Maggie DiNome, MD
The approach and technique with surgery for nonmetastatic breast cancer have evolved since its advent as the primary method of treatment; however, Maggie DiNome, MD, said that although axillary dissection may become a thing of the past, surgery is still a key part of a multimodality treatment approach.
Although the treatment of these patients still includes surgery, the current paradigm has adopted other treatment modalities, which DiNome said control the disease in the axilla just as well as surgery, and possibly with less morbidity.
Clinical trials continue to explore whether surgeons can now do less, given the emergence of effective systemic therapies. DiNome explained that by the time patients with positive lymph nodes receive neoadjuvant chemotherapy and proceed to surgery, 40% to 70% of those patients show no evidence of residual tumor in their lymph nodes. More patients with early-stage breast cancer are surviving, which has enabled surgeons to focus on not only delivering good survival outcomes but good aesthetic outcomes as well, said DiNome.
In an interview during the 2018 OncLive®
State of the Science SummitTM
on Breast Cancer, DiNome, associate professor of surgery, of the University of California, Los Angeles Medical Center, discussed the evolution of surgical approaches in patients with early-stage breast cancer.
OncLive: Please provide an overview of your presentation.
: I spoke about the surgical management of early-stage breast cancer. One of the most fascinating things I find is that it has evolved significantly over the past century. We started off with surgery being the primary treatment for patients with breast cancer. Over the last several decades, we have learned that the biology of the cancer helps us determine the treatment approach. Now, surgery is only 1 part of a multimodality treatment strategy. We're doing good things, but we're learning that more surgery is not [necessarily] better surgery, and our treatment approach is paralleling that.
Is the treatment approach to be more minimally invasive?
What we are understanding is that more surgery is not better. You don’t get a better survival outcome by doing a bigger surgery, and you also don’t get a worse survival outcome by doing a smaller surgery. Most of our patients are surviving breast cancer—certainly early-stage breast cancer. We're finding [the cancer] earlier, and we're treating it better. The systemic therapies given by our medical oncology colleagues are so much more effective, so people are living for long periods of time.
Now, it’s incumbent upon us as surgeons to be focused on quality-of-life and survivorship issues for patients. We want to restore a woman's sense of self-worth, their femininity, and how they feel about themselves—and preserve their breast if we can. If we need to remove the breast, [we want to make] it look as natural as possible. We're moving toward that direction, so it's exciting. We're focusing a lot on the aesthetic outcomes of breast cancer surgery. [We’re] trying not to take out more than we need to, so that we [don’t have to] change the appearance of the breast so much. We're doing that with our other oncology colleagues, who help us to get both a good survival outcome as well as a good aesthetic outcome.
What percentage of patients receive mastectomy versus lumpectomy?
For most early-stage breast cancers, you can opt for either breast-conservation surgery or mastectomy. Most postmenopausal women who have a choice will opt for the easier surgery, so they end up doing a lumpectomy. A good number of women who are diagnosed at a young age tend to opt a little bit more as a group for not only unilateral mastectomy, but bilateral mastectomy.