Breast Cancer Treatment: Optimizing Surgical and Radiation De-escalation

At the CURE Educated Patient® Breast Cancer Summit, held during the 49th Annual Miami Breast Cancer Conference, Dr. Reshma Jagsi, Lawrence W. Davis Professor at Emory University School of Medicine, delivered a presentation on the shifting landscape of local breast cancer therapies. While the medical community often uses the term "de-escalation, Jagsi proposed a more precise framework: optimization.

According to Jagsi, the history of breast cancer management is defined by a steady trajectory of research aimed at identifying patients who can safely forego toxic treatments without compromising survival. This journey has seen the field move from radical mastectomies to breast-conserving lumpectomies, and from complete axillary lymph node dissections to targeted sentinel lymph node biopsies. Today, researchers are even evaluating the total omission of surgery for select women with DCIS or those who show an exceptional response to upfront chemotherapy.

The revolution in radiation therapy

Radiation oncology, which is Jagsi’s primary field, has undergone a similar transformation. Twenty-five years ago, the standard answer for almost every patient was more than six weeks of radiation. Modern practice now utilizes hypofractionated courses, which are shorter treatment windows with higher daily doses but a lower total dose.

What was once 25 treatments over five weeks can now often be delivered in 16 treatments, or even as few as five fractions. Furthermore, many patients can now receive partial breast irradiation rather than treating the whole breast, significantly reducing side effects.

For older women (ages 65 to 70-plus) with small, hormone-sensitive, node-negative tumors, Jagsi noted that research shows no difference in survival whether radiation is administered or omitted. However, omitting radiation may increase the risk of local recurrence from approximately 2% to 10%. Jagsi emphasized that there is no "right" answer in these scenarios; rather, it is a patient-centered decision based on individual values and health priorities.

Understanding the drivers of over-treatment

Despite robust evidence supporting de-escalation, many patients continue to pursue more aggressive treatments than clinically required. One prominent example is contralateral prophylactic mastectomy (CPM), or the removal of the healthy breast in cases of unilateral cancer. While essential for those with specific genetic mutations, CPM is frequently chosen by women without such risks, even though evidence shows it does not improve survival and is associated with poorer quality of life and body image distress.

Jagsi identified several factors driving this trend, including:

• Physician Factors: Doctors are often slow to adopt new data due to a natural aversion to changing established, successful practices.
• Psychological Biases: Both patients and providers are influenced by availability bias (remembering a rare, bad outcome), anticipated regret (wanting to do "everything" to avoid future guilt), and aversion to uncertainty.
• Communication Cues: Patients often look for subtle signals or confirmation from their care team to justify aggressive choices.

The true cost of toxicity

The push for optimization is driven by a desire to avoid "toxicities" that extend far beyond physical pain. Jagsi highlighted the risk of lymphedema following lymph node surgery, which can have devastating functional and financial consequences for patients in labor-intensive occupations. Other rare but serious risks include radiation-induced heart damage or secondary cancers.

Financial toxicity is another critical concern. Jagsi cited a study showing that patients who received chemotherapy were more likely to experience "unwanted lack of employment" even four years after treatment. These indirect costs — missed work and social withdrawal — underscore the need to ensure every intervention is truly necessary.

The path to patient-centered care

To bridge the gap between clinical data and patient choice, Jagsi advocated for better communication tools. One strategy involves changing terminology; for example, reclassifying ductal carcinoma in situ (DCIS) with a less frightening name like "indolent lesion of epithelial origin" to reduce fear-based decision-making.

She also highlighted the use of decision tools, such as those which use conjoint analysis to help patients clarify what matters most to them. This information can then be shared via clinician dashboards to help doctors tailor their advice to the patient’s specific values.

Jagsi concluded that the goal is not merely "shared decision-making," but patient-centered care. "If you tell me as a patient you want me to give you strong advice, then I'm happy to take that responsibility," she said. "And if you tell me you want to make that decision, then I'm happy to respect that."

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