The Lynx Group

Breast-Conserving Surgery Underutilized

January 2013, Vol 4, No 1

Vienna, Austria—Despite a robust response to neoadjuvant chemotherapy, which renders many early breast cancer tumors resectable, breast-conserving surgery is often overlooked in favor of mastectomy, according to an analysis of the Neo-ALLTO clinical trial, which was presented at the 2012 European Society for Medical Oncology Congress.

Carmen Criscitiello, MD, from the Department of Oncology at the European Institute of Oncology in Milan, Italy, and colleagues determined which factors influenced whether to offer mastectomy or lumpectomy (ie, breast-conserving surgery) to the 429 patients who received neoadjuvant chemotherapy in this trial. The use of neoadjuvant chemotherapy with the combination of paclitaxel, lapatinib, and trastuzumab significantly increased the rate of tumor eradication—or pathologic complete response (pCR)—compared with paclitaxel combined with either drug alone, the investigators reported previously.

Although the pCR rate was 51.3% with the triple-drug combination, breast-conserving surgery was performed on only 41.4% of women. Regardless of which treatment the women received, breast-conserving surgery rates hovered at approximately 40%.

“The experimental treatment with paclitaxel plus lapatinib and trastuzumab within the Neo-ALTTO trial nearly doubled the rate of pCRs compared with treatment with paclitaxel combined with either drug alone,” said Dr Criscitiello.

However, she said, “this successful result did not translate into a higher rate of breast-conserving surgery. Indeed, we saw that tumor characteristics prior to neoadjuvant therapy play a main role in deciding the type of surgery, irrespective of the response to given therapies.”

The baseline characteristics that in­fluence the clinician’s choice between mastectomy and breast-conserving surgery are:

  • Type of surgery planned at initial diagnosis
  • The multicentricity and multifocality of the tumor
  • Estrogen receptor–negative (vs positive) status.

Geographic influences were also evident, with much higher mastectomy rates seen in developing countries than in developed countries. Investigators and other breast cancer specialists suggest that this finding stems from a lack of radiotherapy in developing countries, which is required for a breast-conserving approach.

“This study highlights a negative attitude that may deny a large fraction of women the chance of preserving their breasts, with no clinical reasons that justify this decision. One of the goals of the neoadjuvant therapy concerns increasing the rate of breast conservation, but this goal is clearly not achieved if the type of surgery is chosen according to baseline characteristics,” Dr Criscitiello said.

Michael Gnant, MD, surgical oncologist, Vienna’s Medical University, commented, “Dr Criscitiello’s work is very important in our goal to further increase breast conservation rates. Particularly in biologically aggressive subtypes of breast cancer, such as HER2-overexpressing disease [the Neo-ALLTO population], there is still some hesitation in applying breast-conserving surgical strategies....Particularly in patients with an excellent response, a more proactive approach to breast conservation can be used, given the advances in targeted therapy.”

“While long-term confirmation on locoregional control is awaited, I agree that modern breast cancer surgery should orient its strategy according to the posttreatment outcome rather than the baseline situation,” Dr Gnant said.

“When this is implemented in more centers, as our center has done, even more women will benefit from the ad­­vances in multimodality treatment,” he advised.

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