Damien Hansra, MD
BREAST CANCER is a microscopic disease, with most patients presenting with “localized” stage I to III disease, for which they are offered curative-intent surgery often accompanied by radiation therapy, chemotherapy, and hormonal therapy. More accurately, we now know that patients with localized breast cancer present with a macroscopic primary tumor, representing millions of malignant cells in a cluster with varying probabilities of numerous secondary sites of microscopic cellular deposits locally or systemically disseminated at presentation. The degree of preexisting local or systemic dissemination of microscopic disease depends on a variety of clinicopathologic factors, such as age, TNM stage, genomic signature, grade, receptor phenotype, and luminal status.
Modifying the Terms ‘Mastectomy’ and ‘Partial Mastectomy’
THE TERMS ‘mastectomy’ and ‘partial mastectomy’ do not accurately reflect the surgical objective and underlying biology of breast cancer, and this discrepancy often leads to confusion among patients. The surgical terms mastectomy and partial mastectomy need to be updated to add the modifier “macroscopic debulking” mastectomy and partial mastectomy to clarify the surgical objective, enhance patient education, and compliance.
A surgical procedure in which the breast is surgically removed, “mastectomy” was named in 1882 by Dr. William Halsted. Subsequently, other variants of mastectomy have been adopted. Most notably, partial mastectomy (or lumpectomy), in which the tumor is removed together with some normal breast tissue surrounding it, is a form of breast conservation.
“The terms ‘mastectomy’ and ‘partial mastectomy’ do not accurately reflect the surgical objective and underlying biology of breast cancer, and this discrepancy often leads to confusion among patients.”— Damien Hansra, MD
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We now know that breast cancer is a microscopic disease (most tumors have more than 1 cm tumor volume at presentation) harboring a significant chance of microscopic dissemination of varying degrees depending on clinicopathologic factors. In other words when a mastectomy or lumpectomy is performed, there is a certain probability that residual local or systemic disease remains on a microscopic level. Adjuvant radiotherapy has been designed to eradicate micrometastatic deposits remaining after lumpectomy. Also, adjuvant chemotherapy and hormonal therapy has been designed to address systemically disseminated micrometastatic disease.
The terms mastectomy and partial mastectomy have not been updated in decades, and they should be called macroscopic debulking mastectomy and macroscopic debulking partial mastectomy to reflect modern practice. The added adjective “macroscopic debulking” addresses the fact that the primary macroscopic lesion (tens of millions of cells per cm) has been removed on a macroscopic level, and this implies there is still a probability of a significant microscopic residual burden.
Change in Terminology May Clarify Treatment Plans for Patients
FURTHERMORE, ADDING the term “macroscopic debulking” will lead to increased patient education, clarity about treatment plans, and perhaps adherence to treatments. Raising the issue of macroscopic disease with patients will naturally lead to raising the issue of microscopic disease and concepts of adjuvant treatments.
A common question posed by many patients is why do I need adjuvant chemotherapy, endocrine therapy, radiation therapy if my tumor has been removed? Patients should be informed that breast cancer is a microscopic disease and there exists a certain probability of residual microscopic disease after surgery, for which other adjuvant treatments are necessary to eradicate. Also, patients should be educated that probabilities of varying degrees of disseminated microscopic disease exist depending on clinicopathologic factors (eg, age, TNM stage, grade, receptor phenotype, and genomic signatures).
For example, for a patient with a pathologic T3N1 estrogen receptor–negative, progesterone receptor–negative, HER2 receptor–negative invasive ductal carcinoma after macroscopic debulking lumpectomy with sentinel node excision would have a high probability of preexisting microscopically disseminated disease in the ipsilateral breast, systemically warranting adjuvant radiation therapy and chemotherapy. Alternatively, a patient who had a macroscopic debulking mastectomy with a pathologic T1aN0M0 3-mm estrogen receptor–negative, progesterone receptor–negative, HER2-overexpressed tumor would have a low preexisting probability of disseminated micrometastatic disease, thus not warranting adjuvant biochemotherapy.
Other Benefits of Updated Terminology
IN ADDITION to enhancing patient education and compliance, educating patients about “macroscopic debulking” could save physicians much time in the clinic having to explain the rationale behind adjuvant chemotherapy, hormonal therapy, and radiotherapy. Before office visits, patients could be given educational handouts or directed to reputable educational websites that explain the concept of macroscopic debulking and concepts of eradication of microscopic disease with various modalities. If patients understood breast cancer as a microscopic entity and that surgery generally does not remove the malignancy in its entirety, this would refine their expectations and perhaps compliance with adjuvant modalities. Finally, the concept of “macroscopic debulking” not only applies to breast cancer, but also to many other cancer subtypes as well. ■
Specializing in hematology and medical oncology, Dr. Hansra practices at the Cancer Treatment Centers of America, Newnan, Georgia.
Disclaimer: This commentary represents the views of the author and may not necessarily represent the views of ASCO or of The ASCO Post.
DISCLOSURE: Dr. Hansra reported no conflicts of interest.