Study claims patients with early breast cancer may be able to skip surgery. What are the chances of recurrence?

Patients with early-stage breast cancer, who respond favourably to chemotherapy, may be able to skip surgery and receive standard radiation treatment with a low chance of disease recurrence, according to a new study from researchers at the University of Texas MD Anderson Cancer Center.
The study, based on a US-based multi-centre phase II trials and published in The Lancet Oncology, have said that high responses are indicated state-of-the-art breast imaging-guided, vacuum-assed core biopsy (VACB). “In the world of oncology, where the aim is to achieve more doing less, this could be a welcome addition to the equation of achieving that aim. However the morbidity of undergoing a small local excision is considerably a lesser evil than other modalities such as chemotherapy and radiation,” said Dr C B Koppiker, an eminent breast-oncosurgeon and one of the pioneers of breast oncoplasty in India.
This is the first time this kind of result has been shown in patients who have had a complete response documented VACB and then followed up with only radiation, hence avoiding surgery. “The ultimate form of breast-conserving therapy is completely eliminating breast surgery for invasive disease,” said Henry Kuerer, Professor of Breast Surgical Oncology and principal investigator of the study, “Eliminating Surgery or Radiotherapy After Systemic Therapy in Treating Patients With HER2 Positive or Triple Negative Breast Cancer.”
“This research adds to growing evidence showing that newer drugs can completely eradicate cancer in some cases, and very early results show we can safely eliminate surgery in this select group of women with breast cancer,” he added.The Phase II trial results evaluated the likelihood of breast cancer returning in patients who are in complete remission after receiving chemotherapy and radiation without surgery. Each of the 31 patients followed had a complete response to chemotherapy and none had a breast tumour recurrence after a median follow-up of 26.4 months.
“These are ba steps towards proving this possibility. However, a much longer follow-up is needed to prove safety. Also, major properly-designed randomised studies will need to be undertaken in a lot more patients to prove the safety of omitting surgery. Except for the scar, a VACB procedure is still a procedure, which too has potential complications such as infections,” Dr Koppiker said.
The oncosurgeon has welcomed de-escalation of surgical treatment but he feels that there have to be efforts in de-escalating systemic therapy and radiation therapy protocols. One will need to study the effect this will have on the economics of de-escalating such treatments, Dr Koppiker added. One of the areas where onco-surgeons have been arguing for de-escalating radiation treatment is in select elderly patients with a highly hormone-sensitive breast cancer, where radiation and chemotherapy can be omitted. “I believe this seems a more welcome strategy for de-escalation as the patient avoids the side effects from these treatment modalities.
She undergoes a surgery and recovers within a week and needs no further treatment other than anti-hormonal medicine once a day with definitely much better tolerated side effects or none at all,” Dr Koppiker said. Hence researchers need to consider optimising the use of these definitely more elaborate time-consuming armaments in the protocol for treatment, which also have considerably worse potential side effects as compared to surgery of minimal proportions, the expert pointed out.
Previous data on omitting surgery was not encouraging. Many systematic reviews of studies that have looked at post-chemo surgery have been published. One such review, “Early Breast Cancer Trials’ Collaborative Group (EBCTCG)”, published in 2018, provides high quality data on the concept of risk-adapted breast-conserving therapy. This review is one of the most revered and showed that there was an increased risk of local recurrence in patients who underwent breast conservation after receiving chemotherapy as against those who had had a mastectomy.
Yet, they speculated on the reasons and one of them was that some of the studies included in the review had actually omitted surgery in patients who had had a complete response to chemotherapy.
This omission of surgery or a period of long follow-up showed a five per cent increased risk of recurrence. “Thus in this overview, omitting surgery after complete response was catastrophic. There were other reasons also for the increased risk of local recurrence after breast conservation and these were cited in the review. Simply put proper localisation of the tumour was not done,” Dr Koppiker said.
The breast onco-surgeon has himself created a protocol for the management of chemotherapy and surgery. “We tried to eliminate all the shortcomings of the studies mentioned in the EBCTCG review. We have been able to safely achieve breast cancer conservation in a large number of patients with this protocol up to 73 per cent. Though we did not omit surgery completely, we did manage to offer the patients lesser surgeries than would be required otherwise, there reducing the rate of women undergoing mastectomy significantly.
Our study has been completed and awaits publication,” Dr Koppiker said. “Avoiding surgery is something that can only be proved with extremely large and well designed studies. Till then the standard of care would be to offer breast conservation to patients who have had a complete response. That means minimal surgery which avoids mutilation and discomfort to the patient,” Dr Koppiker added.