The Conversation Around De-escalation in Breast Cancer Surgery

By Cari Wade Gervin
Monday, July 25, 2022

Research continues to show that more aggressive surgical treatment is not always better for some breast cancer patients, yet many physicians and patients continue to opt for the maximalist approach. Is change possible?

The rate of radical double mastectomies as a first-line treatment for early stage breast cancer has increased dramatically in the past decade, despite findings that people with low-grade breast cancer may be receiving unnecessary surgery.

“With improvements in systemic therapy, bigger surgery is not better surgery, and bigger surgery is certainly associated with more quality-of-life consequences for patients,” says Tari A. King, MD, FSSO, Vice Chair for Multidisciplinary Oncology in the Department of Surgery and Chief of the Division of Breast Surgery at Brigham and Women’s Hospital Dana-Farber/Brigham Cancer Center and Anne E. Dyson Professor of Surgery in the Field of Women’s Cancers at Harvard Medical School. “The term de-escalation has gotten a lot of attention, but it is really about doing the appropriate amount of surgery and/or radiation and/or systemic therapy in the appropriate patients.”

What the Research Shows

In a recent issue of npj Breast Cancer, a review of the literature shows that breast cancer surgical practices designated as “low value” are still common.

“It’s challenging because a lot of the treatment norms in breast cancer from decades ago are so socially ingrained — everyone knows a woman who’s had bilateral mastectomy,” says Sarah P. Shubeck, MD, MS, Assistant Professor of Surgery at The University of Chicago Pritzker School of Medicine. “We also have this notion around cancer that doing the most means doing the most aggressive thing, and that must somehow translate into survival outcome. But what you see across multiple large, randomized control trials with high-quality data is that if we are better able to match a patient with the intervention needed, they have the same benefit.”

Increasingly, de-escalation with respect to the management of the axillary nodes has been embraced, reducing the incidence of lymphedema among patients with early-stage disease. But other changes in protocols have lagged at a national level.

“The movement of breast cancer therapy forward is often a story of doing less instead of doing more,” Dr. Shubeck says.

Multifaceted Discussions Around Breast Surgery

Jacqui Shine, PhD, a writer and historian, was diagnosed with Stage 0 ductal carcinoma in situ (DCIS) in January at age 38. Shine was aware of her family history of breast cancer — both her mother and half-sister had developed the disease — so her physicians were surprised when she opted to delay surgery for cancer treatment after unexpectedly breaking her ankle around the same time.

While Shine did ultimately receive a double mastectomy in June — after weighing genetic testing and other health factors — she agrees that more physicians need to have longer conversations with patients about breast cancer surgery.

“Patients are giving up their part of their sexual life that involves their breast … and reconstruction is not going to be the same,” Shine says. “And I think [thinking about that] is important, especially for younger people who have been diagnosed with the least-invasive kinds of cancer.”

Shubeck says this should be an important part of treatment discussions but often isn’t.

“Mastectomy leads to sensation changes, at the very minimum,” Shubeck says. “I think de-escalation in terms of the surgical management of breast cancer is important to combat the traditional history of the breast being trivialized. … Some women don’t see themselves as a sexual being when they’re diagnosed with breast cancer, so they don’t really think about how much their breasts mean to them — and then six months after diagnosis, that part might become important again.”

Physicians, Patients and Risk Tolerance

Patient anxiety about poor outcomes is not the only reason for high rates of breast cancer surgery.

“The data indicate that if given the option, patients would decline certain treatments, but they proceed with the treatments because they were not offered a choice for omission,” says Lesly A. Dossett, MD, MPH, Assistant Professor of Surgery and Chief of the Division of Surgical Oncology at the University of Michigan, who co-authored the study with Dr. Shubeck.

However, physicians have a range of professional opinions about optimal treatments for breast disease, and some may proceed more cautiously than others or be willing to tolerate less residual risk for their patients.

Physicians should stay up to date on the data supporting omission of certain treatments and engage in discussions with patients when omission of treatments is an option, Dossett notes. It may also be worthwhile to provide recommendations for mental health care in addition to oncological care to help patients manage anxiety.

“The exciting thing about breast cancer therapy is it’s changing so fast. Dr. Shubeck says. “It’s important to help patients know how we can better tailor their medical therapy.”