Dr. Borgen on the De-Escalation of Surgery in Breast Cancer

Patrick I. Borgen, MD, chair of the Department of Surgery and director of the Breast Cancer Program at Maimonides Medical Center, discusses the trend toward surgical de-escalation in patients with breast cancer.

Historically, almost every woman with breast cancer would undergo a mastectomy to remove the entire breast, says Borgen. In the late 1980s and early 1990s, the field began to move toward an era of breast conservation therapy. Eventually, sentinel lymph node mapping was utilized rather than removing multiple lymph nodes.

The emergence of neoadjuvant therapies into the treatment paradigm will likely further de-escalate surgery, says Borgen. Women who would have needed to undergo a mastectomy due to either extensive disease or poor breast-to-tumor size ratio, can now receive neoadjuvant treatment and potentially become a candidate for breast conservation.

At the 2020 Miami Breast Cancer Conference, the role of targeted axillary node dissection was a topic of discussion, adds Borgen. Although patients with high anatomic levels of axillary nodes have an increased risk of lymphedema and morbidity, level 3 lymph node removal is rarely performed anymore.

The question of whether there is a group of patients who may have exceptional responses to neoadjuvant therapy and can forego surgery completely remains unanswered, says Borgen. As more targeted and efficacious therapies move to the forefront of treatment, the role of surgery will continue to decline, concludes Borgen.

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