Dr Flanagan on Coordinating Breast Cancer Treatment De-Escalation Strategies

“The next step is: How do we find the patients in whom we can both omit nodes and do less radiation?”

Meghan R. Flanagan, MD, MPH, a physician at Fred Hutchinson Cancer Center and an assistant professor of surgery at the University of Washington School of Medicine, discussed the complexities of de-escalating breast cancer treatment that emerged during a multidisciplinary tumor board session held at the 43rd Annual Miami Breast Cancer Conference.

Flanagan addressed a case involving the omission of sentinel node biopsy and the subsequent implications for radiation oncology. She emphasized that although reducing the intensity of therapy is a primary goal, the collaborative team must strategically determine how various treatment de-escalations interact with each other.

Flanagan explained that a significant point of discussion centered on how surgical decisions regarding the axilla are often intertwined with radiation protocols. She noted that many clinical trials supporting the omission of sentinel node biopsies were designed with the requirement that patients receive whole breast radiation. Flanagan’s team at Fred Hutchinson Cancer Center took a distinctive approach by validating these national findings against their own institutional data. This internal review revealed that their axillary positivity rate was lower than the rates reported in the original studies. This data-driven approach allowed Flanagan and her colleagues to feel comfortable implementing current guidelines for node omission, even as other institutions may be slower to adopt these changes.

Furthermore, Flanagan highlighted the debates that often arise between surgeons and radiation oncologists when trying to balance competing treatment de-escalation goals. For instance, although a surgeon may wish to omit node biopsies to reduce surgical morbidity, radiation oncologists traditionally require nodal status to satisfy the criteria for accelerated partial breast irradiation (APBI). However, by reviewing local data, the radiation oncologists at Fred Hutchinson Cancer Center have identified specific patient subsets—such as those with very small tumors—for whom they feel comfortable proceeding with APBI despite the absence of nodal information. Flanagan concluded that the next frontier in multidisciplinary care is identifying the exact patient population that can safely benefit from both the omission of nodes and a reduction in radiation intensity.