‘Tread Lightly’ on De-escalation of Breast Cancer Therapy

De-escalation of treatment for localized breast cancer has emerged as a beneficial strategy for some patients ― but this approach may not be suitable for the most vulnerable of patients, a trio of Boston University oncologists warns.

Pointing out that minority patients are “grossly underrepresented” in cancer clinical trials, they urge all physicians who treat breast cancer patients to question whether the practice-changing data coming out of clinical trials are relevant to the patient sitting in front of them.

“We must tread lightly on the path of minimizing comprehensive breast cancer care and consider its effect on the most vulnerable subset of patients with breast cancer who face the highest financial toxicity and worst mortality from the disease,” they comment.

Oluwadamilola T. Olderu, MD, of the Harvard Radiation Oncology Program and Boston University School of Medicine, and coauthors discuss the issue in a Viewpoint article published on September 24 in JAMA Oncology.

De-escalation of Treatment

Several advances and studies over the past decade have altered the breast cancer treatment landscape, the authors note. Advances include taking steps to minimize aggressive and radical surgery, to reduce or even omit radiotherapy, and to forgo systemic chemotherapy in select estrogen receptor–positive patients.

Studies such as the landmark National Surgical Adjuvant Breast and Bowel Project B-18 study, the Comparison of Operative vs Monitoring and Endocrine Therapy (COMET) trial, and the RESPONDER trial have provided support for de-escalation and in some cases have “informed ongoing discourse and practice changes to deescalate all modalities of breast cancer management,” the authors comment.

“We all love that,” lead author Naomi Y. Ko, MD, MPH, told Medscape Medical News, referring to the idea that less aggressive treatment can result in outcomes comparable to those seen with more aggressive treatment.

However, she points out that “all of these studies that have changed practice in breast cancer care were done in women who were…seeking care at some academic centers that don’t generally see black, brown, or lower socioeconomic status patients as often, unfortunately.

“If we’re basing treatment recommendations on great research that doesn’t include the population we take care of, how relevant are those findings going to be for our patients?” she asked.

“And then, worse, if the pendulum swings too far in the direction of doing less and doing less and doing less, are we going to sacrifice outcomes for some of those patients who may not see the same benefits with less aggressive treatment?”

Ko said she and her colleagues are urging physicians who treat breast cancer patients to “just take a moment, take a pause, and let’s take a look at where we’re at and where we’re headed and make sure we’re being thoughtful about the patients that don’t generally get on the trials.”

Among these patients, diseases may differ in comparison with patients who are included in clinical trials, and there may be differences in their access to care and in their resources, she said.

Minority patients are more likely to harbor aggressive biological breast cancer subtypes, and for a number of reasons, they are the least likely to consistently adhere to adjuvant oral endocrine therapy and the ongoing surveillance required for a de-escalated local treatment approach, the group notes.

“There are some things that affect patients that we have to be thoughtful about…. It’s messy, but it’s something to be thinking about when we decide what the best treatment for breast cancer patients should be,” Ko said.

These issues must be addressed at the policy level, she said. She noted that those who determine high-level policies and make high-level decisions should think about inclusion and equity and “be daring enough” to make the necessary changes.

Oladeru has received grants from the Partners Center of Expertise in Health Policy and Management and the Radiation Oncology Institute outside the submitted work. Ko has received grants and personal fees from Pfizer outside the submitted work.

JAMA Oncol. Published online September 24, 2020. Abstract

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