Do all breast cancer patients need surgery? Maybe not.

While conventional breast cancer treatments typically involve the deployment of “every tool modern medicine has to offer,” including surgery, a new study published Tuesday in The Lancet Oncology suggests that chemotherapy alone may be sufficient for some patients, writes Roni Caryn Rabin for the New York Times.

Study details and key findings

For the study, researchers followed 50 patients in an early-stage clinical trial that evaluated the effectiveness of neoadjuvant systemic therapy (NST) for triple-negative breast cancer and patients with HER2 positive breast cancer.

To be eligible for the trial, patients had to be at least 40 years of age with a diagnosis of single-center cT1-2N0-1M0 triple-negative breast cancer or HER2-positive breast cancer and a residual breast lesion less than two centimeters.

From March 6, 2017 to November 9, 2021, 50 patients participated in the trial. The average age of trial participants was 62 years old. Forty-two percent of patients had triple-negative breast cancer and 58% had HER2-positive breast cancer. Each patient underwent a vacuum-assisted core biopsy (VACB) after receiving an NST to assess their response to treatment.

Over an average follow-up period of 26 months, 31 patients, or about 60 percent, had a positive response and were able to avoid surgery, the researchers said.

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According to Henry Kuerer, professor of surgical breast oncology at the University of Texas MD Anderson Cancer Center and the study’s principal investigator, avoiding surgery for invasive breast cancer is “the ultimate form of breast-conserving therapy.”

“Breast surgery can lead to complications such as infections, and even breast-conserving procedures like lumpectomy can change the shape of the breast, leave scars or indentations, a tight feeling, or lasting nerve pain,” Rabin writes. .

Kuerer noted that some patients prefer radical surgery even if it doesn’t increase their survival rate. However, others find minor surgery “emotionally draining” even if the procedure is successful, Rabin writes.

“Breast cancer is so common, and there will always be people who would rather not have surgery,” Kuerer added.

For example, trial patient Pamela Romero, who was eligible to forgo surgery, wanted to avoid the procedure after doctors discovered a HER2-positive tumor about the size of a grape.

“The doctor asked, ‘How do you feel about the surgery? and I said, ‘I’m very scared of it,'” Romero said. “I said, ‘If I can get rid of the cancer without surgery, I’m all for it.'”

“I didn’t want to be submissive or go under the knife,” added Romero, who had never had surgery.

Romero’s tumor shrank by around 85% after undergoing four infusions of chemotherapy, which allowed him to forego surgery. Two treatments later, her regimen was full. She recently celebrated her third anniversary of completing treatment and is still healthy today.

The work is part of a de-escalation approach to cancer therapy, individualizing treatment to achieve the same results with fewer treatments and fewer interventions, Rabin writes.

“What I really like about the study is that it takes the next step and asks a bold question: how do we take all the advances we’ve made in more tailored and more specific cancer therapy, and convert them into a reduction in the number and types of procedures a patient has to undergo?” said Karen Knudsen, CEO of American Cancer Society.

“Asking if we can reduce surgery is a reasonable next consideration for the future of cancer care,” she added.

While the study followed patients for a significant period of time, experts noted that a larger trial with a comparison group would be needed to determine whether changes in medical practice are warranted, Rabin writes.

“The big picture is that this is a small study,” said Monica Morrow, chief of breast surgery at Memorial Sloan Kettering Cancer Center. “It’s by no means definitive. It won’t change the practice in any way.”

Separately, Kuerer said that while the trial results are promising, most breast cancer patients will still need surgery. “It’s important for patients to know that this is the very beginning of a new type of treatment for some patients,” he said. (Rabin, New York Times, 10/25; Kurer et al., The Lancet Oncology10/25)

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