'Cutting Edge' in Local Breast Cancer Therapy

Kathy D. Miller, MD; J. Michael Dixon, MD


December 23, 2013

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Kathy D. Miller, MD: Hi. I'm Kathy Miller, Associate Professor of Medicine at Indiana University School of Medicine in Indianapolis. Welcome to this edition of Medscape Oncology Insights.

Today we are going to look at several key studies that tell us about the surgical management of breast cancer. These are all recent studies that have been presented at the 2013 San Antonio Breast Cancer Symposium. Joining me for that discussion is Professor Mike Dixon, Professor of Surgery and Consultant Surgeon at the University of Edinburgh. Welcome, Mike.

J. Michael Dixon, MD: Glad to be here.

Local Therapy: More Interesting, More Individualized

Dr. Miller: I have to admit, as a nonsurgeon, local therapy used to seem simple and boring. You did a mastectomy or a lumpectomy with radiation. You irradiated the whole breast, you took out the axillary lymph nodes, and that was it. You were done.

Dr. Dixon: The problem is, first of all, a mastectomy is a fairly destructive operation. Second, even a lumpectomy can differ in different people's hands. They remove different amounts of tissue. So, some of the patients were left with poor cosmetic outcomes.

Then, of course, the axillary surgery is associated with significant morbidity. So it may have sounded easier, but often the patient didn't come out of it very well.

Dr. Miller: The good news is that local therapy has gotten a lot more complicated, and a lot more interesting over the past couple of years, with a lot of data suggesting that local therapy is probably more important than the medical oncologist might have thought.

Dr. Dixon: That is true, in part. As surgeons, we have understood that part of the reason that we are seeing less local recurrence is the improvement in medical systemic therapy. As the systemic therapy has become better, our local recurrence rates have fallen. Surgeons need to do less. We need to target that surgery so that we do good, and don't do harm.

Dr. Miller: Let's talk about the biggest harm that surgeons do -- axillary node dissections. We came to grips several years ago with the fact that sentinel nodes gave you very good predictive information. When the sentinel node has been negative, we have been comfortable for a number of years with stopping axillary dissection. It has been harder to convince folks that you might also be able to stop if the sentinel lymph node is positive.

Dr. Dixon: That is true, and if you look, for instance, in the United States, many more people have been prepared to stop axillary lymph node dissection in patients with a small number of positive lymph nodes (following on from Z0011[1]) than they have been in other countries.

There is very good evidence now that if you have a limited amount of axillary lymph node involvement, you probably don't need an axillary lymph node dissection.

Dr. Miller: Should you follow the AMAROS[2] plan and irradiate those patients? Or, the Z0011 plan and just stop right there and do nothing further?


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