By Karuna Jaggar, Executive Director
In the U.S., we live in a culture where it’s often assumed that more treatment is always better. But over the years there have been a number of important shifts in breast cancer treatment because of data showing us that less is actually better for patients. Twenty years ago, women with breast cancer were given high doses of chemotherapy with stem cell transplant, an extremely aggressive treatment that did not produce the hoped-for results and is now considered somewhat barbaric. Another example where less turned out to be better for patients is the shift from removal of all lymph nodes to removal of only the sentinel node.
In the opening plenary lecture first thing on Wednesday morning, Dr. Jay R. Harris argued that there are some patients who can safely omit radiation after lumpectomy. In a separate blog post, I review the data that Dr. Harris relied on to conclude that women age 50 and older with small (low grade), node negative luminal A breast cancers can safely avoid radiation. (As with radiation, chemotherapy is not worth it in some cases where the benefit is very small. And there has been a push to find tests to help predict risk, such as OncoType, although not reviewed or discussed so far this year.)
As a particularly graphic reminder that less can be better for patients, Dr. Norman Wolmark (Allegheny General Hospital, Pittsburgh, PA)took us back to the days of the Halsted radical mastectomy and the role of clinical trial data in shifting the enduring assumption that more surgery produces better outcomes.
Wednesday afternoon opened with a Danish presentation showing no difference in overall survival between patients who had repeat surgery or not after lumpectomy with positive margins. Breast conserving surgery has been around for 20 years and many women are recommended for a second surgery (re-excision) because of positive margins. In fact, the rate of repeat surgery in Denmark between 2000 and 2009 was nearly one in five, with 11% of women undergoing re-excision and 6% undergoing mastectomy. The standard of “clean margins” has shrunk in recent years, which itself has helped reduce the need for second surgeries. Despite the fact that 20% of all patients had residual disease in resected tissue, it can be relieving for women to know that overall survival is not affected by whether or not women undergo a repeat surgery.
This theme of “less is more” was underscored in a panel discussion as part of the “Hot Topics” Mentor Session hosted by the Alamo Breast Cancer Foundation. Dr. Debu Tripathy noted that our bodies have many protective systems and that all individual cancer cells do not necessarily become cancer. (As Dr. Susan Love says, just because you get on the highway in Los Angeles does not mean you will get all the way to San Diego!) Some cancerous cells self-destruct. Others are handled by our immune system. He suggests that the number of cancers diagnosed are probably not a very good sense of what is going on in the body.
This recognition that the body can and does eliminate some cancer cells without surgery, radiation or systemic therapy helps us understand overdiagnosis, and how it is that some women treated for breast cancer do not benefit from treatment (because these cells would not have been lethal).