Review Article| Volume 103, ISSUE 1, P83-92, February 2023

De-Escalating Breast Cancer Therapy


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        • Shubeck S.P.
        • Morrow M.
        • Dossett L.A.
        De-escalation in breast cancer surgery.
        NPJ Breast Cancer. 2022; 8: 25
        • Morrow M.
        • Winer E.P.
        De-escalating breast cancer surgery-where is the tipping point?.
        JAMA Oncol. 2020; 6: 183-184
        • Giuliano A.E.
        • Hunt K.
        • Blalman K.
        • et al.
        Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial.
        JAMA. 2011; 305: 569-575
        • Sparano J.A.
        • Gray R.J.
        • Makower D.
        • et al.
        Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer.
        N Engl J Med. 2018; 379: 111-121
        • Kalinsky K.
        • Barlow W.
        • Gralow J.
        • et al.
        21-gene assay to inform chemotherapy benefit in node-positive breast cancer.
        N Engl J Med. 2021; 385: 2336-2347
        • Kunkler I.H.
        • Williams L.
        • Jack W.
        • et al.
        Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial.
        Lancet Oncol. 2015; 16: 266-273
        • Wang T.
        • Baskin A.S.
        • Dossett L.A.
        Deimplementation of the choosing wisely recommendations for low-value breast cancer surgery: a systematic review.
        JAMA Surg. 2020; 155: 759-770
        • Veronesi U.
        • Luini A.
        • Galimberti V.
        • et al.
        Conservation approaches for the management of stage I/II carcinoma of the breast: milan cancer institute trials.
        World J Surg. 1994; 18: 70-75
      1. Effects of radiotherapy and surgery in early breast cancer. An overview of the randomized trials.
        N Engl J Med. 1995; 333: 1444-1455
        • Fisher B.
        • Anderson S.
        • Bryant J.
        • et al.
        Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.
        N Engl J Med. 2002; 347: 1233-1241
        • Veronesi U.
        • Cascinelli N.
        • Mariani L.
        • et al.
        Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.
        N Engl J Med. 2002; 347: 1227-1232
        • Wapnir I.L.
        • Dignam J.
        • Fisher B.
        • et al.
        Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS.
        J Natl Cancer Inst. 2011; 103: 478-488
        • Donker M.
        • Litiere S.
        • Werutsky G.
        • et al.
        Breast-conserving treatment with or without radiotherapy in ductal carcinoma In Situ: 15-year recurrence rates and outcome after a recurrence, from the EORTC 10853 randomized phase III trial.
        J Clin Oncol. 2013; 31: 4054-4059
        • Wolmark N.
        • Wang J.
        • Mamounas E.
        • et al.
        Preoperative chemotherapy in patients with operable breast cancer: nine-year results from National Surgical Adjuvant Breast and Bowel Project B-18.
        J Natl Cancer Inst Monogr. 2001; : 96-102
        • van der Hage J.A.
        • Van de Velde C.
        • Julien J.
        • et al.
        Preoperative chemotherapy in primary operable breast cancer: results from the European Organization for Research and Treatment of Cancer trial 10902.
        J Clin Oncol. 2001; 19: 4224-4237
        • Mieog J.S.
        • van der Hage J.A.
        • van de Velde C.J.
        Neoadjuvant chemotherapy for operable breast cancer.
        Br J Surg. 2007; 94: 1189-1200
        • Moran M.S.
        • Schnitt S.
        • Giuliano A.
        • et al.
        Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer.
        Ann Surg Oncol. 2014; 21: 704-716
        • Wang T.
        • Bredbeck B.
        • Sinco B.
        • et al.
        Variations in persistent use of low-value breast cancer surgery.
        JAMA Surg. 2021; 156: 353-362
        • Morrow M.
        • Abrahamse P.
        • Hofer T.
        • et al.
        Trends in reoperation after initial lumpectomy for breast cancer: addressing overtreatment in surgical management.
        JAMA Oncol. 2017; 3: 1352-1357
        • Bhutiani N.
        • Mercer M.
        • Bachman K.
        • et al.
        Evaluating the effect of margin consensus guideline publication on operative patterns and financial impact of breast cancer operation.
        J Am Coll Surg. 2018; 227: 6-11
        • Marinovich M.L.
        • Noguchi N.
        • Morrow M.
        • et al.
        Changes in reoperation after publication of consensus guidelines on margins for breast-conserving surgery: a systematic review and meta-analysis.
        JAMA Surg. 2020; 155: e203025
        • Hughes K.S.
        • Schnaper K.
        • Berry D.
        • et al.
        Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343.
        J Clin Oncol. 2013; 31: 2382-2387
        • Kim T.
        • Giuliano A.E.
        • Lyman G.H.
        Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis.
        Cancer. 2006; 106: 4-16
        • Veronesi U.
        • Viale G.
        • Paganelli G.
        • et al.
        Sentinel lymph node biopsy in breast cancer: ten-year results of a randomized controlled study.
        Ann Surg. 2010; 251: 595-600
        • Krag D.N.
        • Anderson S.
        • Julian T.
        • et al.
        Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial.
        Lancet Oncol. 2010; 11: 927-933
        • Boughey J.C.
        • Suman V.
        • Mittendorf E.
        • et al.
        Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial.
        JAMA. 2013; 310: 1455-1461
        • Kuehn T.
        • Bauerfeind I.
        • Fehm T.
        • et al.
        Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study.
        Lancet Oncol. 2013; 14: 609-618
        • Tan V.K.
        • Goh B.
        • Fook-Chong S.
        • et al.
        The feasibility and accuracy of sentinel lymph node biopsy in clinically node-negative patients after neoadjuvant chemotherapy for breast cancer--a systematic review and meta-analysis.
        J Surg Oncol. 2011; 104: 97-103
        • Tee S.R.
        • Devane L.
        • Evoy D.
        • et al.
        Meta-analysis of sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with initial biopsy-proven node-positive breast cancer.
        Br J Surg. 2018; 105: 1541-1552
        • Pesce C.
        • Liederback E.
        • Wang C.
        • et al.
        Contralateral prophylactic mastectomy provides no survival benefit in young women with estrogen receptor-negative breast cancer.
        Ann Surg Oncol. 2014; 21: 3231-3239
        • Metcalfe K.A.
        • Gershman S.
        • Ghadirian P.
        • et al.
        Frequency of contralateral prophylactic mastectomy in breast cancer patients with a negative BRCA1 and BRCA2 rapid genetic test result.
        Ann Surg Oncol. 2021; 28: 4967-4973
        • Francis A.
        • Fallowfield L.
        • Rea D.
        The LORIS trial: addressing overtreatment of ductal carcinoma in situ.
        Clin Oncol (R Coll Radiol). 2015; 27: 6-8
        • Kanbayashi C.
        • Thompson A.
        • Hwang E.
        • et al.
        The international collaboration of active surveillance trials for low-risk DCIS (LORIS, LORD, COMET, LORETTA).
        J Clin Oncol. 2019; 37: TPS603
        • Hwang E.S.
        • Hyslop T.
        • Lynch T.
        • et al.
        The COMET (Comparison of Operative versus Monitoring and Endocrine Therapy) trial: a phase III randomised controlled clinical trial for low-risk ductal carcinoma in situ (DCIS).
        BMJ Open. 2019; 9: e026797
      2. Francis A., Bartlett J., Billingham L., et al., Abstract OT2-3-01: The LORIS trial: A multicentre, randomized phase III trial of standard surgery versus active monitoring in women with newly diagnosed low risk ductal carcinoma in situ. San Antonio Breast Symposium, San Antonio, TX. 2013.

        • Sun S.
        • Van la Parra R.
        • Rauch G.
        • et al.
        Patient selection for clinical trials eliminating surgery for HER2-positive breast cancer treated with neoadjuvant systemic therapy.
        Ann Surg Oncol. 2019; 26: 3071-3079
        • Heil J.
        • Pfob A.
        • Kuerer H.M.
        De-escalation towards omission is the tipping point of individualizing breast cancer surgery.
        Eur J Surg Oncol. 2020; 46: 1543-1545
        • Sparano J.A.
        • Gray R.
        • Makower D.
        • et al.
        Prospective validation of a 21-gene expression assay in breast cancer.
        N Engl J Med. 2015; 373: 2005-2014
        • Andre F.
        • Ismaila N.
        • Henry N.
        • et al.
        Use of biomarkers to guide decisions on adjuvant systemic therapy for women with early-stage invasive breast cancer: ASCO clinical practice guideline update-integration of results from TAILORx.
        J Clin Oncol. 2019; 37: 1956-1964
      3. Kalinsky K, B.W., Meric-Bernstam F et al., SWOG S1007: Adjuvant trial randomized ER+ patients who had a recurrence score <25 and 1–3 positive nodes to endocrine therapy (ET) versus ET + chemotherapy. Presented at the 2020 San Antonio Breast Cancer Symposium (SABCS): San Antonio, TX, December 8–11, 2020. Abstract GS3-01.

      4. Postmenopausal Women with HR+/HER2- Early Breast Cancer, 1-3 Positive Nodes, and a Low Risk of Recurrence Can Safely Forego Chemotherapy.
        Oncologist. 2021; 26: S11-S12
      5. CompassHER2-pCR: Decreasing Chemotherapy for Breast Cancer Patients After Pre-surgery Chemo and Targeted Therapy. 2022.

        • Wang S.L.
        • Fang H.
        • Song Y.
        • et al.
        Hypofractionated versus conventional fractionated postmastectomy radiotherapy for patients with high-risk breast cancer: a randomised, non-inferiority, open-label, phase 3 trial.
        Lancet Oncol. 2019; 20: 352-360
        • Liu L.
        • Yang Y.
        • Guo Q.
        • et al.
        Comparing hypofractionated to conventional fractionated radiotherapy in postmastectomy breast cancer: a meta-analysis and systematic review.
        Radiat Oncol. 2020; 15: 17
        • Dawood S.
        • Lei X.
        • Dent R.
        • et al.
        Survival of women with inflammatory breast cancer: a large population-based study.
        Ann Oncol. 2014; 25: 1143-1151
        • Stearns V.
        • Ewing C.
        • Slack R.
        • et al.
        Sentinel lymphadenectomy after neoadjuvant chemotherapy for breast cancer may reliably represent the axilla except for inflammatory breast cancer.
        Ann Surg Oncol. 2002; 9: 235-242
        • Macdonald H.R.
        Pregnancy associated breast cancer.
        Breast J. 2020; 26: 81-85
        • Case A.S.
        Pregnancy-associated breast cancer.
        Clin Obstet Gynecol. 2016; 59: 779-788
        • Katz S.J.
        • Jagsi R.
        • Morrow M.
        Reducing overtreatment of cancer with precision medicine: just what the doctor ordered.
        JAMA. 2018; 319: 1091-1092
        • Norton W.E.
        • Chambers D.A.
        • Kramer B.S.
        Conceptualizing de-implementation in cancer care delivery.
        J Clin Oncol. 2019; 37: 93-96
        • Giuliano A.E.
        • Boolbol S.
        • Degnim A.
        • et al.
        Society of Surgical Oncology: position statement on prophylactic mastectomy. Approved by the Society of Surgical Oncology Executive Council, March 2007.
        Ann Surg Oncol. 2007; 14: 2425-2427
        • Smith M.E.
        • Vitous C.
        • Hughes T.
        • et al.
        Barriers and Facilitators to De-Implementation of the Choosing Wisely(®) Guidelines for Low-Value Breast Cancer Surgery.
        Ann Surg Oncol. 2020; 27: 2653-2663
        • Andrews C.
        • Childers T.
        • Wiseman K.
        • et al.
        Facilitators and barriers to reducing chemotherapy for early-stage breast cancer: a qualitative analysis of interviews with patients and patient advocates.
        BMC Cancer. 2022; 22: 141
        • Greenup R.A.
        • Rushing C.
        • Fish L.
        • et al.
        Financial costs and burden related to decisions for breast cancer surgery.
        J Oncol Pract. 2019; 15: e666-e676
        • Berlin N.L.
        • Skolarus T.
        • Kerr E.
        • et al.
        Too much surgery: overcoming barriers to deimplementation of low-value surgery.
        Ann Surg. 2020; 271: 1020-1022