King’s College London & Guy’s and St Thomas’ Hospitals, London, UK
Correspondence to: michael.douek@kcl.ac.uk
Surgery remains the most important treatment for breast cancer and this special issue focusses on the recent application of novel technologies to improve breast cancer surgery. Several randomised controlled trials including 2 with over 20 years of follow-up1,2, demonstrated that survival is equivalent after breast conserving surgery (with radiotherapy) and mastectomy. There have been numerous advancements aimed at better patient selection for breast conserving surgery, improving surgical technique, avoidance of axillary surgery, improving breast reconstruction post-mastectomy and evaluation of the effectiveness of percutaneous treatment.
Recent years have seen greater focus on avoidance of axillary surgery following the publication of the ACOSOG Z0011 now with long-term follow-up data on locoregional recurrence, out to 10 years3. There has also been a greater awareness of the drawbacks of the combined technique for sentinel node biopsy and the significant impact of radioisotope dependence on the use of sentinel node biopsy in developing countries. Several novel techniques for sentinel node biopsy have emerged.
Randomised controlled trials and meta-analyses demonstrated that adjuvant radiotherapy following breast conserving surgery reduces local recurrence and that if the reduction exceeds 10% in absolute terms at 5 years, then it can lead to a survival benefit of a quarter of the difference4. But external beam radiotherapy is delivered over a number of weeks and has recognised side-effects. The observation that over 90% of local recurrences occurred at the index quadrant, led to growing interest in ways of delivering radiotherapy more locally and most conveniently, intra-operatively. Recently, a meta-analysis of published data from randomised controlled trials of partial breast radiotherapy (PBI) with 5 years follow-up data, demonstrated that use of PBI instead of WBI in selected patients results in a lower 5-year non-breast cancer and overall mortality, amounting to a 25% reduction in relative terms5. Emanuela Esposito and Michael Douek have reviewed the application of intra-operative radiotherapy given our current understanding and knowledge.
Following breast conserving surgery, the rate of re-excision for positive margins is unacceptably high with 20% of women undergoing at least 1 re-excision6. There is a clinical need to develop minimally invasive ablative techniques that can define better the target and tumour margins, potentially avoiding surgery for smaller tumours. High intensity focussed ultrasound (HIFU) has been successfully applied to other cancers and Mirjam Peek and Feng Wu discuss the potential treatment of breast tumours with HIFU. Dorin Dumitru and John Benson reviewed novel techniques that can be used for assessment of margin involvement during surgery. Several different techniques are currently being evaluated at different stages of development.
Patients with multifocal disease, large tumours not responding to primary medical treatment, patients with local recurrence or those at high genetic risk still require mastectomy. Lorna Cook and Tibor Kovacs address recent advances in breast implant reconstruction and how these should be used.
This special issue provides an excellent focus as to where we are with respect to novel technologies for breast cancer surgery and where improvements are still needed. Despite the fast pace of development of novel devices, there is a clinical need to evaluate them rigorously in order to be able to provide patients with efficacy data in a similar way to that provided for novel drugs. I hope you find these articles interesting and informative.
References:
1. Fisher B, Jeong JH, Anderson S et al. (2002) Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation N Engl J Med 347 567–575
2. Veronesi U, Cascinelli N, Mariani L et al. (2002) Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer N Engl J Med 347:1227–1232
3. Giuliano AE1, Ballman K, McCall L et al. (2016) Locoregional Recurrence After Sentinel Lymph Node Dissection With or Without Axillary Dissection in Patients With Sentinel Lymph Node Metastases: Long-term Follow-up From the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 Randomized Trial Ann Surg. Sep 264 (3) 413-20
4. Early Breast Cancer Trialists' Collaborative Group (EBCTCG), Darby S, McGale P, Correa C et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011 Nov 12 378 (9804) 1707-16
5. Vaidya JS, Bulsara M, Wenz F et al. (2016) Reduced Mortality With Partial-Breast Irradiation for Early Breast Cancer: A Meta-Analysis of Randomized Trials Int J Radiat Oncol Biol Phys. Oct 1 96 (2) 259-265
6. Jeevan R, Cromwell DA, Trivella M et al. (2012) Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics BMJ. Jul 12 345 e4505
