Addressing the problem of overtreatment in breast cancer

ABSTRACT

Introduction

As breast cancer treatment options have multiplied and biologic diversity within breast cancer has been recognized, the use of the same treatment strategies for patients with early-stage and favorable disease, and for those with biologically aggressive disease, has been questioned. In addition, as patient-reported outcome measures have called attention to the morbidity of many common treatments, and as the cost of breast cancer care has continued to increase, reduction in the overtreatment of breast cancer has assumed increasing importance.

Areas covered

Here we review selected aspects of surgery, radiation oncology, and medical oncology for which scientific evidence supports de-escalation for invasive carcinoma and ductal carcinoma in situ, and assess strategies to address overtreatment.

Expert opinion

The problems of breast cancer overtreatment we face today are based on improved understanding of the biology of breast cancer and abandonment of the ‘one-size-fits-all’ approach. As breast cancer care becomes increasingly complex, and as our knowledge base continues to increase exponentially, these problems will only be magnified in the future. To continue progress, the move must be made from advocating the maximum-tolerated treatment to advocating the minimum-effective one.

KEYWORDS:

• breast cancer
• overtreatment
• radiotherapy
• chemotherapy
• ductal carcinoma in situ
• breast-conserving therapy
• axilla

Article highlights

• Recognition of the biologic diversity of breast cancer offers the opportunity to reduce overtreatment.

• Neoadjuvant chemotherapy increases eligibility for breast conservation, decreases the need for axillary dissection, and, in the future, may allow identification of patients suitable for shorter, less-toxic chemotherapy regimens.

• The duration and extent of radiotherapy, and the use of chemotherapy have been reduced in patients with biologically favorable tumors, and genomic assays offer the promise of improved tailoring or even elimination of radiotherapy in some patient subsets.

• Treatments that do not prolong survival may be sought by patients because they value other outcomes such as improved local control, making de-escalation of treatment challenging.

• A functioning multidisciplinary breast team that develops integrated treatment plans across disciplines is essential to reducing overtreatment as care becomes more complex.

Declaration of interest

M Morrow has received speaking honoraria from Exact Sciences and Roche. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The preparation of this manuscript was supported in part by NIH/NCI Cancer Center Support Grant No. P30 CA008748 to Memorial Sloan Kettering Cancer Center.