VIDEO: Assessing when to escalate, de-escalate therapy in early breast cancer

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[Walker Lyons, MD] So, I think that the data that's coming out these days is really focusing on escalation and de-escalation of care for patients. So, what that means is for certain patients we know we need to be a little bit more aggressive or more invasive with our care and treatments. And in other patients, we can safely forego that and decrease their risk for some of the complications or side effects that might come with those treatments. So, some examples of that are the IDEA trial was recently published and that focused on omitting radiation therapy in patients who were undergoing breast-conserving treatment with early-stage breast cancers that were deemed low risk. This study was a single-arm study that focused on a very specific patient population, and they had strict adherence to endocrine therapy, but I think it showed some promising results. Their five-year, breast cancer-free survival data was around 100%. So, I think that this is interesting and we're obviously going to need some longer-term follow up and probably a randomized-control trial, but I think it shows where treatments are headed.

Additionally, just at the end of last year, there was data that was presented from the NSABP B-51 trial and the ICARO study. Both of these focused on patients who are undergoing neoadjuvant treatment, so neoadjuvant treatment or chemotherapy before surgery. The NSABP B-51 [trial] looked at the omission of nodal radiation treatment in patients that had a prior positive lymph node before neoadjuvant treatment, that those then converted to node negative at the time of surgery. And they showed some really promising results. It's yet to be published, but it looks like what they're going to show is that these patients had the two groups, the omission group and the one that got radiotherapy, had no significant difference in both local and distant recurrence rates.

The ICARO study also focused on neoadjuvant patients, but looked at patients where their nodes went from node positive to what we call micro metastatic or isolated tumor cells, just a small amount of tumor in their lymph nodes at the time of surgery, and whether or not these patients would benefit from a completion axillary lymph node dissection. An axillary lymph node dissection is where we remove the majority of the lymph nodes from under the armpit, but it does carry an increased risk of complications, such as lymphedema or swelling of the arm. This study showed promising results, in that at five years, there's no significant difference between the two groups in axillary recurrence, local regional recurrence, or any type of invasive cancer recurrence between the groups.

And then lastly, this past April, the SENOMAC trial was published and that focused on patients who were undergoing upfront surgery for early breast cancer and were found to have one to two positive lymph nodes on sentinel lymph node biopsy. And they split this into two groups. One group, again, had a completion axillary lymph node dissection and the other didn't. And it showed great data at five years that there was no significant difference between the two groups in recurrence rates. So we've had similar trials like this, but this is really promising for us as surgeons because it gives us confidence [be]cause this trial was a little bit bigger, it had a good long-term follow-up, and it had more inclusion criteria than some of the other studies that we have, so that we know we can safely omit a completion axillary lymph node dissection in these patients and spare them the morbidity of that procedure.