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Axillary surgery may be avoidable for some women with breast cancer
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Patients with triple-negative or HER-2–positive breast cancer who achieved a complete response after neoadjuvant chemotherapy appeared unlikely to have residual axillary nodal metastasis, according to results of a prospective cohort study.
Because there was a low risk for missing nodal metastases without axillary surgery, these data suggest some patients may be able to avoid axillary surgery.
“There is an urgency to test whether surgery is needed,” Henry M. Kuerer, MD, PhD, professor of breast surgical oncology in the department of breast medical oncology at The University of Texas MD Anderson Cancer Center, said in a press release. “[Patients] want the most personalized care with as minimal treatment as possible. If some women are able to avoid unnecessary surgery, it would be groundbreaking for patients, both physically and psychologically.”
Forty percent to 50% of women with triple-negative and HER-2–positive breast cancer achieve pathologic complete response to neoadjuvant chemotherapy.
“This high rate of [pathologic complete response] naturally raises the question of whether breast surgery is required for all patients, particularly those who will receive adjuvant radiation,” Kuerer said.
Kuerer, Audree B. Tadros, MD, fellow from the department of breast surgical oncology at The University of Texas MD Anderson Cancer Center, and colleagues conducted an analysis of 527 patients (median age, 51 years; range, 23-84) with triple-negative or HER-2–positive breast cancer treated with neoadjuvant chemotherapy at MD Anderson Cancer Center between January 2010 and December 2014. The goal was to identify patients who have a low risk for axillary metastases after achieving breast pathologic complete response who may be eligible for a trial that evaluates the omission of surgery.
All patients received chemotherapy and underwent standard breast or nodal surgery. Researchers compared patients who did and did not achieve a pathologic complete response based on subtype, initial ultrasonographic findings and documented pathologic nodal status.
More than one-third (36.6%) of patients achieved a breast pathologic complete response, which included a slightly greater proportion of patients with triple-negative breast cancer than HER-2–positive breast cancer (37.5% vs. 35.7%).
Among 290 patients with initial nodal ultrasonography showing N0 disease, 116 (40.4%) had a breast pathologic complete response, and 100% had no evidence of axillary lymph node metastases after neoadjuvant chemotherapy.
Among 237 patients with N1 disease, a greater proportion of those with than without a breast pathologic complete response showed no residual nodal disease (89.6% vs. 42.5%; P<.01).
“In our study, patients achieving a breast [pathologic complete response] were more than seven times less likely to have residual nodal disease, with even more pronounced differences among patients presenting with N0 stage disease,” Tadros said in the release. “Based upon these findings, we anticipate women with initial node-negative disease may avoid breast and axillary surgery if they achieve a [pathologic complete response] after [neoadjuvant chemotherapy] and move on to standard radiotherapy.”
Patients without a pathologic complete response had a significantly greater risk for positive nodal metastases than patients who responded (RR = 7.4; 95% CI, 3.7-14.8).
A clinical trial is planned to extend these findings and determine the need for surgery after a clinical complete response to neoadjuvant chemotherapy.
That plan to evaluate need for surgery in a trial is supported by these data and an important effort for this patient population, Monica Morrow, MD, surgical oncologist from the department of surgery at Memorial Sloan Kettering Cancer Center, wrote in a related editorial.
“The proposed trial is an important effort to leverage the high response rates to [neoadjuvant chemotherapy] seen in triple-negative and HER-2–positive breast cancers to decrease the burden of treatment,” Morrow wrote.
The study also reminds clinicians that surgery after neoadjuvant chemotherapy is still the standard of care.
“Until elimination of surgery is proven to be safe in appropriately conducted clinical trials, surgery after neoadjuvant chemotherapy remains standard, even in patients who have had a clinical complete response,” Morrow wrote. – by Melinda Stevens
Disclosures: Kuerer reports a speakers bureau role with PER; research funding from Genomic Health; and publishing patents, royalties and other intellectual property from New England Journal of Medicine Group and McGraw-Hill Publishing. Tadros reports no relevant financial disclosures. Please see the full study for a list of all other researchers’ relevant financial disclosures. Morrow reports no relevant financial disclosures.
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