Are too few women being offered breast-conserving treatment?

Two new studies presented at the ESMO 2012 Congress in Vienna, Austria show how improvements in breast cancer treatments are making it possible for more women to conserve their breasts following therapy, but raise concerns about whether enough women are being offered these approaches.

Prof Michael Gnant, a from Vienna's Medical University, who was not involved in the studies, commented: "Clearly, advances in interdisciplinary preoperative approaches have contributed to the revolution in that has provided huge benefits to women in the . Less , conserving approaches as standard of care, sentinel node surgery, reduced pain and hospital stays, have been achieved. Modern aims at fine-tuning and even improving these ."

Call for action to improve rates of breast-conserving surgery

A new study suggests that not enough women with are being offered the chance to undergo the kind of treatments that may conserve their breasts.

At the ESMO 2012 Congress, Dr Carmen Criscitiello from the European Institute of in Milan, Italy, and colleagues report on an analysis of the different factors that may have affected the choice of surgery offered to patients in the NeoALTTO trial, which showed that the combination of , lapatinib and significantly increased the rate of tumor eradication (pathological complete response) compared to paclitaxel combined with either drug alone. The NeoALTTO trial was published in January this year.

Despite this high rate of response, the proportion of women receiving breast-conserving surgery remained around 40%, regardless of which treatment the 429 women in the study received.

"The with paclitaxel plus and trastuzumab within the NeoALTTO trial nearly doubled the rate of pathological complete response compared to treatment with paclitaxel combined with either drug alone," said Dr Criscitiello. "However, this successful result did not translate into a higher rate of breast conserving surgery. Indeed, we saw that tumor characteristics prior to neoadjuvant therapy play a main role in deciding the type of surgery, irrespective of the response to given therapies."

"This study highlights a negative attitude that may deny a large fraction of women the chance of preserving their breast, with no clinical reasons that justify this decision. One of the goals of the neoadjuvant therapy concerns increasing the rate of breast conservation, but this goal is clearly not achieved if the type of surgery is chosen according to baseline characteristics."

Dr Criscitiello and colleagues call for a clear consensus in the role of breast conserving surgery for patients responding to neoadjuvant therapy. "This will translate the progress in neoadjuvant therapies and the consequent high pathological complete response rates into higher rates of breast conservation," they say.

Prof Gnant added: "Dr. Criscitiello's work is very important in our goal to further increase breast conservation rates. Particularly in biologically aggressive subtypes of breast cancer, such as HER-2/neu over-expressing disease, there is still some hesitation in applying breast-conserving surgical strategies. The abstract suggests that —particularly in patients with an excellent response— a more proactive approach to breast conservation can be used, given the advances in targeted therapy. While long-term confirmation on locoregional control is awaited, I agree that modern breast cancer surgery should orientate its strategy according to the post-treatment outcome rather than the baseline situation. When this is implemented in more centres (as some —including ours— already have), even more women will benefit from the advances in multimodality treatment."

Synchronous radiotherapy and chemotherapy improves outcomes, without damaging breast cosmesis

Treating women with early breast cancer using chemotherapy and radiotherapy at the same time reduces the risk of recurrence, without having a negative impact on breast appearance, say British researchers at the ESMO 2012 Congress.

Dr Indrajit N Fernando from University Hospitals Birmingham NHS Foundation Trust and colleagues took breast photographs of 301 women who underwent breast surgery in the study, and asked them about their own perceptions before surgery and 1, 2 and 5 years after surgery. The women included in this analysis were a subset of patients from a trial of 2296 randomized to receive either sequential or synchronous chemo-radiation.

Their aim was to study cosmesis —the overall aesthetic appearance of the breasts— and telangiectasia, the appearance of small red blood vessels on the surface of the skin.

"There was no significant difference in cosmesis or telangiectasia between the two arms as assessed by the clinician or by independent photographic review. There was no difference in patient perception of breast appearance," they report.

Prof Gnant noted: "The report from Birmingham adds important information to the current concept of post-surgical adjuvant therapy. While concomitant radiotherapy and chemotherapy is contradictory to most institutions' current standards, it is apparently feasible without additional harm. Clearly, such data must be confirmed in other studies, and the benefits and risks of this approach have to be carefully balanced. Also, longer follow up is important to ensure the safety of this approach."

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