Henry M. Kuerer, MD, is a Professor and Executive Director Breast Programs, MD Anderson Cancer Network, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX

Henry M. Kuerer, M.D., Ph.D., F.A.C.S., CMQ

"I do believe this model is feasible in nearly every type of breast practice across the United States. As I mentioned, we didn’t require MRI. We’re not opposed to MRI—it just wasn’t mandated for eligibility or to standardize the eligibility or biopsy procedure. The majority [of biopsies were performed using] image-guided stereotactic techniques.

Henry M. Kuerer, MD, PhD, FACS, CMQ, a professor and executive director of the Breast Programs of MD Anderson Cancer Network in the Department of Breast Surgical Oncology at The University of Texas MD Anderson Cancer Center, described the safety and feasibility of selectively eliminating surgery in patients with early-stage HER2-positive breast cancer or triple-negative breast cancer (TNBC) who achieve a pathologic complete response (pCR) following neoadjuvant systemic therapy.

Results from this phase 2 trial (NCT02945579) showed that, at a median follow-up of 55.4 months (IQR, 44.0-63.5), the study reported a 0% ipsilateral breast tumor recurrence rate among 31 evaluable patients who did not undergo surgery. Five-year disease-free survival and overall survival were both 100%, suggesting that for select patients, surgical omission may be a viable strategy with favorable oncologic outcomes.

Patients were monitored closely for safety and efficacy, Kuerer stated, adding that the primary procedural difference in this trial was the incorporation of image-guided core biopsies after neoadjuvant therapy to confirm pCR. Among 50 patients, no hematomas occurred, and only 2 grade 1 toxicities were observed—one case of nausea and one technical complication requiring a second biopsy pass.

All participants received whole-breast, hypofractionated radiotherapy with a boost to the tumor bed, he noted. The majority (75%) were clinically node-negative and received only tangential irradiation to the axillary region, avoiding both breast and axillary surgery, Kuerer detailed.

This approach may challenge the long-standing surgical paradigm in breast cancer care, Kuerer asserted. In randomized trials, equipoise, which is typically required for randomized trials and means investigators genuinely do not know which approach is better, is usually standard, Kuerer stated. However, with this novel approach of surgical omission, there is no equipoise, he said.

Accordingly, these findings underscore a potential shift toward nonoperative management in carefully selected patients.

Importantly, the study did not require breast MRI for eligibility or biopsy planning, supporting the feasibility of this model across diverse clinical settings, he said. Image-guided stereotactic techniques were predominantly used for biopsy confirmation of response, indicating that this approach may be broadly applicable in routine practice, Kuerer concluded.

Videos

Henry M. Kuerer, MD, PhD, FACS, CMQ, discusses the feasibility of eliminating surgery in select patients with a pCR after neoadjuvant therapy for breast cancer. 

Dr Kuerer on the Safety, Feasibility of Omitting Surgery in Select Patients With HER2+, Triple-Negative Breast Cancer  

"People may say a lumpectomy is not a big deal, so why even do this [evaluation of the omission of surgery]? It is because I don't believe that those patients without any residual disease [after neoadjuvant therapy] will benefit from surgery."

Henry M. Kuerer, MD, PhD, FACS, CMQ, a professor and executive director of the Breast Programs of MD Anderson Cancer Network in the Department of Breast Surgical Oncology at The University of Texas MD Anderson Cancer Center, discussed the clinical rationale for evaluating the selective elimination of breast surgery in patients with HER2-positive or triple-negative breast cancer who achieve a pathologic complete response (pCR) following neoadjuvant systemic therapy.

Five-year follow-up of a phase 2 trial (NCT02945579) investigating the omission of surgery in patients with early-stage triple-negative breast cancer (TNBC) or HER2-positive disease who achieved a complete response to neoadjuvant systemic therapy showed promising long-term outcomes. At a median follow-up of 55.4 months (IQR, 44.0-63.5), among 31 evaluable patients who did not undergo surgery, the ipsilateral breast tumor recurrence rate was 0%, and both 5-year disease-free survival (DFS) and overall survival (OS) were 100%.

This strategy was driven by the recognition that a substantial proportion of patients with early-stage TNBC or HER2-positive breast cancer now achieve high responses following neoadjuvant chemotherapy, Kuerer stated, adding that the pCR rates for these subtypes, even without the addition of immunotherapy, approach 60%. The rationale for evaluating the omission of surgery centers on the hypothesis that patients without residual disease may derive limited benefit from surgical intervention, including lumpectomy, he explained.

However, one of the primary challenges in identifying these patients lies in the limitations of imaging modalities—mammography, ultrasound, and breast MRI—which may inaccurately estimate the extent of residual disease, Kuerer said. To address this, the investigators developed a rigorous protocol involving strict eligibility criteria and a biopsy approach designed to optimize diagnostic accuracy, he stated. Specifically, they used image-guided vacuum-assisted core biopsy of the tumor bed following neoadjuvant therapy, which in prior analyses demonstrated an accuracy of approximately 98%, Kuerer noted.

This biopsy technique involves inserting a single device under image guidance to systematically sample around the tumor bed, he detailed. The group’s foundational research determined that approximately 12 tissue samples were needed to ensure adequate detection of residual disease, Kuerer shared. The investigators emphasized that inadequate sampling and loose selection criteria in other studies have contributed to higher false-negative rates, highlighting the importance of methodological precision in this surgical omission approach, he concluded.

Henry M. Kuerer, MD, PhD, FACS, CMQ, discusses eliminating surgery for select patients with a pCR after neoadjuvant therapy for early breast cancer.

Dr Kuerer on the Rationale for Eliminating Surgery in Select Patients With HER2+ or Triple-Negative Breast Cancer

, which provides oncology professionals with the resources and information they need to provide the best patient care. In both digital and print formats, OncLive covers every angle of oncology practice, from new technology to treatment advances to important regulatory decisions.

In today’s OncClub episode, we had the opportunity to speak with Henry M. Kuerer, MD, PhD, FACS, CMQ, about the potential to safely omit surgery in a subset of patients with early-stage HER2-positive or triple-negative breast cancer who achieve a pathologic complete response (pCR) following neoadjuvant systemic therapy. Dr Kuerer is a professor of breast surgical oncology at The University of Texas MD Anderson Cancer Center in Houston, Texas.

In our conversation, Dr Kuerer reviewed the rationale behind a prospective phase 2

clinical trial (NCT02945579) testing image-guided vacuum-assisted core biopsy to identify patients with no residual disease after neoadjuvant therapy. He outlined the strict technical and eligibility criteria that enabled accurate detection of pCR—including tumors downsizing to less than 2 cm and biopsy of at least 12 cores from the tumor bed—and discussed why this biopsy-based approach may be more reliable than standard surgery in detecting residual disease. He also highlighted the broader clinical implications of the findings, noting that patients with biopsy-confirmed pCR may proceed directly to radiotherapy and avoid breast surgery altogether.

 to see additional findings and insights from this research! 

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Podcasts

Dr Kuerer discusses the potential to omit surgery in patients with HER2-positive or triple-negative breast cancer who have pCR after neoadjuvant therapy. 

Biopsy-Guided Approach Enables Surgery Omission After pCR in HER2+ and Triple-Negative Breast Cancer: With Henry M. Kuerer, MD, PhD, FACS, CMQ

Our 5-year analysis of the trial demonstrated that this new paradigm for the management of highly selected patients with HER2-positive and triple-negative breast cancer is both safe and effective."

Henry M. Kuerer, MD, PhD, FACS, CMQ, a professor and executive director of the Breast Programs of MD Anderson Cancer Network in the Department of Breast Surgical Oncology at The University of Texas MD Anderson Cancer Center, discussed long-term outcomes from a phase 2 study (NCT02945579) evaluating the selective elimination of breast surgery in patients with exceptional response to neoadjuvant systemic therapy for early-stage breast cancer.

The trial assessed whether surgery could be feasibly and safely omitted in a highly selected group of patients with HER2-positive or triple-negative invasive breast cancer who achieved radiographic resolution and biopsy-confirmed pathologic complete response (pCR) following neoadjuvant therapy. In lieu of surgery, patients underwent radiation therapy as the sole local treatment modality, Kuerer explained.

At a median follow-up of 55.4 months (interquartile range, 44.0-63.5), the ipsilateral breast tumor recurrence rate was 0%, with 100% ipsilateral breast tumor recurrence–free survival,, disease-free survival, and overall survival rates observed, Kuerer reported. These findings support the oncologic safety of a nonoperative approach in select patients with breast cancer meeting stringent eligibility criteria.

This management strategy may offer a viable alternative to surgery in a subset of patients with favorable tumor biology and excellent response to therapy, Kuerer stated. The results represent a potential paradigm shift for patients with HER2-positive or triple-negative breast cancer, in whom modern systemic regimens frequently induce pCR. According to Kuerer, careful radiologic and pathologic assessment is essential to accurately identify those eligible for surgery omission.

Although these findings are promising, broader clinical application will require further validation in prospective, multicenter trials. Kuerer emphasized that patient selection remains critical, and omission of surgery should only be considered in the context of rigorous imaging, targeted biopsy, and multidisciplinary consensus. Additionally, long-term follow-up will be essential to ensure durable control and inform future guidelines on treatment de-escalation.

Henry M. Kuerer, MD, PhD, FACS, CMQ, discusses a study on selective elimination of breast surgery after exceptional response to neoadjuvant therapy in early breast cancer.

Dr Kuerer on Selective Surgery Omission After Response to Neoadjuvant Therapy in Invasive Breast Cancer

You would think that 15 years after experiencing my first episode of burnout, studying the subject and continually lecturing on it would ultimately have prevented it from coming back. This has not been the case. Burnout for me has been like the stock market—mostly going up and sometimes, though rarely, going extremely low.

How many reading this article routinely receive 100 or more work emails a day that often demand an immediate response? There are only so many hours in a day. We have to be accountable to our loved ones and ourselves. If you think you can take good care of your patients without taking good care of yourself and family, then you are dead wrong.

I hypothesize that what may have worked before to mitigate burnout may no longer work now. Why? Because one thing is certain: We change, and so do our work environments. Often we have minimal to no control over life and family events. Add to that the realities of practicing healthcare in the digital age, such as the burden of constant increases in expenses related to delivery of optimal patient care.

We age, our energy levels decrease without appropriate renewal, and our goals within our careers change. What might have worked as part of your personal wellness strategy may no longer be effective. As this article will describe, I may also have some underlying core issues to better manage.

In the academic world, senior faculty commonly take on many other roles and duties. And most of the time, we do not give up things to make time for new roles.

To some extent, it is on us to speak up about toxic work environments to ensure that we deliver the highest-quality patient care with appropriate resources to be efficient and effective in our practices and hospitals. On the other hand, we are responsible for our lives and our behaviors. We need to set personal boundaries. We also need to enforce these boundaries and sometimes get help to strike a balance.

The statistics on physician suicide are alarming and tragic. A recent survey on physician burnout and suicide reported that about 23% of us have thought about suicide.

 Each year, at least the equivalent of 2 to 3 entire medical school classes of physicians die from suicide. It is quite sobering when you think about it in those terms.

Burnout is a syndrome of emotional exhaustion, depersonalization, and feelings of low personal accomplishment. It is an epidemic among us and much more common among physicians compared with other working adults. Depending on specialty, nearly 50% of US physicians meet the criteria for professional burnout.

 Our jobs as physicians can provide rich meaning to our lives, but factors beyond our control undermine this. In short, our work can be tough both physically and emotionally, and it takes a toll on our professional performance and satisfaction as well as on our personal health and happiness.

Long hours and demands for routine excellence, often in the most difficult situations, are the norm for cancer clinicians. Decreasing rates of reimbursement and increasingly complex rules of reimbursement further frustrate our efforts to achieve work-life balance. For those in academic medicine, funding for education, clinical trials, and basic research is at an all-time low despite the expectation that we will continue to excel in these arenas without appropriate resources. Trying to compensate by increasing already busy practices while maintaining our essential missions of teaching and research further compounds the problem. When burnout and career dissatisfaction ensue, everyone in our circle is adversely affected: our patients and their families, our colleagues and our staff, our trainees and students, and our families.

Denying That Problems Exist Does Not Make Them Go Away

Physicians share an unwritten but clearly understood code of rules, norms, and expectations. These often include coming in early and staying until the job is completed, working nights and weekends, seeing a high volume of patients under pressure, meeting multiple simultaneous deadlines, keeping emotions or personal problems from interfering with the job at hand, and facing adversity with vigor and resolve.

Pretending that burnout and other such maladies are a problem of the weak, the lazy, or the uncommitted is unhelpful. Many of us trained with mentors who perpetuated these myths, and we are at risk of repeating the cycle. Despite the prevalence of burnout in hospitals and clinics throughout America, we have increasing productivity requirements, creating “new normals” and all the while we are expected to continue delivering the same quality of care and to make the same contributions to research, education, and administration. We are not weak, lazy, or uncommitted. We are simply human. However, the bills must be paid.

However, hospitals and universities across America have a renewed interest in fostering work-life balance and preventing burnout. This is due to the very real recognition that burnout is extremely expensive for our healthcare system. When we lose the best and most experienced physicians to either retirement or another hospital system that may better respect their time and wellness, the system can lose millions of dollars in revenue and in the time and expenses related to recruitment.

On the bright side, the media has paid so much attention to physician burnout and the association with quality of care, increased litigation, costs, and patient satisfaction that I do believe this will become more of a central focus, leading to improvements.

Institutional Support Is Necessary to Maintain Physicians’ Health and Resilience

In the interest of maximizing quality patient care, there is no room for denial at the institutional level. Institutions play a decisive role in creating and preventing professional burnout. It is one thing to make sporadic difficult demands on surgeons; it is another to impose chronic difficult demands. It is one thing to place increasing high demands on physicians; it is another to place high demands without providing the resources to meet them.

Institutions around the United States are beginning to develop programs to prevent physician burnout and promote health and well-being. A strong business case exists for ensuring professional fulfillment, a culture of wellness, the efficiency of practice, and assistance in maintaining personal resilience. This is the central dogma for the Stanford Medicine WellMD Center, led by center director and chief wellness officer Tait Shanafelt, MD, a worldrenowned medical oncologist and a prolific investigator and speaker on physician wellness and prevention of burnout.

 Physicians and institutions can do many things to improve our work environments including the implementation of systems, processes, and practices that promote not only safety, quality, effectiveness, and positive patient and collegial interactions but also the vital component of commitment to work-life balance.

Any one of us can quickly list how our practices could be more efficient with appropriate assistance with patient intake, gathering of medical records, triaging to the right medical expert, real-time assistance with electronic health records, charting/scribing, billing, and follow-up. A pillar of the Stanford model of professional fulfillment includes a culture of wellness that starts at the top of the organization and includes all staff.

 These are not just platitudes but rather items that the organization needs to ensure to cultivate personal and professional growth. They are shared values that exist within the community that result in the development of compassion for all members of the team, including the leaders.

This high rate of burnout has also led many organizations to offer services and personal coaching on how to improve work-life balance for individual physicians.

A recent survey of 15,181 responding licensed US physicians included some interesting new data on burnout. The survey’s respondents comprised 23% millennials (ages 25-39), 35% Generation Xers (ages 40-54), and 41% baby boomers (ages 55-73). Approximately 42% of US physicians reported burnout, with certain specialties and generations being more affected than others.

Burnout ranged from 29% in public health and preventive medicine to 54% in the urology specialty. The highest rate of burnout occurred midcareer. The Generation X group had burnout in the range of 48%; the millennials, 38%; and the baby boomers, 39%. What is not new is that women suffered burnout more often than men (48% vs 37%, respectively). The biggest reported contributors to burnout included too much electronic charting/paperwork, too many hours at work, and lack of respect from administrators, employers, colleagues, staff. Twenty-nine percent of physicians reported feeling insufficiently compensated and reimbursed for work performed. The highest reported coping mechanism for dealing with burnout was, unfortunately, isolation, in 45% of physicians.

Most surprising to me was that 48% to 52% of physicians said they would voluntarily take a salary reduction to get a better work-life balance.

 I believe this will be a more formalized and increasingly common strategy for physicians, practices, and hospitals to ensure happier and more productive physicians, a model that many other professions have similarly employed. Specifically, I mean physicians will have alternative work schedules for various amounts of time per week; for example, 1 to 3 days versus full-time. This can be worked out for almost every specialty.

One of the biggest changes in the burnout field has been the shift away from blaming the victim. Essentially, this translates to having physicians attend stress management workshops, putting fitness centers in our hospitals, and teaching us yoga or mindfulness meditation to help fix the situation. As mentioned earlier, the next wave will be multifactorial and address the problem from many other directions, including the development of efficiencies in our practices that allow us to complete our work and go home for needed rest and renewal.

In 1985, Glen O. Gabbard, MD, noted the prevalence of shared “physician—personality” characteristics. We have many adaptive characteristics, including thoroughness, commitment, desire to stay current in practice, responsibility, trustworthiness, and an interest in helping other human beings. Many of the characteristics of a physician are maladaptive: difficulty relaxing, problems allocating time for our family and loved ones, a persistent sense of responsibility beyond what we can control, the feeling of never doing enough, difficulty setting limits and boundaries, often not taking time off, and not taking care of our own physical, spiritual, and emotional health.

Unfortunately, many of us are addicted to our work. The American Society of Addiction Medicine criteria regarding general signs and symptoms for an addiction include lacking the ability to stay away from destructive behaviors, ignoring relationships/isolation, ignoring potential consequences of maladaptive behaviors, increasing lack of interest in hobbies and activities that used to bring joy, irritability/ depression/apathy, and obviously ignoring self-care.8 Addicts also spend an inordinate amount of time with other addicts and time pursuing their addiction. If you look around, you, too, may be surrounded by others in your organization who appear to be workaholics.

Looking deeper into this, I was surprised to find Workaholics Anonymous, a 12-step program designed to help group members recover from their workaholism. In one of their brochures, they list 20 questions under the heading “How do I know if I’m a workaholic?”

 They mentioned that if a respondent answers yes to 3 or more questions, they could potentially be a workaholic or well on their way to becoming one.

I was shocked to note that I answered yes to 15 of the 20 questions. I think many of us would fit the criteria in this handout. They asked questions such as “Do you take work with you to bed? On weekends? On vacation? Have your family or friends given up expecting you home on time? Do you get irritated when people ask you to stop doing your work in order to do something else? Do you work or read during meals?”

I ran into a colleague this past week who was a bona fide workaholic and is now retired. She has indeed become a workaholic in retirement, as well, volunteering for numerous organizations and juggling endless meetings, conference calls, events, emails, etc. She was exhausted and very unhappy with the life she had created in her retirement. Why do I think this is important? Personally, I need to take some responsibility for my behavior and my part in creating an imbalance between my outside life and my job and take a closer look at the reasons for this. It’s easy to say that my work provides meaning and that I am doing important work or that I have a passion for my work. These are all true sentiments, but I need to take a good look within myself as well as within my field and organization.

Developing Our Own Strategies for Work-Life Balance

There is no magic formula for establishing a better work-life balance and happiness in our chosen professions. It is a huge loss to society and to our fields when experienced physicians leave practice because of burnout. Fortunately, most of us can recraft our jobs to better meet our needs. After some critical personal work and soul-searching, you may ultimately decide that your current profession is no longer serving your best interests. That is also OK. That is not a personal failure; it is simply a new beginning.

It is never too late to reinvent yourself and your life. The fact that you’re reading this article is already a step forward in this path.

Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. 

. 2009;374(9702):1714-1721. doi: 10.1016/ S0140-6736(09)61424-0.

Kane L. Medscape national physician burnout & suicide report 2020: the generational divide. Medscape website. medscape.com/ slideshow/2020-lifestyle-burnout-6012460. Published January 15, 2020. Accessed February 10, 2020.

Shanafelt TD, Boone S, Tan, L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. 

. 2012;172(18):1377-1385. doi: 10.1001/archinternmed.2012.3199.

Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. 

. 2017;177(12) 1826-1832. doi: 10.1001/jamainternmed.2017.4340.

WellMD Center. Stanford Medicine website. wellmd.stanford. edu/center1.html. Accessed February 10, 2020.

Stop physician burnout. The Happy MD website. thehappymd. com. Accessed February 10, 2020.

Gabbard GO. The role of compulsiveness in the normal physician. 

American Society of Addiction Medicine. An introduction to the ASAM criteria for patients and families. Aetna website. aetna.com/ healthcare-professionals/documents-forms/asam-criteria.pdf. Published 2015. Accessed February 10, 2020.

A brief guide. Workaholics Anonymous website. workaholicsanonymous. org/pdf_files/ABriefGuide.pdf. Updated March 2006. Accessed February 10, 2020.

View more from the 2020 Miami Breast Cancer Conference

Taking exquisite care of our patients is not enough; we must also care for ourselves. In so doing, we can become more resilient and productive over the long term. Achieving career satisfaction and work-life balance requires personal attention, and cultivating the 6 areas of our lives—beliefs, relationships, renewal, habits, skills, and personality traits&mdash;can provide an effective road map (

Articles

What may have worked before to mitigate burnout may no longer work now because we change, and so do our work environments.

Henry M. Kuerer, MD, PhD, FACS, CMQ

Articles

Dr Kuerer on the Safety, Feasibility of Omitting Surgery in Select Patients With HER2+, Triple-Negative Breast Cancer

Dr Kuerer on the Rationale for Eliminating Surgery in Select Patients With HER2+ or Triple-Negative Breast Cancer

Biopsy-Guided Approach Enables Surgery Omission After pCR in HER2+ and Triple-Negative Breast Cancer: With Henry M. Kuerer, MD, PhD, FACS, CMQ

Dr Kuerer on Selective Surgery Omission After Response to Neoadjuvant Therapy in Invasive Breast Cancer

Burnout in Doctors and Mitigation Strategies