Melanie Cole, MS (Host): The studies surrounding breast cancer therapies can be confusing. We're here to clear up misconceptions about breast conservation therapy for early-stage breast cancer. We're talking about that today on AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices ensuring you stay at the forefront of your field.

I'm Melanie Cole. And joining me today is Dr. Suzanne Coopey. She's the Breast Surgery Division Chief at the Allegheny Health Network and an Associate Professor of Surgery at Drexel University College of Medicine. Dr. Coopey, thank you so much for joining us today. I'd like you to start by giving us a little bit of a history of breast conservation based on trials from the 1970s and '80s. Tell us a little bit about how that evolved.

Suzanne Coopey, MD: Sure. Until the 1970s, everyone really thought that breast cancer was a local disease that spreads by contiguous extension and that more extensive surgery would provide a better chance of disease control. So, every patient with breast cancer, no matter the size of the tumor or the extent of the disease, was treated with a radical mastectomy. This was a very morbid surgery, which removed the breast, the overlying skin of the breast, the pectoralis muscles beneath the breast, and all of the axillary lymph nodes. But as we started to understand really the biology of breast cancer, there was a realization that breast cancer is a systemic disease, and there was a real shift in focus instead to systemic and radiation therapy, and then less extensive surgery in both the breast and the axilla. And then, this led to landmark trials being published in the 1980s, which compared the radical mastectomy to lumpectomy plus radiation in women that had early-stage breast cancer.

Melanie Cole, MS: Why do historical contraindications for breast conservation really no longer exist?

Suzanne Coopey, MD: I would say that historically there were several groups of patients that were only given the option of mastectomy instead of breast conservation. These would really include patients that had multicentric tumors or tumors in more than one quadrant of the breast, or patients that had had a previous history of breast cancer and prior radiation in that same breast, or patients that had a large tumor compared to their overall breast size.

But recent studies are actually showing that select patients with multicentric tumors can safely undergo a two or three-site lumpectomy, followed by radiation, and their five-year local recurrence rate is excellent, around 3%. Also, patients that had breast cancer and now have an in breast recurrence, if it's small, say under three centimeters, unifocal, and their lymph nodes are negative, they can have a repeat breast conservation probably about 90% of the time with a very low risk of re-recurrence of the breast cancer with partial breast re-irradiation. So, patients who really want to avoid a mastectomy can do that even with a second bout of breast cancer.

The other thing is large tumors now can be shrunk prior to surgery if you give treatment upfront with either chemotherapy or endocrine therapy to downstage the tumor and make it smaller. And a neoadjuvant therapy approach can make about 40-50% of patients who are not eligible for breast conservation eligible after. So, a lot of women can now safely save their breasts.

 There's also some newer techniques we're doing in the operating room with oncoplastic surgery where we can actually reshape the breast tissue at the time of lumpectomy by doing local tissue rearrangements or even complex surgeries where we do a breast reduction technique or involve a plastic surgeon. So, there's a lot of different things that we can do now to kind of individualize the treatment.

Melanie Cole, MS: Dr. Coopey, in your opinion, why may conservation therapy now have that advantage over mastectomy as you're giving us these studies and statistics? We're taking into other factors as well, as you mentioned, endocrine therapies and lymph node involvement, development of systemic treatments and pre-treatments and socioeconomic factors. When you put all of these things together, and I've been reading some of the studies, tell me in your opinion, when you are speaking to patients, what factors are you looking at for them?

Suzanne Coopey, MD: Yeah. So, I think that there are so many reasons why breast conservation today would be better than it was when those studies were published 40 or 50 years ago, which showed that lumpectomy and radiation and mastectomy were equivalent. We've had huge improvements with breast imaging, with 3D mammograms, and also breast MRIs, so the planning for surgery, the making sure that patients are good lumpectomy candidate is better.

We also have developed more precise localization methods that help guide the removal of the tumor during the lumpectomy surgery. And also intraoperatively, we have ways to image the removed breast specimen and all these things just help to really localize and make sure that we're taking out the right area with the right margins. We've also had improvements in breast pathology with more rigorous margin assessment of the lumpectomy to really ensure that we're not leaving tumor cells behind, in addition to the huge improvements in radiation therapy to allow for better treatment planning through technological advances. And also, we can avoid surrounding tissues, the heart and the lungs. And most of all, we've developed more effective and more targeted systemic therapies to treat all types of breast cancer with much less toxicity to the patient. So many things have improved over time that have really led to breast conservation not just being equivalent, but maybe even a little bit superior.

Melanie Cole, MS: Dr. Coopey, again, in your opinion, as we're talking, and we're going to get into survival, and I want to talk about survival outcomes. But before we do, when we look at the two, lumpectomy and anxiety of recurrence, have you looked at recurrence rates? I think you mentioned just a little bit before, but the anxiety, quality of life, worrying about it, mammograms, whether they get reconstruction or not. Has that been an issue that you speak with your patients about the worry factor in lumpectomy versus mastectomy?

Suzanne Coopey, MD: We talk about it a lot. Yeah, I think that's a good question. It's interesting because people do have this sense that if they have a mastectomy, they would worry less than if they had a lumpectomy. But I think once you have a diagnosis of breast cancer in general, that worry is always going to be there. It's not just the risk of the cancer coming back in the breast, there's a risk that the cancer could come back somewhere else in your body. So, removing the breast will never take away that worry or anxiety completely. And they've actually done like quality of life studies in women and even young women in their 30s or 40s that have had breast conservation and mastectomy. And a lot of times, the quality of life, that satisfaction is just as good, if not better with lumpectomy.

Melanie Cole, MS: Now, what about survival outcomes? When we think of those adjuvant therapies and hormone blockers now, some tamoxifen, anastrozole, things like that, and radiation, what about survival outcomes? What have you seen?

Suzanne Coopey, MD: We know that the disease-free survival and the overall survival with lumpectomy and radiation is just as good as mastectomy, if not better. And the only slight difference is when you're saving the breast with a lumpectomy, you do have a slight increased risk of something called an in-breast tumor recurrence. But again, with all the advances in technology, that risk is really quite low, like a couple percentage points that someone would get an in-breast tumor recurrence.

Melanie Cole, MS: I'd like you to wrap this up with your key takeaways, Dr. Coopey, what you think are some of the most important messages for other providers that are counseling their patients? Because as we said, these studies go back and forth just a little bit and it can be quite confusing. So, what would you like the final message to be today?

Suzanne Coopey, MD: I think that there's many reasons why women decide to have lumpectomy or mastectomy. And there's a lot of things that go into that decision-making from their initial imaging to their tumor type to their response to treatment, their family history and genetic testing. So, every patient is really an individual case, and there's a lot of things that need to be factored in and weighed as we're trying to decide the best course of action.

So, I think you never really know which way it's going to go when someone's initially diagnosed and you really need to put together all the pieces and get all the information. But a lot of those initial thoughts about, "Oh, you should just have a mastectomy and just get rid of the breast and you're not going to have to worry about it again," you know, that's a little bit naive and not the truth. And really, I hope just a little bit of education today goes a long way to show that breast conservation is actually a really good option for many women with early-stage breast cancer. And it's definitely not inferior to having a mastectomy.

Melanie Cole, MS: Well, it certainly is about shared decision-making. And thank you so much, Dr. Coopey, for joining us today. To learn more or to refer a patient, please call 844-MD-REFER, or you can visit ahn.org. Thank you so much for joining us on this edition of AHN MedTalks with the Allegheny Health Network. I'm Melanie Cole.