In the future, fewer oncologic breast operations?
Prof. Sohn and Prof. Schütz explain in this interview why breast cancer is transforming from a primarily surgically to a primarily systemically treated tumor.
About every 8th woman is afflicted by breast cancer over the course of her life. One-third of those affected are under 55 years of age. The certified Breast Center of the National Center for Tumor Diseases (NCT) at Heidelberg University Hospital is a front-runner for the treatment and research of breast cancer. This success can be measured: of all women with breast cancer treated here, more than 80% are still living after 10 years. In addition, the interdisciplinary Breast Center is a focal point for clinical trials far beyond Heidelberg.
Professor Christof Sohn, the Medical Director of Heidelberg University Women‘s Hospital, and Professor Florian Schütz, the Director of the Breast Center, explain why breast cancer is transforming from a tumor treated primarily with surgery to one treated primarily with systemic methods.
The Breast Center of the NCT was one of the first certified breast centers in Germany. What is special about treatment at NCT?
Prof. Sohn: Most special is the quality assurance. At NCT, a pre-therapeutic tumor conference has been established. In many other facilities, there are only post-operative tumor conferences. We have moved the conference earlier, so that the optimal treatment route for patients can be planned prior to the initial therapeutic steps. At NCT, we often begin with medical therapy. If this initial step is inappropriate, it is often very difficult to remedy it after-the-fact.
How is interdisciplinary cooperation implemented in general practice?
Prof. Sohn: Each patient is individually introduced to a conference of about ten experts, including all diagnostic findings. I am personally present at practically all of these conferences. Senior physicians in the areas of systemic therapy, diagnostics, and surgery are always included. The result of the meeting is written and then discussed with the patient. We have over 600 new patients per year. If we extrapolate that number, there are ten full weeks of work including only these conferences. Thus, we consider this way the optimal one for treatment, and it is a decisive factor regarding survival.
How have successful medical therapies changed the management of breast cancer as a whole?
Prof. Schütz: For each woman with invasive breast cancer, treatment is founded on two pillars, namely surgery / radiation and systemic medication with chemo, hormonal, or antibody therapy. The importance of systemic therapy has increased considerably. Currently, we treat 30 to 40 percent of patients systemically before surgery.
Why is it sometimes better to receive systemic therapy prior to surgery?
Prof. Schütz: For particular types of breast cancer, the following is true. We don't know for sure which systemic therapy works. If the tumor shrinks after administration of the medication, then we have confirmation that therapy was effective. If the tumor were removed straightaway, we would have no confirmation. In addition, if the breast tumor decreases in size, we know that metastases, invisible but often already present in other body regions, will also be successfully treated with systemic therapy. This is very important, because these metastases can continue to grow. When the breast tumor does not shrink, we know that we must change medication, because the initial therapy was not effective. Ideally, the tumor is no longer detectable in each subsequent operation, because it has been obliterated by pre-operative therapy.
Have studies investigated whether surgery can be avoided altogether?
Prof. Sohn: Such considerations are available, but they are in early stages. For example, the NCT has the VacuPredict study. In this study, women treated preoperatively with systemic medications undergo an ultrasound-controlled vacuum punch biopsy just prior to surgery, to examine whether this technique is sufficiently accurate to identify when the tumor has completely disappeared. This is called "pathological complete remission", which is a prerequisite to even consider randomized trials in which surgery is omitted. In other words, we must first be able to diagnose pathologic complete remission without the need for surgical confirmation. We expect preliminary results over the summer.
Which surgical procedures do you use and how do you ensure a good cosmetic result?
Prof. Schütz: If possible, we perform a breast-sparing procedure. Sometimes compete removal of the breast is necessary to achieve an optimal chance of cure. The goal of surgery is to achieve a good cosmetic result along with complete removal of the tumor. An experienced, expert team for plastic breast reconstruction surgery works with us to reestablish an aesthetically good result. This is often extremely important to our patients, and we place high value on it.
What can you offer international patients?
Prof. Sohn: For international patients with new onset of disease, we offer consultations on request. Generally, this must be performed with a personal appointment in Heidelberg. The patient can then decide whether she would like to receive partial or complete therapy at our Breast Center. We are also pleased to offer collaboration with our colleagues from the patient's home country, to achieve the best possible results of therapy.