Judy C. Boughey, MD, breast surgical oncologist, division chair, Breast and Melanoma Surgical Oncology, chair, Breast Cancer Disease Group, Mayo Clinic Comprehensive Cancer Center, discusses key characteristics that define the ideal population for surgical de-escalation among patients with breast cancer.

Within the breast cancer field, there is a growing emphasis on tailoring surgical interventions to individual patients to minimize potential surgical complications, Boughey begins. To identify the ideal candidates for surgical de-escalation, their specific patient characteristics and tumor biology are considered, Boughey states. Patients most suited for surgical de-escalation typically exhibit favorable prognostic features, she explains, indicating that they are likely to achieve responses despite undergoing less extensive surgery. This includes individuals with smaller tumors and biologically favorable tumor subtypes, such as luminal A breast cancers, Boughey notes.

The assessment of breast and axillary lymph nodes throughstandard imaging modalities also plays a pivotal role in surgical decision-making, Boughey continues. Recent efforts in surgical de-escalation have centered on avoiding axillary surgery whenever possible, Boughey says. To achieve this, clinicians must accurately identify patients with a high probability of developing negative lymph nodes, as these individuals are not likely to require lymph node removal, Boughey states. Patients who fit this profile are typically older, have small, low-grade tumors, and have favorable pathological features like tubular breast carcinoma or low Ki-67 expression, she details.

Clinicians confirm the presence of these clinical characteristics with imaging assessments, such as axillary ultrasound and magnetic resonance imaging, to ensure that lymph nodes appear normal, Boughey adds. By leveraging the available clinical and imaging data, clinicians can stratify patients who are most likely to display negative lymph nodes, Boughey says. This approach enables patients to avoid unnecessary axillary surgery, reducing disease burden, she emphasizes. Boughey concludes that this shift toward surgical de-escalation marks a promising advancement in breast cancer management.

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Judy C. Boughey, MD, discusses key characteristics that define the ideal population for surgical de-escalation among patients with breast cancer.

Dr Boughey on Defining Optimal Candidates For Surgical De-Escalation in Breast Cancer

Judy C. Boughey, MD, breast surgical oncologist, division chair, Breast and Melanoma Surgical Oncology, chair, Breast Cancer Disease Group, Mayo Clinic Comprehensive Cancer Center, discusses the significance of results from the phase 2 ACOSOG Z11102 (Alliance) trial (NCT01556243) evaluating breast conserving therapy (BCT) in multiple ipsilateral breast cancer (MIBC). 

The single-arm, prospective trial evaluated the effect of BCT when combined with whole breast radiation therapy on the local recurrence rate in patients over 40 years of age with MIBC. The study enrolled 270 patients, 204 of which were deemed evaluable, with the primary end point of a 5-year local recurrence rate for BCT, which was defined as less than 8%. 

Results from the trial were presented at the 2022 San Antonio Breast Cancer Symposium, whichdemonstrated that the estimated 5-year local recurrence rate was 3.1%, which was deemed clinically acceptable, Boughey states. Patients with endocrine receptor (ER)–positive breast cancer who did not pursue endocrine therapy had a higher rate of local recurrence compared with patients who did, Boughey says. This indicates that adherence to endocrine therapy is associated with low rates of local recurrence across most breast cancer populations, she explains. Other factors such as patient age, number of preoperative biopsy sites, and HER2 status were not found to be associated with risk of local recurrence.

Moreover, the study included 15 patients who did not undergo a preoperative breast magnetic resonance imaging (MRI) scan, Boughey continues. An unplanned secondary analysis of this population revealed that these patients had a significantly higher rate of local recurrence than those who underwent preoperative breast MRIs.

Definitive conclusions cannot be drawn from these data due to the limited patient population, Boughey cautions. However, for patients who have 2 or more foci of disease in the breast, it is reasonable to suggest a breast MRI in order to evaluate the risk of disease, she says. The MRI can then evaluate the extent of a patient’s disease before they commit to the operation, Boughey concludes. 

Judy C. Boughey, MD, discusses the significance of results from the phase 2 ACOSOG Z11102 trial evaluating breast conserving therapy in multiple ipsilateral breast cancer. 

 Dr. Boughey on Key Results From the ACOSOG Z11102 Trial in Multiple Ipsilateral Breast Cancer

Judy C. Boughey, MD, chair, Division of Surgery Research, Mayo Clinic, discusses the surgical management of patients with node-positive breast cancer.

Traditionally, patients with node-positive breast cancer received a full axillary dissection. However, work is investigating whether patients who receive neoadjuvant chemotherapy can avoid the morbidity of the procedure and receive a sentinel lymph node surgery instead. Trials to date have shown false negative rates with the procedure, but there have been several advances in approaches that are driving down the false negative rate and improving the safety of the procedure, Boughey explains.

Examples of these approaches include ensuring that the surgeon uses a dual tracer to increase the identification rate of the sentinel node and decrease the false negative rate associated with sentinel lymph node surgery. Another technique is using a clip to identify the lymph node during surgery. A third technique that is widely adopted is the use of immunohistochemistry to better select patients who stand to benefit from an axillary lymph node dissection.

Dr. Boughey on Surgical Management of Patients With Node-Positive Breast Cancer

Judy C. Boughey, MD, chair, Division of Surgery Research, Mayo Clinic, discusses the surgical approach for patients with HER2-positive breast cancer.

There is not usually a difference in surgery among patients with differing subtypes of breast cancer, Boughey explains, as most surgical resections are based on the relationship between tumor size and breast size, extent of disease in the lymph nodes, and patient preference.

Among patients treated with neoadjuvant chemotherapy higher response rates have been seen in those with triple-negative or HER2-positive disease. Therefore, patients with HER2-positive breast cancer are more likely to benefit from neoadjuvant therapy, as well as breast conservation surgery versus mastectomy.

Dr. Boughey on Surgery in Patients With HER2+ Breast Cancer

Judy C. Boughey, MD, chair, Division of Surgery Research, Mayo Clinic, discusses locoregional clinical trials for breast cancer.

Boughey stresses the importance of understanding active clinical trials and unanswered questions to advance breast cancer care. For example, a recent study examined patients with node-positive breast cancer treated with neoadjuvant chemotherapy. Medical oncologists, she adds, are becoming more effective at administering systemic therapy.

While systemic therapies and targeted therapies are improving, Boughey says that surgical oncologists are also observing less disease in the breast and lymph nodes prior to surgery. This raises the question whether or not surgical oncologists need to remain maximally invasive in these patients or if they can adjust surgical management. 

Dr. Boughey on Locoregional Trials for Breast Cancer

Judy C. Boughey, MD, associate professor of surgery, director, Breast Surgical Oncology Training Program, Mayo Clinic, on breast conservation in patients with multiple ipsilateral tumors.

In clinical practice, a second or third focus of cancer is often found after women are initially diagnosed with breast cancer, Boughey says, and the recommendation for multiple ipsilateral tumors has historically been mastectomy.

The question remains as to whether or not these women should undergo mastectomy or if the opportunity exists to preserve the breast. A prospective clinical trial is currently ongoing to answer this question. The patients in the study will receive a lumpectomy before being treated with radiation. Boughey notes that this question is important because mastectomy rates are increasing in parallel with the use of MRI.

Dr. Boughey Discusses Breast Conservation in Patients with Multiple Ipsilateral Tumors

Judy C. Boughey, MD, associate professor of surgery, director, Breast Surgical Oncology Training Program, Mayo Clinic, discusses implications for axillary radiation following review of the ACOSOG Z11 trial.

Boughey says the trial has left physicians with a big question. Data from the study suggested that the patients should not receive radiation directed towards the axilla, but no data was collected on how the patients were treated. This finding led some physicians to believe that some radiation oncologists may have radiated the axilla due to the low rate of recurrence seen in the trial, Boughey says. Definitively radiating the axilla would have been a protocol violation, but the procedures were not tracked well during the trial.

A recent study was presented in which ACOSOG researchers looked at radiation reports from the trial. Boughey says these results showed that the majority of patients were treated with standard tangents and not with definitive radiation to the axilla. In the study, 89% of patients received radiation to the breast and about 15% had definitive radiation to the supraclavicular area.

A small subset of 200 patients from the study showed no difference in the radiation field planning between the group that was randomized to sentinel node only and the group that underwent axillary lymph node dissection. Boughey says this is encouraging information, but it is too small of a group to provide a definitive answer.

Dr. Boughey Discusses the Z11 Trial in Breast Cancer

Judy C. Boughey, MD, associate professor of surgery, director, Breast Surgical Oncology Training Program, Mayo Clinic, discusses surgical resection of the primary breast tumor in patients with stage IV breast cancer.

Over the last 3-5 years, there has been data presented that supports surgical resection in this space as well as data that demonstrates the opposite.

It is critical to evaluate the patient, the patient’s tumor factors, and, most importantly, the patient’s response to systemic therapy. Boughey says she always informs patients that there is no strong data regarding the best way to treat them in terms of surgical resection. Surgery must be performed in a way that ensures minimal morbidity.

Dr. Boughey on Surgical Resection of Stage IV BC

Judy C. Boughey, MD, associate professor of surgery at the Mayo Clinic in Rochester, Minnesota, discusses surgical techniques examined in the American College of Surgeons Oncology Group (ACOSOG) Z1071 study that could help minimize the false negative rates experienced with sentinel lymph node (SLN) surgery.

The Z1071 trial found that SLN surgery was able to detect residual nodal disease in approximately 91.2% of women with early-stage breast cancer, following neoadjuvant chemotherapy. However, the false negative rate for those receiving SLN surgery was 12.6%. Boughey notes that a clinically acceptable false negative rate is generally considered to be 8-10%, warranting further investigation into approaches that reduce this rate.

In general, the Z1071 trial found that using both a blue dye and radiolabeled colloid mapping agent decreased the false negative rate to 10.8% and when more than 3 SLN were examined the rate decreased to 9.1%. Combining these approaches could further reduce the false negative rate into a clinically acceptable level, Boughey believes.

Judy C. Boughey, MD, from the Mayo Clinic in Rochester, MN, discusses surgical techniques examined in the Z1071 study that could help minimize the false negative rates experienced with SLN surgery.

Judy C. Boughey, MD

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