Assisting Community-Based Oncologists and Surgeons in Making Neoadjuvant Treatment Decisions for Patients with Early Breast CancerAdvantages to neoadjuvant treatment in patients preferring mastectomy
3:31 minutes.
TRANSCRIPTION:
DR BLACKWELL: I think an important point here is, if there isn’t a deciding reason to do neoadjuvant and the patient wants to go to surgery — she comes in, “I’m having bilateral mastectomies no matter what the genetic testing shows, no matter how much my tumor shrinks. I don’t want reconstruction no matter what” — I mean, there’s a lot of very practical things. And a patient says to me, with a 3-centimeter, node-negative, triple-negative breast cancer, “I just want to have my surgery, and then I’ll come back and see you,” that’s perfectly fine. I set an expectation that you’re going to get the same treatment afterwards, as before, because really at this point, you’re going to give a third-generation regimen for a 3-cm, node-negative, triple-negative breast cancer. But in general, there’s usually some reason that there might be an advantage to giving neoadjuvant. And I don’t mean outcome reason. I mean, literally, waiting for the genetic testing, coordinating the plastic surgery, letting the patient really digest — does she really want bilateral mastectomies? And it’s a crisis when you meet these patients in a multi-d clinic. And letting that die down, I actually think that’s a pretty compelling reason to do neoadjuvant therapy in a patient who you know is going to get that therapy independent of when you administer it. DR MAMOUNAS: The other reason that we’ve found to be actually an important reason often is the issue of the patient who has already decided that she wants bilateral mastectomy and will get reconstruction. So the idea behind the neoadjuvant therapy is that you get all your therapy before in a timely fashion and you don’t worry too much about a potential complication. Because those patients often will have flap problems. They have to go back for excision of some residual necrotic tissue. And then you potentially can delay adjuvant therapy for weeks at that time. Or, potentially not healing very well on one that has been compromised some by the surgery, and then you now give chemotherapy that delays wound healing. DR BLACKWELL: And even when you start it, you’re putting that patient at increased infection risk, because typically the drains are in for a while with an extensive reconstruction. So again, that’s why I gave the example of the patient who comes in, “I don’t want reconstruction. And my mother had breast cancer. I’ll wait for the genetic, but it doesn’t matter. I’m going to have bilateral mastectomies.” For those patients, I don’t think it’s wrong to go ahead and send them to surgery. But there’s usually a compelling reason, genetic testing, coordination of care, patients really — “I think,” those are the words I listen for. “I think I want bilateral mastectomies,” as opposed to “I will have bilateral mastectomies.” I think those are typically the times where I’ll discuss, “Hey. Let’s buy ourselves some time for a very practical reason. You’re going to get this whether you do it now or after surgery. It might make the surgeon’s job easier. We’ll have all the information so you can make the surgical decision. Let’s go ahead and get you started on chemotherapy.” DR LOVE: Any evidence that using neoadjuvant therapy in any way interferes with surgery in terms of wound healing? DR MAMOUNAS: Not much. Actually, we did not see any adverse effect in the neoadjuvant trials, comparing adjuvant to neoadjuvant chemotherapy. That may be a little different, if you give something like bevacizumab, which we did. But, of course, that’s not given anymore. But for straight chemotherapy, we don’t have any evidence of adverse. |