VIDEO: Surgery considerations in early-stage breast cancer

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[E. McAuley Fish, DO] So, the role for surgery in early breast cancer is, typically, one of the first things that we do in early-stage breast cancers. However, it really depends on the characteristics of the tumor or the cancer itself. So, tumor size, hormone receptor status, their lymph node status, potentially. If they're clinically node-positive, they may be undergoing neoadjuvant therapy. So, it really depends on that patient and that specific type of cancer that they have.

Surgery can come midway, so if a patient is diagnosed with a triple-negative larger breast cancer, it could still be in early-stage breast cancer, but they may really need that neoadjuvant chemotherapy first. Surgery for breast cancer involves either a partial mastectomy, otherwise known as lumpectomy, so that targeted portion of the breast that has the cancer in it, and a REM of healthy tissue or a mastectomy removing the entire breast. And then also with these operations, we do sample the lymph nodes. So, sentinel lymph node or sentinel lymph node biopsy, sentinel lymphadenectomy, and that helps with axillary staging. So that's kind of the options we have in terms of surgical treatment.

I think that's important too, like I just said, about triple-negative breast cancers and then some positive lymph nodes can still be early-stage. We don't always think about that. We think about those as being the more aggressive later stages, but not always. They can still be stage one or two breast cancers. But in those cases, the triple-negative, so we look at Keynote-522, which is a trial that looks at neoadjuvant chemotherapy plus an immunotherapy drug, pembrolizumab [Keytruda; Merck], doing that neoadjuvant, then having the operation, and then doing adjuvant or after the operation doing more of the immunotherapy drug. And we know that that increases event-free survival in these patients quite a bit, really significantly.

And then if we think about HER2-positive cancer, so maybe it's a HER2-positive and it's still an early-stage breast cancer, you may think, "Oh, let's jump to surgery first." But in those patients too, based on the KATHERINE trial, we know that if a patient does undergo neoadjuvant chemotherapy based on that tumor and then they, based on their operation, do not have a complete pathologic response, we know that then prescribing a specific adjuvant chemotherapy, it may be beneficial, and it can actually reduce their mortality risk and risk of recurrence by about 50%.

So, you can see where surgery can kind of be in the front. It can kind of be in the middle. It's not always cut and dry for even early-stage breast cancers. It's also just important to note, as we just kind of did, that surgery is one component of a very robust multidisciplinary approach to breast cancer, not just the later stages, but also these earlier stages.