A very close family friend was just recently diagnosed with breast cancer. Even before all of her tests results came back she said, “Take both of my breasts, I don’t care.” When someone you know or love is diagnosed with breast cancer, it’s terrifying. All too commonly, our minds go to surgery. This is what we believe will save our mom, our sister, our friend from breast cancer. For my friend, like many others, the thought of cancer growing inside of her was scary and surgery to remove the cancer was her first thought.
Many women with early stage breast cancer have the choice between breast conserving surgery and mastectomy. Historically management of breast cancer has involved surgery to remove the tumor first, followed by systemic treatment with chemotherapy, hormonal therapy or both. However, new treatment paradigms are emerging that place the systemic treatment first and surgical removal of the tumor as secondary.
The American College of Surgeons Oncology Group Z1031 trial, of which Mayo Clinic was a participating site, demonstrated that neoadjuvant endocrine therapy, or endocrine therapy given before surgery, increased breast-conserving surgery rates for postmenopausal patients with clinical tumor stage 2-4c estrogen receptor-positive breast cancer. Practically speaking, this means that women receiving neoadjuvant endocrine therapy had their tumor size shrink significantly. Thus, utilizing the neoadjuvant endocrine therapy approach can increase the number of women that are able to receive breast-conserving surgery. Meaning that they can have their breasts spared by removing only a small portion of their breast tissue.
This treatment breakthrough may be the “silver lining” for some.
Breast conserving surgery when compared to mastectomy has many positives: it is less invasive and less expensive, it has shorter recovery time, women experience less body disfigurement and ultimately fewer surgeries are required.
If this new approach is so great, why is it that the uptake of this approach has not sky-rocketed?
For breast surgeon, Judy Boughey, M.D., this is the reason that drove her to study the question in the first place. “Incorporation of clinical trials into standard clinical practice typically takes many years. This is suboptimal and there are many ongoing efforts to encourage the results of clinical trials to impact patients in a shorter timeline.”
To that end, Boughey and her team wanted to look at national trends of use of neoadjuvant endocrine therapy before, during and after the ACOSOG Z031 clinical trial and evaluate its influence on rates of breast conserving surgery. The results are thus unsurprising: the rates of use of neoadjuvant endocrine therapy increased slightly, but overall remain very low. There remains an important opportunity to raise awareness about the benefits of neoadjuvant endocrine therapy and increase its use across the country.
Furthermore, studying patients treated with neoadjuvant endocrine therapy can help identify patients that are very responsive to endocrine therapy and may do well in the long term without chemotherapy. This subsequent trial, the Alliance A011106 (Alternate) trial, is underway nationally and is open at Mayo Clinic.
Many patients have the overwhelming preference to have the cancer removed from their body first and the concept of systemic treatment first can be challenging for patients to understand. Sometimes it seems the research and innovation cannot come fast enough. Yet other times, here we are, new research and new treatment paradigms at our fingertips, yet we hesitate as patients and as providers. More rapid translation of research into practice in an era of rapid discovery is in order to keep patient care up-to-date with research offering greater ability to impact care and change lives.