Experts Explore Intersections Between Breast Surgery and Radiation for Comprehensive Care: With Hirsch Matani, MD; Elizabeth Zhang-Velten, MD; and Valentina Bonev, MD, DABS, FACS, FSSO

In this episode of Precision and Progress: Radiotherapy in Oncology, Hirsch Matani, MD, and Elizabeth Zhang-Velten, MD, co-hosted a discussion with Valentina Bonev, MD, DABS, FACS, FSSO, about the interplay between surgery and radiation in breast cancer care.

Dr Matani is a clinical assistant professor of radiation oncology at the Keck School of Medicine of the University of Southern California (USC) and a radiation oncologist at the USC Norris Comprehensive Cancer Center. Dr Zhang-Velten is a radiation oncologist and a clinical assistant professor with Keck Medicine of USC. Dr Bonev is a breast surgical oncologist at Breastlink in Orange, California.

The experts highlighted the ongoing shift toward individualized, de-escalated breast cancer management that is aimed at maximizing outcomes and minimizing complications. They explained that patients with early-stage cancer often choose between a lumpectomy, which preserves breast tissue, or a mastectomy. They noted that lumpectomy typically requires follow-up radiation, whereas a mastectomy usually omits radiation unless the pathology reveals aggressive features or nodal involvement. To guide radiation targeting, Dr Bonev emphasized the importance of placing hemoclips in the lumpectomy cavity. These permanent markers help radiation oncologists pinpoint the "boost" dose, assist surgeons if margins need re-excision, and clarify future imaging by distinguishing scar tissue from recurrence, she noted.

The experts also discussed the "Choosing Wisely" guidelines, which allow for the omission of sentinel lymph node biopsies in specific favorable cases—such as patients at least 70 years of age with small, hormone receptor–positive tumors. Although these guidelines reduce the risk of lifelong complications like lymphedema, the experts noted that radiation oncologists may lean toward whole-breast radiation rather than partial-breast radiation to ensure microscopic disease in the axilla is addressed.

The speakers also advocated for a multidisciplinary approach to breast cancer care, where patients meet the entire care team—including medical and radiation oncologists—before surgery to set expectations. They addressed common misconceptions, noting that radiation does not make a patient radioactive and does not cause hair loss. Ultimately, they spotlighted advanced techniques like intensity-modulated radiation therapy that allow for precise treatment that maintains cosmesis and simultaneously provides effective cancer control.