We learned a lot over the last years and some of the information that was already known in 2015 asked for more time to be digested, for example, the role of radiation therapy in early stage breast cancer after lumpectomy, so breast conserving surgery. We always thought it was only a matter of local control and much less of an improvement in overall and disease specific survival but data more and more point to the fact that even in node negative breast cancer, even low risk breast cancer, that optimising local control has a long-term influence on breast cancer specific and overall survival. We had, for example, data presented fairly recently about population based cancer registries in The Netherlands with more than 100,000 patients, mastectomy and breast conserving therapy including radiation therapy, you can see that outcome after ten years is much better in patients who are treated with the breast conserving approach. How to explain it is difficult; we controlled for as much as possible the factors that are known and present in the cancer registries but, of course, there are residual confounding factors so further research is needed.
What’s important is that we have for early stage breast cancer no real arguments favouring mastectomy for those patients who are eligible otherwise for breast conserving therapy. Another is the role of regional radiation therapy, so lymph node treatment. We see, and it is very good that the presentation before me given by Monica Morrow on axillary surgery, because you see that a lot less axillary surgery is done nowadays, depending from country to country, but a lot of patients who have node positive disease on sentinel node or, even worse, clinically node positive disease that is brought to a complete remission with primary systemic therapy, more and more do not receive axillary completion surgery. But a lot of those patients now are treated with radiation therapy and quite some of those patients did not have radiation therapy before that. This nicely joins to the internal mammary lymph node trials that we have published after the most recent St Gallen meeting in which you can see a long-term benefit of regional radiation therapy in subgroups of patients with early stage breast cancer.
So bringing all that together, we see a shift from surgery to the axilla, to more comprehensive regional nodal treatment by radiation therapy which is quite an important shift. I’m convinced that with modern radiation therapy techniques we can do this very safely, that the benefit that we see at ten years will not be lost at longer follow-up due to adverse treatment effects.
Other topics that will be presented at a symposium dedicated to escalation and de-escalation is about more focalised radiation therapy, partial breast irradiation, intraoperative techniques where you can have one stage treatment including surgery with intraoperative radiation therapy. In very early stage breast cancers they have a one day local treatment and it’s done for the local treatment. Some patients are eligible for this and one of the speakers will focus more in-depth on that.
What we see also is that patients who have immediate breast reconstruction often have an indication for post-operative radiation therapy. We know that the chest wall is part of the target volume but what is the target volume exactly and how to treat it optimally will be presented at the symposium. I will give a little bit of information on that.
Finally, of course, what is early stage breast cancer? It varies hugely from early stage low risk breast cancer in a patient with, because of comorbidity, a short life expectancy up to patients who have a very long life expectancy and high risk breast cancer but are treated optimally with systemic therapy and then favour again much more from optimised local regional treatment. So there is a huge variety, every breast cancer patient should be offered individualised, personalised treatment based on tumour characteristics, based on also modern tumour characteristics, genetics and molecular assays are often required. Patient preferences, that’s very important; quality of life should not be forgotten because it is hugely important for those who are treated successfully for breast cancer, and availability of treatments. In Western Europe most of the countries have optimised resources for any treatment that we can offer. Of course budgetary issues are more and more a problem but outside of Western Europe a lot of countries are lacking infrastructure for giving treatment and then you have to make choices where to invest in expensive drugs or the infrastructure for optimal surgery or optimal radiation therapy.
What can we expect to see in the future?
More personalised treatment for sure. We will have with future patients an individual discussion where we say, ‘This is your tumour with all the risk factors. This is you as a person with physically spoken risk factors, comorbidity for example, but also your desires, your wishes, your environment, the people who are with you, what you expect of the future.’ Patient reported expectations, not only patient reported outcomes but also expectations are more important. Then we have a battery of possible treatments and then you can say, ‘If we give everything you have the highest chance for definitive cure but there are possible side effects. Where can we de-escalate?’ Some patients, early stage breast cancer, may say, ‘OK, I’ll go for an optimal local treatment but I don’t take the years of endocrine therapy.’ Other patients might say, ‘OK, I’ll skip radical surgery and radiation therapy but I go for a prolonged endocrine therapy, hormonal therapy.’ So there are a lot of options and we have to learn about optimising these combinations of choices for every individual patient and to inform the patient, really, to the 100% level in this.
Do you have a closing statement?
Maybe this is my most important statement: we have to do it together and together means all those who are involved, from screening to diagnosis to treatment to follow-up and not to forget the patients. When doing this we also have to involve all the stakeholders which is not only the industry but also the policy makers because they often set the possibilities that we can work with.