De-escalation towards omission is the tipping point of individualizing breast cancer surgery

Patient Interest in Exploring Nonsurgical Treatment Approaches for Early-Stage Breast Cancer: A Qualitative Study

PURPOSE

Advances in radiation therapy have enabled the ability to deliver ablative treatments, but there has been limited application of these treatments to early-stage breast cancers with a goal of omitting surgery. The purpose of this study was to explore patient interest in pursuing nonsurgical treatment approaches for their early-stage breast cancer.

METHODS AND MATERIALS

We conducted a qualitative study involving interviews with 21 patients with early-stage breast cancer who were eligible for participation in a phase 2 clinical trial offering omission of definitive surgery. Interviews were transcribed and an inductive, thematic analysis was performed by 3 independent reviewers to generate themes and subthemes.

RESULTS

Data analysis revealed the following factors that affected patient willingness and desire to explore nonsurgical treatment options: (1) perceptions and feelings about their cancer; (2) current quality of life and the level of support available in their daily life; (3) external conversations focusing on family members' and friends' experiences with cancer and/or cancer treatments; (4) personal health care experiences, including their current breast cancer diagnosis; (5) perceptions and feelings about their physicians; (6) conversations with their physicians about their treatment options; and (7) self-identified desire to direct care decisions. Specifically, patients verbalized fearing surgery and surgical recovery; wanting to preserve their breast(s); the prior negative surgical experiences of friends, family, and themselves; a desire to receive treatment per the latest research; wanting to match the level of treatment with the severity of their cancer; and other comorbidities as reasons for wanting to explore omitting surgery.

CONCLUSIONS

Our findings demonstrate an unmet need directed by patient interest to explore nonsurgical options for early-stage, biologically favorable breast cancer. These results may shape conversations around shared decision-making and clinical trial design, and result in more personalized treatment options for women with early-stage breast cancer.

Cryoablation Allows the Ultimate De-escalation of Surgical Therapy for Select Breast Cancer Patients

BACKGROUND

Widespread use of screening mammography has allowed breast cancer to be detected at earlier stages. This allows for increased customization of treatment and less aggressive management. De-escalation of therapy plays an important role in decreasing treatment burden and improving patient quality of life. This report examines cryoablation as the next step in the surgical de-escalation of breast cancer.

METHODS

Women with a diagnosis of clinically node-negative, estrogen receptor-positive (ER +), progesterone receptor-positive (PR +), human epidermal growth factor receptor 2-negative (HER2 -) infiltrating ductal carcinomas 1.5 cm or smaller underwent ultrasound-guided cryoablation. Either the Visica 2 treatment system (before 2020) or the ProSense treatment system (since 2020) was used to perform the cryoablation. Patients received mammograms and ultrasounds at a 6 months follow-up visit, and magnetic resonance images at baseline, then at 1 year follow-up intervals. Adjuvant therapy decisions and disease status were recorded.

RESULTS

This study enrolled 32 patients who underwent 33 cryoablation procedures (1 patient had bilateral cancer). One patient had a sentinel node biopsy in addition to clinical staging of the axilla. For all the patients, adjuvant endocrine therapy was recommended, and six patients (18.75%) received adjuvant radiation. Of the 32 patients, 20 (60.6%) have been followed up for 2 years or longer, with no residual or recurrent disease at the site of ablation.

CONCLUSION

Cryoablation of the primary tumor foregoing sentinel node biopsy offers an oncologically safe and feasible minimally invasive office-based procedure option in lieu of surgery for patients with early-stage, low-risk breast cancer.

Artificial intelligence to de-escalate loco-regional breast cancer treatment

In this review, we evaluate the potential and recent advancements in using artificial intelligence techniques to de-escalate loco-regional breast cancer therapy, with a special focus on surgical treatment after neoadjuvant systemic treatment (NAST). The increasing use and efficacy of NAST make the optimal loco-regional management of patients with pathologic complete response (pCR) a clinically relevant knowledge gap. It is hypothesized that patients with pCR do not benefit from therapeutic surgery because all tumor has already been eradicated by NAST. It is unclear, however, how residual cancer after NAST can be reliably excluded prior to surgery to identify patients eligible for omitting breast cancer surgery. Evidence from clinical trials evaluating the potential of imaging and minimally-invasive biopsies to exclude residual cancer suggests that there is a high risk of missing residual cancer. More recently, AI-based algorithms have shown promising results to reliably exclude residual cancer after NAST. This example illustrates the great potential of AI-based algorithms to further de-escalate and individualize loco-regional breast cancer treatment.

Breast and axillary surgery after neoadjuvant systemic treatment - A review of clinical routine recommendations and the latest clinical research

Breast and axillary surgery after neoadjuvant systemic treatment for women with breast cancer has undergone multiple paradigm changes within the past years. In this review, we provide a state-of-the-art overview of breast and axillary surgery after neoadjuvant systemic treatment from both, a clinical routine perspective and a clinical research perspective. For axillary disease, axillary lymph node dissection, sentinel lymph node biopsy, or targeted axillary dissection are nowadays recommended depending on the lymph node status before and after neoadjuvant systemic treatment. For the primary tumor in the breast, breast conserving surgery remains the standard of care. The clinical management of exceptional responders to neoadjuvant systemic treatment is a pressing knowledge gap due to the increasing number of patients who achieve a pathologic complete response to neoadjuvant systemic treatment and for whom surgery may have no therapeutic benefit. Current clinical research evaluates whether less invasive procedures can exclude residual cancer after neoadjuvant systemic treatment as reliably as surgery to possibly omit surgery for those patients in the future.

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Breast and axillary surgery after neoadjuvant systemic treatment has evolved.

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Choice of axillary surgery depends on lymph node status before and after treatment.

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Optimal management of exceptional responders to neoadjuvant treatment is unclear.

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Clinical research aims to reliably exclude residual cancer without surgery.

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For exceptional responders, breast cancer surgery may be omitted in the future.

Vacuum-Assisted Breast Biopsy After Neoadjuvant Systemic Treatment for Reliable Exclusion of Residual Cancer in Breast Cancer Patients

Background

About 40 % of women with breast cancer achieve a pathologic complete response in the breast after neoadjuvant systemic treatment (NST). To identify these women, vacuum-assisted biopsy (VAB) was evaluated to facilitate risk-adaptive surgery. In confirmatory trials, the rates of missed residual cancer [false-negative rates (FNRs)] were unacceptably high (> 10%). This analysis aimed to improve the ability of VAB to exclude residual cancer in the breast reliably by identifying key characteristics of false-negative cases.

Methods

Uni- and multivariable logistic regressions were performed using data of a prospective multicenter trial (n = 398) to identify patient and VAB characteristics associated with false-negative cases (no residual cancer in the VAB but in the surgical specimen). Based on these findings FNR was exploratively re-calculated.

Results

In the multivariable analysis, a false-negative VAB result was significantly associated with accompanying ductal carcinoma in situ (DCIS) in the initial diagnostic biopsy [odds ratio (OR), 3.94; p < 0.001], multicentric disease on imaging before NST (OR, 2.74; p = 0.066), and age (OR, 1.03; p = 0.034). Exclusion of women with DCIS or multicentric disease (n = 114) and classication of VABs that did not remove the clip marker as uncertain representative VABs decreased the FNR to 2.9% (3/104).

Conclusion

For patients without accompanying DCIS or multicentric disease, performing a distinct representative VAB (i.e., removing a well-placed clip marker) after NST suggests that VAB might reliably exclude residual cancer in the breast without surgery. This evidence will inform the design of future trials evaluating risk-adaptive surgery for exceptional responders to NST.

A qualitative study to evaluate physician attitudes regarding omission of surgery among exceptional responders to neoadjuvant systemic therapy for breast cancer (NRG-CC006)

PURPOSE

Accrual to clinical trials that challenge well-established treatment paradigms represents a unique challenge. Physician opinions on investigation of a novel approach to breast cancer treatment, in which patients with complete response to neoadjuvant chemotherapy are offered omission of lumpectomy, are unknown. NRG-CC006 sought to describe physician attitudes toward a novel approach to breast cancer treatment.

METHODS

We recruited 18 participants in the fields of surgery, medical oncology, and radiation oncology to participate in the semi-structured telephone interviews. Main outcomes are qualitative themes associated with omission of surgery.

RESULTS

Of 18 interview participants, specialty and gender were evenly represented across surgery, medical oncology, and radiation oncology. Qualitative themes included general attitudes toward treatment de-escalation, stakeholder considerations, and trial/protocol considerations. The vast majority of participants expressed interest in investigation of omission of surgery, with all participants endorsing need for further investigation into treatment de-escalation. Stakeholder considerations in opening such a trial emphasized need for multidisciplinary involvement and, particularly, the unique role of surgeons as gatekeepers in breast cancer treatment. Finally, participants endorsed a need for further foundational studies to develop ways to predict complete pathologic response to chemotherapy without surgical intervention.

CONCLUSIONS

Physicians expressed interest in investigating a novel approach to breast cancer treatment that would omit surgery in complete responders to neoadjuvant chemotherapy. Multidisciplinary input, and specifically surgeon engagement, will be key to the success of future investigations. Ongoing work to develop approaches to predict pathologic complete response accurately is needed to achieve the promise of this idea. ClinTrials #: BR005: NCT03188393 June 13, 2017.

Identification of breast cancer patients with pathologic complete response in the breast after neoadjuvant systemic treatment by an intelligent vacuum-assisted biopsy

BACKGROUND

Neoadjuvant systemic treatment elicits a pathologic complete response (pCR) in about 35% of women with breast cancer. In such cases, breast surgery may be considered overtreatment. We evaluated multivariate algorithms using patient, tumor, and vacuum-assisted biopsy (VAB) variables to identify patients with breast pCR.

METHODS

We developed and tested four multivariate algorithms: a logistic regression with elastic net penalty, an Extreme Gradient Boosting (XGBoost) tree, Support Vector Machines (SVM), and neural network. We used data from 457 women, randomly partitioned into training and test set (2:1), enrolled in three trials with stage 1-3 breast cancer, undergoing VAB before surgery. False-negative rate (FNR) and specificity were the main outcome measures. The best performing algorithm was validated in an independent fourth trial.

RESULTS

In the test set (n = 152), the logistic regression with elastic net penalty, XGboost tree, SVM, and neural network revealed an FNR of 1.2% (1 of 85 patients with missed residual cancer). Specificity of the logistic regression with elastic net penalty was 52.2% (35 of 67 women with surgically confirmed breast pCR identified), of the XGBoost tree 55.2% (37 of 67), of SVM 62.7% (42 of 67), and of the neural network 67.2% (45 of 67). External validation (n = 50) of the neural network showed an FNR of 0% (0 of 27) and a specificity of 65.2% (15 of 23). Area under the ROC curve for the neural network was 0.97 (95% CI, 0.94-1.00).

CONCLUSION

A multivariate algorithm can accurately select breast cancer patients without residual cancer after neoadjuvant treatment.