The study of the biology of breast cancer, and an understanding of the diversity of disease, and the differential impact of care based on tumor type is foundational for the training of surgeons specializing in the care of breast cancer patients.
The biology of the tumor determines the options for care as well as the type of treatment and the order of therapy. Surgeons can play a critical role in advancing more tailored care- including participation in trials that test new therapies and those that test less therapy when it is warranted. As well, as the science of risk evolves, we have to incorporate tumor biology, host risk, and response to therapy to better tailor screening and surgical treatment.
There are several areas of advancement that help to minimize the impact of surgery. One is to continue to refine the extent of lymph node surgery even in a patient with positive nodes at diagnosis, after neoadjuvant therapy by localizing both the sentinel node and the positive node at diagnosis. However, standards for the management of the axilla in the neoadjuvant setting are essential because the information is a critical component of residual cancer burden. The fastest way to improve outcomes for women at the highest risk of recurrence is to participate in neoadjuvant trials where the early endpoint in complete pathologic response. So leadership is setting the surgical standards for evaluating extent of residual disease is essential.
Surgeons likewise need to play a leadership role in de-escalating care for those with minimal risk. The spectrum of breast cancer ranges from indolent to extremely aggressive. Screening increases the likelihood that indolent lesions will be detected. The key to preventing harm is to understand biology at the time of diagnosis. Tools to determine ultralow risk have been developed, allowing a much more minimal approach to care. Using these tools as well as other criteria to adopt the level 1 evidence for the omission of radiation will improve health care value and quality of life. For DCIS, a condition identified primarily by screening, the challenge is to develop the evidence base for intervention. Eliminating the urgency for intervention and allowing time to determine the need for intervention is a strategy that will safely allow us to learn more about the natural history of this condition and prevent overtreatment. We also need to work with our radiology colleagues to better understand what should truly be a target for screening.
Technical advances have also decreased the adverse impact of surgical interventions. These include cosmetic approaches to partial mastectomy, mastectomy, and reconstruction, including total skin sparing mastectomy, fat grafting, oncoplastic reductions as a tool for primary resection. Now is a good time to think about the future of how we train breast surgeons and whether surgical training should evolve to make that the requisite skills reside in one surgeon rather than requiring two to optimize a cosmetic outcome.