Dr Mamounas on Surgical De-Escalation Strategies in HER2+ Breast Cancers

Terry P. Mamounas, MD, medical director, Comprehensive Breast Program, University of Florida Health, Health Cancer Center at Orlando Health, discusses surgical de-escalation strategies in the treatment of patients with HER2-positive breast cancer.

The initial focus of surgical de-escalation strategies in this patient population revolved around de-escalating the primary tumor surgery by inducing a robust response to neoadjuvant chemotherapy, potentially shifting patients from needing mastectomy to being eligible for breast-conserving surgery, Mamounas begins. In some ongoing trials, investigators are exploring the possibility of omitting formal surgical resection, though this is not standard practice yet, he states. Notably, prospective trials are addressing this question by using imaging to identify a strong response to neoadjuvant chemotherapy in the breast, Mamounas says, adding that core biopsies of the tumor bed are employed to confirm the absence of residual disease. In cases without residual disease, there is consideration for avoiding surgery, although this is not the current standard, Mamounas expands. A recent study conducted out of The University of Texas MD Anderson Cancer Center demonstrated promising local control rates with this approach, showcasing its potential, especially as systemic therapy advances, he emphasizes.

In more recent years, another approach aims to de-escalate surgery for axillary nodes, Mamounas states. For patients with subclinically or clinically involved axilla, traditional surgical methods often involve more extensive procedures to determine whether lymph node dissection is necessary, he adds. However, by sterilizing the lymph nodes and ensuring residual disease negativity at the time of surgery, surgeons can perform a sentinel lymph node (SLN) biopsy alone, avoiding a comprehensive axillary dissection, Mamounas continues. This minimizes the risk of lymphedema and reduces axillary morbidity. Notably, investigators have improved false negative rates in SLN biopsy by employing techniques such as clipping nodes that were positive before neoadjuvant chemotherapy and removing them with the clip after treatment, he explains.

This approach has lowered SLN biopsy false negative rates to be comparable with those seen when conducting SLN biopsies in upfront settings, Mamounas says. The goal of this strategy is to decrease the morbidity associated with axillary surgery by adopting an equally effective yet less invasive approach, he concludes.

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Terry P. Mamounas, MD, discusses surgical de-escalation strategies in the treatment of patients with HER2-positive breast cancer.

Eleftherios P. Mamounas, MD, surgical oncologist, UF Health Cancer Center-Orlando Health, discusses the common adverse events associated with mastectomy and breast conserving surgery for patients with breast cancer, as well as how oncologists can best manage these toxicities.

Mastectomy is often combined with reconstructive surgery, which is where the majority of adverse events stem from, Mamounas explains. This is due to the addition of expanders and implants that are inserted into the breasts, which can cause infection, bleeding, and, occasionally, loss of expander or implant. Flap reconstruction can also have a significant recovery time.

The key is to properly select patients who are likely to develop risk during mastectomy. Such characteristics include smoking, prior radiation therapy, and diabetes. It is also important for oncologists to administer prophylactic antibiotics prior to and after surgery and to have good surgical techniques, Mamounas adds.

Eleftherios P. Mamounas, MD, surgical oncologist, UF Health Cancer Center - Orlando Health, discusses the common adverse events associated with mastectomy and breast conserving surgery for patients with breast cancer, as well as how oncologists can best manage these toxicities.

Dr. Mamounas on Adverse Events With Mastectomy in Breast Cancer

Eleftherios P. Mamounas, MD, surgical oncologist, UF Health Cancer Center - Orlando Health, shares the future of surgical treatments for patients with breast cancer.

Individualization will play a major role in determining surgical options for patients with breast cancer, Mamounas says. For younger patients who are candidates for endocrine therapy versus mastectomy, the risk of recurrence is up to 25%, leading some women to opt for mastectomies. However, older patients are less likely to undergo mastectomies as they have less of a benefit, Mamounas explains.

For women with HR-positive disease, however, the risk of breast cancer recurrence is significantly reduced by approximately 50%. These statistics are important for oncologists to discuss with patients, so they are informed on all of their treatment options.

Eleftherios P. Mamounas, MD, surgical oncologist, UF Health Cancer Center - Orlando Health, shares the future of surgical treatments for patients with breast cancer.


Dr. Mamounas on Future of Surgical Treatments in Breast Cancer

Eleftherios P. Mamounas, MD, surgical oncologist, UF Health Cancer Center - Orlando Health, discusses which patients with breast cancer are most likely to benefit from endocrine therapy.

In the frontline setting, patients are selected by the expressing estrogen receptor, Mamounas says. Patients who are estrogen receptor (ER)-positive are more likely to benefit from endocrine therapy versus those who are ER-negative. However, it is unclear which patients will benefit from delayed endocrine therapy. Several clinical trials are examining this and researchers are awaiting the results.

Another frequently used factor for determining treatment is tumor size and node status, Mamounas explains. For example, patients with positive nodes upfront, even after five years, have a significantly higher chance of benefitting from endocrine therapy than those with negative nodes. For patients with node-negative disease, oncologists can sub-stratify them with genomic tests.

Eleftherios P. Mamounas, MD, surgical oncologist, UF Health Cancer Center - Orlando Health, discusses which patients with breast cancer are most likely to benefit from endocrine therapy. 

Dr. Mamounas on Patient Selection for Endocrine Therapy

Eleftherios Mamounas, MD, MPH, medical director, Comprehensive Breast Program, University of Florida Health Cancer Center, discusses the need to select patients for neoadjuvant chemotherapy.

There are breast cancer subtypes that respond very well to neoadjuvant chemotherapy: triple-negative, HER2-positive, and ER-positive. Once a pathologic complete response is achieved, the oncologist should be aware of clinical trials that test the concept of less aggressive treatment.

It is important to select patients for neoadjuvant chemotherapy, not only by size or nodal status, but also by subtype.

Dr. Mamounas on Selecting Patients With Breast Cancer for Neoadjuvant Chemotherapy

Eleftherios (Terry) P. Mamounas, MD, MPH, Medical Director, Northeastern Ohio Universities College of Medicine, Medical Director, Aultman Hospital Cancer Center, discusses the controversial topic of surgery for patients who present with stage IV breast cancer at the time of diagnosis.

Traditionally, Mamounas explains, patients who are diagnosed with stage IV breast cancer are treated with palliative therapy. In general, at this stage, surgery is only performed for symptom management and to improve quality of life. However, some early studies have suggested that early local therapy with surgery may improve outcomes. Inherent in these early studies is a bias, Mamounas notes, since surgery is usually only performed on patients with minimally metastatic stage IV breast cancer.

To examine if surgery is efficacious in this population, the randomized phase III ECOG 2108 trial was formed and is currently enrolling patients, Mamounas points out. This trial will evaluate the value of early surgery compared to standard palliative therapy in treating patients with stage IV breast cancer (

Eleftherios (Terry) P. Mamounas, MD, MPH, from the Aultman Hospital Cancer Center, discusses the controversial topic of surgery for patients who present with stage IV breast cancer at the time of diagnosis.

Dr. Mamounas on Surgery in Stage IV Breast Cancer

Eleftherios (Terry) P. Mamounas, MD, MPH, Medical Director, Northeastern Ohio Universities College of Medicine, Medical Director, Aultman Hospital Cancer Center, discusses the administration of neoadjuvant chemotherapy for patients with early-stage breast cancer.

Preoperative chemotherapy can be tailored based on the subtype of breast cancer. It is used most commonly for patients with HER2-positive or triple-negative breast cancer who show greater sensitivity to chemotherapy.

Unique challenges occur when administering neoadjuvant chemotherapy, since treatment with radiotherapy and surgery must be delayed until the completion of treatment. Moreover, whether to assess the lymph nodes before or after neoadjuvant therapy has caused controversy among physicians.

Mamounas explains that the consensus among many experts suggests that sentinel biopsy after chemotherapy is accurate and provides a good indication of the patient’s current stage. Additionally, it may be possible to downstage a tumor when the biopsy is performed following treatment, resulting in less aggressive surgery.

Mamounas notes that further data on sentinel node biopsy following neoadjuvant chemotherapy will be presented at the 2012 San Antonio Breast Cancer Symposium.

Terry P. Mamounas, MD, MPH, from Aultman Hospital Cancer Center, discusses the administration of neoadjuvant chemotherapy for patients with early-stage breast cancer.

Dr. Mamounas on Neoadjuvant Chemo for Breast Cancer

Eleftherios P. Mamounas, MD, MPH, medical director, Aultman Hospital Cancer Center, Breast Committee Chairman, National Adjuvant Breast and Bowel Project, discusses the 12-gene assay used to predict the risk of recurrence in women with ductal carcinoma in situ (DCIS).

The DCIS Score test was validated in the ECOG 5194 study that enrolled 327 patients with all grades of DCIS. Patients on the trial had been treated with breast conserving surgery, had wide negative margins, and did not receive radiation treatment. The prognostic abilities of the DCIS Score were proven by the study, which showed it was a strong predictor of local recurrence risk.

Mamounas explains that the test was able to predict recurrence above and beyond traditional factors, such as grade, age, and tamoxifen administration. The traditional factors maintain a prognostic ability and the DCIS Score should be incorporated alongside the traditional factors.

Dr. Eleftherios Mamounas, from Aultman Hospital Cancer Center, on Predicting the Risk of DCIS Recurrence

Eleftherios P. Mamounas, MD

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