Professor Michael Gnant is a Professor of Surgery at the Medical University of Vienna, Austria, where he also serves as president of the Austrian Breast and Colorectal Cancer Study Group.
He was also a guest speaker at Breast Cancer Trial’s 45th Annual Scientific Meeting in Cairns. We spoke to him about the trends in surgery de-escalation and management of the axilla.
“The reason for me attending the Annual Scientific Meeting of Breast Cancer Trials is that we have developed a pretty good collaboration in recent years, doing global academic clinical trials for early breast cancer together.”
“And I was invited to share some of the experience in creating an academic study group, as well as some of the aspects of modern contemporary breast cancer surgery and medical treatment.”
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We spoke with Professor Michael Gnant about trends in surgery de-escalation and management of the axilla.
What is surgery de-escalation?
“Well, historically breast cancer surgery was amputation. Basically, we have moved from there to breast conservation as the gold standard of care. I think that’s still an important goal in addition to providing care for our patients.”
“Obviously, we want to succeed in preserving their physical integrity as much as possible. And for the surgeon, that means preserving the breast. I think strategically, we have learned a lot, both in terms of surgical technique, but also in terms of changing the order of treatments, such as bringing the medical treatment before the breast surgery itself shrinking down the tumour, thus enabling breast conservation in situations where previously mastectomy would’ve been the case.”
“But I still believe it’s an important goal to eliminate mastectomy eventually. When you ask patients before their treatment, what do you want the outcome to be? Obviously their first thought is ‘I want to be cured’. And fortunately, we can achieve this nowadays for the majority of breast cancer patients.”
“But in addition, we want to keep our treatments as acceptable as possible. That means side effects need to be controlled and impacts on quality of life need to be alleviated.”
“In terms of breast surgery, that obviously means avoiding mutilating amputations, because quite obviously, aesthetic, physical appearance, and the continuation of integrity of a woman’s body, these are also very important goals that never should compromise the cure aspect. But in most instances nowadays they can be ideally combined.”
What are some examples of surgery de-escalation in breast cancer?
“Examples of surgical de-escalation, in addition to like moving from mastectomy to breast conservation as a standard of care, mainly means in recent years the different treatment of the axilla, under the armpit. There are lymph nodes that used to be removed for diagnostic purposes, which historically had some adverse effects like lymphoedema, which is swelling of the arm which can impair our patient’s quality of lives for good.”
“And we have moved away from doing that to a more selective approach where this is called the sentinel node procedure. So, we just take one or two nodes, check them under the microscope. If they are okay, then the remaining lymph nodes can stay in place.”
“Meanwhile, even in some situations where certain nodes are affected by the disease, we have developed techniques and strategies, to leave the axilla alone to avoid surgical complications.”
“I think nowadays it is obligatory that we have what is called shared decision making. Eventually patients have to know about the options and to decide eventually what is the individually best solution for that.”
How are treatment decisions made with both the patient and the treatment team?
“Having said this, obviously it sounds a little bit easier than it actually is. There’s a lot of confusing information out there. I mean, when you Google or use social media, you will get all kinds of information without knowing what is accurate, and what is not. So, I think it’s good that we have informed decision making nowadays with multiple sources, but it eventually doesn’t take away the need for a trusted caregiver.”
“At some point, even when you do all your research, most profoundly, you will have to trust the caregiver who tells you this is what I believe is the best situation for you. Or sometimes there might be two or three options, and here are the advantages, here are the disadvantages, to help you make your choice.”
“That needs time that in reality is not always available. So, I think healthcare systems need to keep in mind that if we want to achieve that, and everybody talks about shared decision making, we also need to provide the necessary resources in terms of caregivers’ time. And that’s a challenge in many places around the world.”
What are the primary goals of surgery in managing breast cancer?
“Well, I think that the goals of breast cancer treatment in general are curing the disease, preservation of quality of life, and eventually just getting rid of the problem. And that’s fortunately possible now for the majority of people affected by the disease, which is quite different than the perception and expectation.”
“So, I think one of the most important jobs that we have, particularly in the beginning of the interaction, is to take away the panic, to try to alleviate the fear, to be realistic on one hand, but also optimistic because there’s a reason to be. Clinical research has helped in the last two decades, both in my country as well as in Australia and New Zealand, to cut back by at least 25-30% of the mortality of the disease.”
“The majority of patients being affected with breast cancer nowadays will die from something else, which is the ultimate definition of cure, from our perspective. So, I believe that finding that balance between, yes there is a problem, we need to do something, we need to be mindful, but also, yes it can, for most cases, be resolved.”
“Even when you are at an advanced stage of the disease, nowadays, that means that you can still live for many years and live well. So, I think we can have a rather optimistic outlook into the future.”
What research has been done in this area?
“I think the main advances of surgery is both in the technical field, there is advances in the surgical techniques in terms of strategies, conception, but probably the implementation of a strictly interdisciplinary process.”
“I remember having a patient about 25 years ago and she said, I had a dream, and the dream would be that all the experts of the world come together and discuss my case. And then they would find the optimal solution for me and suggest it to me. So, I keep thinking of her because actually that’s now reality.”
“You have the experts of an institution, involved in national and international case discussions. We have guidelines and recommendations, that are moving the field forward. In addition to all the advances in individual disciplines, such as surgery, medical oncology, radiotherapy, I think the main progress has been made that these people now on a regular basis discuss every patient.”
“They optimise and individualize the treatment approach, which may mean that surgery is not the first step. We may start with some infusion treatment for six months, shrinking the tumour, rendering the surgery much easier. I think that’s what we have learned recently.”
What is the role of the axillary lymph node dissection in breast cancer treatment?
“It’s important to realise that historically the axilla was treated with curative intent. So, removing disease that sits there. Now that has changed, not in all cases. There are still situations of locally advanced regional breast cancer where that aspect is still there and needs to be done.”
“However, as a diagnostic procedure. The invasiveness of what surgeons are doing under the armpit has been massively reduced. Reducing axillary dissection to sentinel node procedure, maybe even not touching the axilla in selected cases, that’s a very new development and needs to be applied in clinical practice with caution.”
“But we see some data that not everybody necessarily may need axillary surgery. However, it’s also kind of a fashion to de-escalate and we need to be mindful that, for example, the number of lymph nodes affected by the disease could offer important information in helping to tailor the individual’s adjuvant treatment.”
“So, it’s always important to find a balance between, the fashion trend, which is de-escalation, whilst also maintaining what is necessary for an optimal treatment decision.”
What’s been the primary evolution in this area?
“Traditionally, the concept was when the central node is negative, that’s it. When the central node is affected, there will be a full accelerator section. That has changed recently. Nowadays, if there is limited involvement of the central nodes, one to two accelerator nodes. Accidental dissection may not be a necessary unless there is additional information important for further treatment decisions.”
“But we are testing these concepts in the context of clinical trials, which is always important because just having a nice idea is not good enough if you want to change standard practice. We obviously have to prove that this is beneficial and without harm at the same time. With respect to alternatives to axillary node dissection, there have been trials demonstrating that radiotherapy can also do the job in controlling the disease.”
“Personally, I have to say I’m rather critical of that substitution of surgical techniques with radiotherapy while acknowledging that disease control would be the same. If we leave the lymph nodes in there, we don’t have the information whether they are affected or not. So, I think it’s important to understand that disease control, yes, radiotherapy to the axilla might be equally effective compared to surgery.”
“But when I remove five nodes, and I know two out of five are affected, that’s important information for the treatment decision. When I just irradiate the axilla, I don’t know if that’s one node, two nodes, or even five nodes? So, I missed that information. with all the hype about surgical de-escalation, we need to be careful not to de-escalate surgery too much and then compensate with the escalation of radiotherapy.”
“As a matter of fact, modern breast cancer radiotherapy is also de-escalating, and reducing from five weeks to two weeks down to five days, maybe not having to irradiate all patients. So, I think it would be unfair to abuse, so to speak, radiotherapy to compensate for insufficient surgery.”
Are there specific breast cancer diagnoses where ALNDs are still relevant?
“I think with all the reduction in the frequency of ALNDs we are doing, we need to realise when there is Crohn’s disease, when there is symptomatic disease. Unfortunately, we’re still not catching every situation early enough, and in those cases then yes, there is a role for curative axillary dissection. Having said this, in a locally advanced situation nowadays, we usually start the treatment with medical treatment, because that has been proven effective.”
“We want to reduce the extent of the disease before tackling it with local regional treatment.”
What are the main advancements or excitements around de-escalation and improved surgical techniques?
“I think in terms of the future, we will see further improvement in our ability to tailor the treatment approach to the individual. Yes, we might find situations occasionally where we can avoid surgery altogether, which is a little bit like a fashionable goal from a patient’s perspective. But actually, that’s not a high priority. I mean, breast surgery nowadays is almost without complications and can be done on an outpatient basis in many situations.”
“As for surgery, as for radiotherapy, as for medical treatment, further individualisation is the most important priority for the immediate fruit of future.”
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