical option in patients who are not good candidates for surgery due to multiple medical comorbidities or with limited life expectancy. This approach can also be used as a temporary measure in patients whose surgery may be delayed due to the need to address other medical problems that could prevent timely surgical intervention. Over time, cancers can develop resistance to these medications, so hormonal therapy is not generally used for long-term control of tumors without surgical intervention.
Two treatment concepts are on the horizon that may allow for the complete omission of surgery. First, studies are underway to investigate the safety of using cryoablation to destroy cancers by freezing them. This procedure is performed by inserting a thin probe through the skin into the mass. The probe is then cooled using liquid nitrogen or argon gas to form an “ice ball” around the cancer. The cancer cells are killed, and the dead tissue fragments are absorbed by the body over time. Second, another line of study involves patients who are treated with neoadjuvant (upfront) chemotherapy and have follow-up scans suggesting a complete eradication of the cancer. In these excellent responders, researchers are assessing surgical intervention versus active surveillance. Both of these concepts are still under investigation and are not being used outside of the research setting, but they are an exciting glimpse of what the future may hold.
The goal of breast cancer surgery is to remove the tumor and find out if it has spread to lymph nodes while trying to preserve the breast appearance and the patient's quality of life. Each individual cancer is incredibly unique, and the optimal treatment plan must therefore be tailored, or personalized, based on the particular features of the cancer as well as the patient’s condition and wishes. This requires a team-based strategy to consider the full spectrum of care through diagnosis, treatment, and survivorship. A multidisciplinary approach is the cornerstone of modern breast cancer care. Although “less may be more” in terms of surgical operations for breast cancer, “more is more” when it comes to the crafting of a coordinated and personalized plan of care.
Learn more about breast surgery at Northside.
