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Top 10 Takeaways To Implement Into Practice Following ASBrS

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The American Society of Breast Surgeons (ASBrS) 2023 annual meeting convened in Boston, MA on April 27-30, 2023. There was a record over 1700 in attendance. ASBrS President Nathalie Johnson MD, FACS delivered an inspirational Presidential Address titled “A Long Time Ago in the Future” which focused on learning from important historical lessons in the treatment of breast cancer to radically shape the future. Themes of her talk included abandonment of radical surgery, enrolling more patients into clinical trials to find answers faster, surgeons using endocrine manipulation to downstage surgery, understanding differences in the biology of breast cancer, using neoadjuvant therapy to determine optimal treatment for improved survival, incorporating multi-modality therapy to leverage maximal benefits, and restoring cosmesis and function to the hundreds of thousands of patients diagnosed annually with breast cancer. 

Surgeons who treat patients with breast cancer are looking for practical data and tips that can be used immediately. Here are my top 10 takeaways that can be implemented in practice now following the meeting.

  1. KEYNOTE-522 is a phase 3, randomized study of neoadjuvant pembrolizumab, an immunotherapy drug, plus chemotherapy vs placebo plus chemotherapy, followed by adjuvant pembrolizumab vs placebo, in patients with early triple negative breast cancer (TNBC). Results showed an absolute 13.6% increase in pathologic complete response and a 7.7% improvement in event-free survival at 36 months in the group that received pembrolizumab. Heather MacArthur MD, MPH presented data that showed addition of pembrolizumab to neoadjuvant chemotherapy had no adverse impact on surgical outcome. Similar proportions of patients had breast-conserving surgery and mastectomy in both treatment groups. There were no delays from neoadjuvant treatment to surgery or from surgery to adjuvant treatment with the addition of pembrolizumab. Following definitive surgery, more patients in the pembrolizumab group than in the placebo group had a complete nodal response. No new safety signals were identified and most treatment-related adverse events were mild to moderate in severity. These results further support the use of the KEYNOTE-522 regimen for patients with TNBC. 
  2. Exercise oncology is increasingly recognized as an integral aspect of treatment in cancer patients. Documented benefits of exercise during breast cancer treatments have been shown to improve fatigue, sleep, quality of life, anxiety, depression, body composition, function, and breast cancer related lymphedema. Kathryn H. Schmitz, PhD, MPH reviewed supporting evidence for these benefits as well as the adoption into guidelines by all national medical societies. Karen Wonders, Ph.D., FACSM reported on a randomized, prospective, comparative clinical trial of 240 patients with early-stage breast cancer given either a 12-week exercise program or standard care. Results showed that patients in the exercise program had emergency department visits reduced by 33.2%, hospital outpatient visits cut by 21.5%, and private office visits decreased by 41.8%, leading to decreased health care costs as well as significant improvement in quality of life. 
  3. Time to surgery after neoadjuvant chemotherapy impacts survival. Jennifer R. Garreau, MD presented data in a retrospective review that showed delays of greater than 4 weeks adversely affects recurrence free survival (HR 4.614, p <0.0001) and delays of greater than 6 weeks adversely affects overall survival (HR 2.461, p <0.01). Additionally, delays of greater than 6 weeks affect the residual cancer burden score almost as much as presenting with a stage 3 cancer.
  4. Recurrence after breast conservation therapy often necessitates mastectomy. However, repeat breast conservation in selected patients with a favorable tumor profile is acceptable. Nora Hansen MD, FACS reviewed data that showed older patients, with smaller luminal A tumors of less than 2cm, and more than 5 years from primary treatment may not have worse outcomes undergoing a repeat lumpectomy for a local recurrence. Re-irradiation is possible with minimal toxicity and acceptable cosmetic outcomes in most patients.
  5. Patients with limited lymph node metastasis undergoing mastectomy may be able to avoid significant morbidity of an axillary lymph node dissection (ALND). However, intraoperative pathology assessment in this setting may lead to overtreatment of the axilla. Robert M. Pride, MD presented data from the National Cancer Database of 8,222 patients who had a mastectomy and 1-2 positive sentinel lymph nodes. Not performing or not acting on intraoperative pathology in this population led to a 17% reduction in receiving both ALND and axillary radiation in patients with micrometastasis and a 38% reduction in patients with macrometastasis.
  6. MRI of the breasts is often obtained prior to surgery as a reason to better understand the tumor burden and reduce re-excision rates. Ashley Cairns, MD presented data on 631 women who had participated in two prior randomized trials on margins (SHAVE1 and SHAVE2). Of these patients, 193 individuals underwent MRI. Patients who obtained a preoperative MRI did not have a higher rate of negative surgical margins (P = .110).
  7. Idiopathic granulomatous mastitis is a common benign breast disease that carries significant morbidity. Neslihan Cabioglu, MD, PhD showed that intralesional steroid injection of triamcinolone acetonide 40mg/ml monthly has therapeutic benefits. 
  8. Older women with breast cancer are often required to undergo annual mammography after treatment as part of surveillance. Elizabeth Berger, MD, MS presented a study of 44,445 women 67 years or older in the SEER database. Even among women with a life expectancy of less than 1 year, 51% underwent at least one mammogram within 12 months of death. The incidence of a second breast cancer diagnosis in women with life expectancy less than 5 years was only 3.7%.
  9. The Great Debates between J. Michael Dixon, OBE, MD and Judy Boughey, MD, FACS showed that neoadjuvant endocrine therapy is effective, is much less toxic than chemotherapy, and is vastly underused. However, in premenopausal women with hormone receptor positive disease, only upfront surgery or chemotherapy should be utilized outside of a clinical trial. 
  10. The Great Debates between Michael Alvarado, MD, FACS and Monica Morrow, MD, FACS centered on the utility of clipping axillary lymph nodes. Removal of the biopsied clipped node that had metastatic disease is not successful in about 25% of routine sentinel lymph node biopsy. However, optimal surgical techniques with dual tracers in axillary surgery can increase the number of sentinel lymph nodes retrieved and may obviate the need for removal of the clipped node because it results in an acceptable false negative rate when 3 or more nodes are taken. Furthermore, removal of the clipped node has not been shown to be associated with decreased locoregional recurrence rates or improved disease-free survival or overall survival.

Dr. Nguyen has no conflicts of interest to report.

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